Should prenatal hydronephrosis that resolves before birth be followed postnatally? Analysis and comparison to persistent prenatal hydronephrosis.

PubMed

Scarborough, Patrick L; Ferrara, Elizabeth; Storm, Douglas W

2015-09-01

Prenatal ultrasonography has greatly enhanced detection of congenital genitourinary abnormalities. However, although persistent prenatal hydronephrosis (PPH) is typically imaged and followed postnatally, it remains unclear if prenatal hydronephrosis that resolves in utero (RPH) should be similarly managed. We determined postnatal abnormalities associated with RPH and compared these to those associated with PPH. We performed a retrospective review of all consecutive patients evaluated for prenatal hydronephrosis over 24 months. Patients were followed prenatally with serial ultrasounds and postnatally with ultrasonography and a voiding cystourethrogram. Of the consecutive 165 patients enrolled in the study, 72 had RPH. The average prenatal anterior-posterior renal pelvis length was significantly longer in patients with PPH (5.5 mm) than in those with RPH (4.9 mm) (p = 0.01). Recurrent postnatal hydronephrosis occurred in 44% of patients with RPH, with eventual resolution in 34% of those affected. In comparison, 29% of PPH cases resolved postnatally. Mean time to resolution was statistically shorter for PPH (116 days) than for RPH (175 days) (p = 0.01). Seven PPH patients required surgery, while no RPH patients needed intervention (difference was statistically significant). A significant number of RPH children had postnatal hydronephrosis. Despite a slower resolution time, no children with RPH required intervention. Although RPH may recur postnatally, the significantly lower chance of intervention being required suggests that these children may not require postnatal imaging.

Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis.

PubMed

Cahen, Djuna L; Gouma, Dirk J; Laramée, Philippe; Nio, Yung; Rauws, Erik A J; Boermeester, Marja A; Busch, Olivier R; Fockens, Paul; Kuipers, Ernst J; Pereira, Stephen P; Wonderling, David; Dijkgraaf, Marcel G W; Bruno, Marco J

2011-11-01

A randomized trial that compared endoscopic and surgical drainage of the pancreatic duct in patients with advanced chronic pancreatitis reported a significant benefit of surgery after a 2-year follow-up period. We evaluated the long-term outcome of these patients after 5 years. Between 2000 and 2004, 39 symptomatic patients were randomly assigned to groups that underwent endoscopic drainage or operative pancreaticojejunostomy. In 2009, information was collected regarding pain, quality of life, morbidity, mortality, length of hospital stay, number of procedures undergone, changes in pancreatic function, and costs. Analysis was performed according to an intention-to-treat principle. During the 79-month follow-up period, one patient was lost and 7 died from unrelated causes. Of the patients treated by endoscopy, 68% required additional drainage compared with 5% in the surgery group (P = .001). Hospital stay and costs were comparable, but overall, patients assigned to endoscopy underwent more procedures (median, 12 vs 4; P = .001). Moreover, 47% of the patients in the endoscopy group eventually underwent surgery. Although the mean difference in Izbicki pain scores was no longer significant (39 vs 22; P = .12), surgery was still superior in terms of pain relief (80% vs 38%; P = .042). Levels of quality of life and pancreatic function were comparable. In the long term, symptomatic patients with advanced chronic pancreatitis who underwent surgery as the initial treatment for pancreatic duct obstruction had more relief from pain, with fewer procedures, than patients who were treated endoscopically. Importantly, almost half of the patients who were treated with endoscopy eventually underwent surgery. Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.

Multifocal necrotising fasciitis and septic shock complicating varicella infection in an adult

PubMed Central

Mifsud, Simon; Schembri, Emma Louise; Mallia Azzopardi, Charles; Zammit, Maria Alessandra

2013-01-01

A 35-year-old woman with a 3-day history of chickenpox, presented to the hospital in septic shock and with multifocal, non-adjacent lesions of necrotising fasciitis. Necrotising fasciitis is a rare yet life-threatening complication of chickenpox. Blood cultures and wound swabs confirmed the presence of Streptococcus pyogenes. The initial emergency management included oxygen, aggressive fluid resuscitation and antimicrobial therapy. Once the patient was stabilised, surgical management ensued. This included debridement and eventual grafting of the necrotic skin lesions. Intensive management and follow-up for 8 weeks were required before the patient was deemed fit for discharge. PMID:24130210

Retained intraaortic balloon. Case report and review of the literature.

PubMed Central

Grande, A M; Martinelli, L; Graffigna, A; Viganò, M

1995-01-01

We report a case of intraaortic balloon entrapment in a 70-year-old man who underwent emergency triple coronary bypass. Intraaortic balloon rupture caused the formation of a clot inside the balloon that eventually was responsible for the balloon's entrapment at the aortic bifurcation. The patient had severe atherosclerosis of the aorta and iliac arteries. Balloon removal required aorto-iliac exposure and aorto-bifemoral bypass. After 16 months, he is symptom free and at home. Images PMID:8605436

Allergic reaction to stainless steel sternotomy wires requiring removal: A case report and literature review.

PubMed

Lopez, J; Sachithanandan, A; Leow, M

2016-06-01

Hypersensitivity to stainless steel sternal sutures are an uncommon occurrence. We present a case of such a patient who developed chronic tissue overgranulation over a sternotomy wound eight weeks post-operatively. Primary suspicion was infection, a more common complication however radiological and laboratory investigation showed otherwise. Conservative management provided limited ephemeral success. After ensuring adequate sternal bone healing, the sutures and granulation tissue were eventually surgically removed without complication and the reoperated wound healed well.

Fetal-onset Congenital Dyserythropoietic Anemia Type 1 due to a Novel Mutation With Severe Iron Overload and Severe Cholestatic Liver Disease.

PubMed

Chin, Hui-Lin; Lee, Le Ye; Koh, Pei Lin

2018-04-17

We report a rare case of severe congenital dyserythropoietic anemia type 1 with fetal onset. Our patient presented with fetal hydrops from 19 weeks of gestation, requiring multiple intrauterine transfusions. At birth, she had severe hemolytic anemia with severe jaundice, and was subsequently transfusion dependent. She eventually developed severe iron overload and fulminant liver failure before her demise at 5 months of age. Genetic testing revealed a novel mutation in CDAN1.

Large datasets, logistics, sharing and workflow in screening.

PubMed

Cook, Tessa S

2018-03-29

Cancer screening initiatives exist around the world for different malignancies, most frequently breast, colorectal, and cervical cancer. A number of cancer registries exist to collect relevant data, but while these data may include imaging findings, they rarely, if ever, include actual images. Additionally, the data submitted to the registry are usually correlated with eventual cancer diagnoses and patient outcomes, rather than used with the individual's future screenings. Developing screening programs that allow for images to be submitted to a central location in addition to patient meta data and used for comparison to future screening exams would be very valuable in increasing access to care and ensuring that individuals are effectively screened at appropriate intervals. It would also change the way imaging results and additional patient data are correlated to eventual outcomes. However, it introduces logistical challenges surrounding secure storage and transmission of data to subsequent screening sites. In addition, in the absence of standardized protocols for screening, comparing current and prior imaging, especially from different equipment, can be challenging. Implementing a large-scale screening program with an image-enriched screening registry-effectively, an image-enriched electronic screening record-also requires that incentives exist for screening sites, physicians, and patients to participate; to maximize coverage, participation may have to be supported by government agencies. Workflows will also have to be adjusted to support registry participation for all screening patients in an effort to create a large, robust data set that can be used for future screening efforts as well as research initiatives.center.

Out-of-hospital and emergency department management of epidemic scombroid poisoning.

PubMed

Eckstein, M; Serna, M; DelaCruz, P; Mallon, W K

1999-09-01

To report two epidemic outbreaks of scombroid food poisoning and their emergency medical services (EMS) response and emergency department (ED) treatment, analyzing the impact of early physician involvement and on-line medical control. Retrospective case series of two multiple-casualty incidents (MCIs) involving scombroid food poisoning. A total 57 patients were treated from two separate incidents, with 30 patients transported to area hospitals. One patient required treatment with a cardiac medication in the field and another patient eventually required hospital admission. On-scene medical control (incident 1) and early identification of the index case (incident 2) were instrumental to out-of-hospital care interventions and conservation of resources. Patient triage, field treatment, and hospital transport were expedited, with some patients treated and released from the scene. Immediate diagnosis of a food-borne illness in the out-of-hospital setting allows rapid treatment at the scene and allows for the efficient transport of multiple patients to a single receiving facility. EMS medical directors should be able to immediately respond to such incidents to make presumptive diagnoses and accurately direct patient care. When this is not possible, early identification of the index case facilitates early diagnosis and treatment.

Diabetic ketoacidosis in acromegaly; a rare complication precipitated by corticosteroid use.

PubMed

Weiss, Jeremy; Wood, Anna J; Zajac, Jeffrey D; Grossmann, Mathis; Andrikopoulos, Sofianos; Ekinci, Elif I

2017-12-01

Diabetic ketoacidosis has been described in the literature as a rare possible initial presentation of acromegaly before a diagnosis of acromegaly is eventually made. Indeed, diabetic ketoacidosis is a recognised complication of acromegaly. There are a number of factors that can predispose patients with acromegaly to diabetes as well as to diabetic ketoacidosis. These include high levels of growth hormone and insulin-like growth factor 1 in acromegaly and the effect on glycaemia by medications used in the management of acromegaly. Ketoacidosis has been described in patients with acromegaly even without the presence of an underlying autoimmune diabetes. Patients with acromegaly and ketoacidosis often respond to treatment and may not require long-term insulin. Copyright © 2017. Published by Elsevier B.V.

Asymptomatic carriage of Klebsiella pneumoniae producing extended-spectrum beta-lactamase by patients in a neurological early rehabilitation unit: management of an outbreak.

PubMed

Holländer, R; Ebke, M; Barck, H; von Pritzbuer, E

2001-07-01

During 11 months 58 extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (ESBL-Kp) isolates were grown from 10 patients on a neurological early rehabilitation unit. The patients had no signs of infection but were colonized in the nose and trachea, and unusually only one had colonization in the gut. A single clone of ESBL-Kp was identified by pulse field gel electrophoresis. Strong hygienic precautions similar to those for Methicillin-resistant Staphylococcus aureus patients prevented spread of the bacteria to other wards. However, rehabilitation for patients with severe neurological failures made it very difficult to follow hygienic requirements. Disinfection of mucous membranes was difficult. Eventually the application of a nasal spray containing povidone-iodine proved to be successful. Copyright 2001 The Hospital Infection Society.

The predictive value of 2-year posttreatment biopsy after prostate cancer radiotherapy for eventual biochemical outcome

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

Vance, Waseet; Tucker, Susan L.; Crevoisier, Renaud de

2007-03-01

Purpose: To determine the value of a 2-year post-radiotherapy (RT) prostate biopsy for predicting eventual biochemical failure in patients who were treated for localized prostate cancer. Methods and Materials: This study comprised 164 patients who underwent a planned 2-year post-RT prostate biopsy. The independent prognostic value of the biopsy results for forecasting eventual biochemical outcome and overall survival was tested with other factors (the Gleason score, 1992 American Joint Committee on Cancer tumor stage, pretreatment prostate-specific antigen level, risk group, and RT dose) in a multivariate analysis. The current nadir + 2 (CN + 2) definition of biochemical failure wasmore » used. Patients with rising prostate-specific antigen (PSA) or suspicious digital rectal examination before the biopsy were excluded. Results: The biopsy results were normal in 78 patients, scant atypical and malignant cells in 30, carcinoma with treatment effect in 43, and carcinoma without treatment effect in 13. Using the CN + 2 definition, we found a significant association between biopsy results and eventual biochemical failure. We also found that the biopsy status provides predictive information independent of the PSA status at the time of biopsy. Conclusion: A 2-year post-RT prostate biopsy may be useful for forecasting CN + 2 biochemical failure. Posttreatment prostate biopsy may be useful for identifying patients for aggressive salvage therapy.« less

Machine Learning Algorithms Utilizing Quantitative CT Features May Predict Eventual Onset of Bronchiolitis Obliterans Syndrome After Lung Transplantation.

PubMed

Barbosa, Eduardo J Mortani; Lanclus, Maarten; Vos, Wim; Van Holsbeke, Cedric; De Backer, William; De Backer, Jan; Lee, James

2018-02-19

Long-term survival after lung transplantation (LTx) is limited by bronchiolitis obliterans syndrome (BOS), defined as a sustained decline in forced expiratory volume in the first second (FEV 1 ) not explained by other causes. We assessed whether machine learning (ML) utilizing quantitative computed tomography (qCT) metrics can predict eventual development of BOS. Paired inspiratory-expiratory CT scans of 71 patients who underwent LTx were analyzed retrospectively (BOS [n = 41] versus non-BOS [n = 30]), using at least two different time points. The BOS cohort experienced a reduction in FEV 1 of >10% compared to baseline FEV 1 post LTx. Multifactor analysis correlated declining FEV 1 with qCT features linked to acute inflammation or BOS onset. Student t test and ML were applied on baseline qCT features to identify lung transplant patients at baseline that eventually developed BOS. The FEV 1 decline in the BOS cohort correlated with an increase in the lung volume (P = .027) and in the central airway volume at functional residual capacity (P = .018), not observed in non-BOS patients, whereas the non-BOS cohort experienced a decrease in the central airway volume at total lung capacity with declining FEV 1 (P = .039). Twenty-three baseline qCT parameters could significantly distinguish between non-BOS patients and eventual BOS developers (P < .05), whereas no pulmonary function testing parameters could. Using ML methods (support vector machine), we could identify BOS developers at baseline with an accuracy of 85%, using only three qCT parameters. ML utilizing qCT could discern distinct mechanisms driving FEV 1 decline in BOS and non-BOS LTx patients and predict eventual onset of BOS. This approach may become useful to optimize management of LTx patients. Copyright © 2018 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

Surgical excision for recurrent herpes simplex virus 2 (HSV-2) anogenital infection in a patient with human immunodeficiency virus (HIV).

PubMed

Arinze, Folasade; Shaver, Aaron; Raffanti, Stephen

2017-10-01

Recurrent anogenital herpes simplex virus infections are common in patients with human immunodeficiency virus (HIV), of whom approximately 5% develop resistance to acyclovir. We present a case of a 49-year-old man with HIV who had an 8-year history of recurrent left inguinal herpes simplex virus type 2 ulcerations. He initially responded to oral acyclovir, but developed resistance to acyclovir and eventually foscarnet. The lesion progressed to a large hypertrophic mass that required surgical excision, which led to resolution without recurrences. Our case highlights the importance of surgical excision as a treatment option in refractory herpes simplex virus anogenital infections.

The changing practice of transurethral resection of the prostate.

PubMed

Young, M J; Elmussareh, M; Morrison, T; Wilson, J R

2018-04-01

Introduction Transurethral resection of the prostate (TURP) is considered the gold standard surgical treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia. The number of TURPs performed has declined significantly over the last three decades owing to pharmaceutical therapy. TURP data from a single institution for the years 1990, 2000 and 2010 were compared to assess the difference in performance. Methods A retrospective analysis was undertaken of all patients who underwent TURP between January and December 2010. These findings were compared with historical data for the years 1990 and 2000: 100 sets of case notes were selected randomly from each of these years. Results The number of TURPs performed fell from 326 in 1990 to 113 in 2010. The mean age of patients increased from 70.6 years to 74.0 years. There was also a significant increase in the mean ASA grade from 1.9 to 2.3. The most common indication for TURP shifted from LUTS to acute urinary retention. No significant change in operating time was observed. The mean resection weight remained constant (22.95g in 1990, 22.55g in 2000, 20.76g in 2010). A reduction in transfusion rates was observed but there were higher rates of secondary haematuria and bladder neck stenosis. There was an increase from 2% to 11.5% of patients with long-term failure to void following TURP. Conclusions The number of TURPs performed continues to decline, which could lead to potential training issues. Urinary retention is still by far the most common indication. However, there has been a significant rise in the percentage of men presenting for TURP with high pressure chronic retention. The number of patients with bladder dysfunction who either have persistent storage LUTS or eventually require long-term catheterisation or intermittent self-catheterisation has increased markedly, which raises the question of what the long-term real life impact of medical therapy is on men with LUTS secondary to benign prostatic hyperplasia who eventually require surgery.

Eventual Suicide in Interrupted and Uninterrupted Attempters: A Challenge to the Cry-for-Help Hypothesis.

ERIC Educational Resources Information Center

Steer, Robert A.; And Others

1988-01-01

Followed patients (N=499) hospitalized for suicide attempts (attempters) between 1970 and 1975 until 1982. Found under six percent eventually committed suicide. Found the interrupted attempters were approximately three times more likely to commit suicide than were the uninterrupted attempters. (Author/ABL)

Nonsurgical acute traumatic subdural hematoma: what is the risk?

PubMed

Bajsarowicz, Paul; Prakash, Ipshita; Lamoureux, Julie; Saluja, Rajeet Singh; Feyz, Mitra; Maleki, Mohammad; Marcoux, Judith

2015-11-01

The Brain Trauma Foundation has published guidelines on the surgical management of traumatic subdural hematoma (SDH). However, no data exist on the proportion of patients with SDH that can be selected for conservative management and what is the outcome of these patients. The goals of this study were as follows: 1) to establish what proportion of patients are initially treated conservatively; 2) to determine what proportion of patients will deteriorate and require surgical evacuation; and 3) to identify risk factors associated with deterioration and delayed surgery. All cases of acute traumatic SDH (869 when inclusion criteria were met) presenting over a 4-year period were reviewed. For all conservatively treated SDH, the proportion of delayed surgical intervention and the Glasgow Outcome Scale score were taken as outcome measures. Multiple factors were compared between patients who required delayed surgery and patients without surgery. Of the 869 patients with acute traumatic SDH, 646 (74.3%) were initially treated conservatively. A good outcome was achieved in 76.7% of the patients. Only 6.5% eventually required delayed surgery, and the median delay for surgery was 9.5 days. Factors associated with deterioration were as follows: 1) thicker SDH (p<0.001); 2) greater midline shift (p<0.001); 3) location at the convexity (p=0.001); 4) alcohol abuse (p=0.0260); and 5) history of falls (p=0.018). There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease. The majority of patients with SDH are treated conservatively. Of those, only 6.5% later required surgery, for raised intracranial pressure or SDH progression. Patients at risk can be identified and followed more carefully.

Long-term follow-up of patients after antegrade continence enema procedure.

PubMed

Siddiqui, Anees A; Fishman, Steven J; Bauer, Stuart B; Nurko, Samuel

2011-05-01

Antegrade continence enema (ACE) has become an important therapeutic modality in the treatment of intractable constipation and fecal incontinence. There are little data available on the long-term performance of the ACE procedure in children. A retrospective review of patients who underwent the ACE procedure was conducted. Irrigation characteristics and complications were noted. Outcome was assessed for individual encounters based on frequency of bowel movements, incontinence, pain, and predictability. One hundred seventeen patients underwent an ACE. One hundred five patients had at least 6 months of follow-up, and were included in the analysis. Diagnoses included myelodysplasia (39%), functional intractable constipation (26%), anorectal malformations (21%), nonrelaxing internal anal sphincter (7%), cerebral palsy (3%), and other diagnoses (4%). The average follow-up was 68 months (range 7-178 months). At the last follow-up, 69% of patients had successful bowel management. Of the 31% of patients who did not have successful bowel management, 20% were using the ACE despite suboptimal results, 10% required surgical removal, and 2% were not using the ACE because of behavioral opposition to it. Patients were started on normal saline, but were switched to GoLYTELY (PEG-3350 and electrolyte solution) if there was an inadequate response (61% at final encounter). Additives were needed in 34% of patients. The average irrigation dose was 23 ± 0.7 mL/kg. The average toilet sitting time was 51.7 ± 3.5 minutes, with infusions running for 12.1 ± 1.2 minutes. Stomal complications occurred in 63% (infection, leakage, and stenosis) of patients, 33% required surgical revision and 6% eventually required diverting ostomies. Long-term use of the ACE gives successful results in 69% of patients, whereas 63% had a stoma-related complication and 33% required surgical revision of the stoma.

Transient Hypothyroidism after Radioiodine for Graves’ Disease: Challenges in Interpreting Thyroid Function Tests

PubMed Central

Sheehan, Michael T.; Doi, Suhail A.R.

2016-01-01

Graves’ disease is the most common cause of hyperthyroidism and is often managed with radioactive iodine (RAI) therapy. With current dosing schemes, the vast majority of patients develop permanent post-RAI hypothyroidism and are placed on life-long levothyroxine therapy. This hypothyroidism typically occurs within the first 3 to 6 months after RAI therapy is administered. Indeed, patients are typically told to expect life-long thyroid hormone replacement therapy to be required within this timeframe and many providers expect this post-RAI hypothyroidism to be complete and permanent. There is, however, a small subset of patients in whom a transient post-RAI hypothyroidism develops which, initially, presents exactly as the typical permanent hypothyroidism. In some cases the transient hypothyroidism leads to a period of euthyroidism of variable duration eventually progressing to permanent hypothyroidism. In others, persistent hyperthyroidism requires a second dose of RAI. Failure to appreciate and recognize the possibility of transient post-RAI hypothyroidism can delay optimal and appropriate treatment of the patient. We herein describe five cases of transient post-RAI hypothyroidism which highlight this unusual sequence of events. Increased awareness of this possible outcome after RAI for Graves’ disease will help in the timely management of patients. PMID:26864507

Temporarily detained: tuberculous alcoholics in Seattle, 1949 through 1960.

PubMed Central

Lerner, B H

1996-01-01

Repeatedly noncompliant tuberculosis patients (who are often homeless or substance users) are once again being forcibly detained. Health officials intend that confinement be used only when "less restrictive alternatives" have failed. Past programs of detention can inform current efforts. In 1949, Seattle's Firland Sanatorium established a locked ward. Although initially intended only for active public health threats, the ward was eventually used to maintain order among Firland's alcoholic patients. That is, the staff detained alcoholics--regardless of their infectivity or compliance with medications--for breaking sanatorium rules. In this manner, maintaining institutional order became a legitimate reason for invoking public health powers. Although new detention regulations strive to protect patients' civil liberties, attention must also be paid to the day-to-day implementation of coercive measures. When public health language is used to justify administrative or institutional requirements, disadvantaged patients may be stigmatized. Images p260-a p260-b p261-a p262-a PMID:8633748

Interventional and surgical therapeutic strategies for pulmonary arterial hypertension: Beyond palliative treatments.

PubMed

Sandoval, Julio; Gomez-Arroyo, Jose; Gaspar, Jorge; Pulido-Zamudio, Tomas

2015-10-01

Despite significant advances in pharmacological treatments, pulmonary arterial hypertension remains an incurable disease with an unreasonably high morbidity and mortality. Although specific pharmacotherapies have shifted the survival curves of patients and improved exercise endurance as well as quality of life, it is also true that these pharmacological interventions are not always accessible (particularly in developing countries) and, perhaps most importantly, not all patients respond similarly to these drugs. Furthermore, many patients will continue to deteriorate and will eventually require an additional, non-pharmacological, intervention. In this review we analyze the role of atrial septostomy and Potts anastomosis in the management of patients with pulmonary arterial hypertension, we summarize the current worldwide clinical experience (case reports and case series), and discuss why these interventional/surgical strategies might have a therapeutic role beyond that of a "bridge" to transplantation. Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Long-term response to hydroxychloroquine in patients with discoid lupus erythematosus.

PubMed

Wahie, S; Meggitt, S J

2013-09-01

The recommended first-line oral therapy for discoid lupus erythematosus (DLE) is the antimalarial hydroxychloroquine. To the best of our knowledge, there is no published information regarding the long-term (i.e. > 6 months) response of DLE to hydroxychloroquine in clinical practice. To describe the long-term clinical response of DLE to hydroxychloroquine after 6 months of use. A multicentre retrospective cohort study was conducted in patients with DLE who had received treatment with hydroxychloroquine. All patients were recruited and interviewed by a single investigator and response to hydroxychloroquine assessed by the same individual through a retrospective review of case notes using a specified protocol. A total of 200 patients with DLE were recruited (F:M = 4 : 1) with a median age at diagnosis of 40 years (range 16-81) and median follow-up of 8 years (range 0·5-37). An adequate clinical response to hydroxychloroquine was recorded in 91 patients (45·5%) but nonresponse occurred in 85 patients (42·5%). The remainder of patients either had partial response or withdrew from therapy due to toxicity or were unclassifiable. Importantly, of those individuals that did respond to hydroxychloroquine within the first 6 months of use, almost one in five eventually lost their response, despite continued administration, after a median interval of 2 years. These patients often regained disease control if treated with a combination of hydroxychloroquine and mepacrine. Of those that did not respond to hydroxychloroquine within the first 6 months of use, almost one in 10 became eventual responders either after continued administration for up to 2 years or when rechallenged on hydroxychloroquine. The remaining nonresponders relied frequently on oral corticosteroid. In this cohort of patients with DLE, long-term clinical response to hydroxychloroquine occurred in less than 50% of patients. Nonresponders to hydroxychloroquine frequently required oral steroid to achieve disease control. These findings merit further investigation through a multicentre prospective study using a validated disease activity measure. © 2013 British Association of Dermatologists.

[Actinomyces empyema treated with decortications].

PubMed

Shteinberg, Michal; Perek, Shoshan; Ghanem, Nesrin; Sarafov, Israel; Peysakhovich, Yury; Adir, Yochai

2012-04-01

Actinomyces infections are rare infections, involving the head and neck, abdominal cavity, and the lung. We report a case of a 66 year old woman with shortness of breath and a pleural effusion from which Actinomyces meyeriwas cultured. The diagnosis was confirmed by the polymerase chain reaction technique. The infection was successfully treated with a combination of ampicillin and surgical decortication. Due to their rarity, Actinomyces infections are not often suspected. These infections are difficult to diagnose due to specific microbiologic requirements for isolation of Actinomyces. In many reviewed cases of Actinomyces infection, patients underwent surgery for presumed cancer but were eventually diagnosed as being infected with actinomycosis. Due to lack of improvement of our patient, surgical decortication was performed, which led to a successful outcome.

An updated look at document security: from initiation to storage or shredder.

PubMed

McConnell, Charles R

2014-01-01

In these days of close attention to security of information handled electronically, there is often a tendency to overlook the security of hard-copy documents. Document security can involve many areas of business, but the health care department manager's concerns are primarily for patient records and employee documentation. Document security is closely related to growing concerns for individual privacy; guidelines are furnished for protecting employee privacy by separating retention practices for business information from personal information. Sensitive documentation requires rules and procedures for processing, retaining, accessing, storing, and eventually destroying. Also, documents that are missing or incomplete at times present unique problems for the organization. The department manager is provided with some simple rules for safeguarding employee and patient documentation.

Emerging innovations in clinical trial design.

PubMed

Berry, D A

2016-01-01

Designs of clinical trials have changed little since the advent of randomization in the 1940s. Modern innovations in designs are being driven by the increasing recognition in clinical research that diseases are heterogeneous and patients who apparently have the same disease require different therapies. This article describes some innovations in clinical trial design across therapeutic areas but with a focus on oncology. No one knows what the future holds for clinical trial design but the status quo of large trials that pretend the patient population is homogeneous is not sustainable, either economically or scientifically/medically. No one knows what the eventual business model and regulatory model will be, but they will be very different from today's. © 2015 American Society for Clinical Pharmacology and Therapeutics.

An Automated, Gravity-driven CSF Drainage System Decreases Complications and Lowers Costs

PubMed Central

Lieberson, Robert E; Meyer, William; Trang, Tung

2017-01-01

Background: FlowSafeTM (BeckerSmith Medical, Irvine, CA, USA) is a novel, robotic, external lumbar drainage (ELD) system, which was designed to control cerebrospinal fluid (CSF) drainage, reduce complications, and decrease treatment costs. Methods: Forty-seven consecutive neurosurgical patients requiring ELD were treated using the FlowSafe system. Results: In 39 of 40 patients with traumatic and surgical dural openings, potential CSF leaks were avoided. In seven patients with suspected normal pressure hydrocephalus, post-infectious ventriculomegaly, or pseudotumor cerebrum, we were able to assess the likelihood of improvement with shunting. The system, therefore, produced what we considered to be the “desired result” in 46 of 47 patients (98%). Our one treatment failure (2%) involved a patient with unrecognized hydrocephalus who, following a Chiari repair with a dural patch graft, was drained for six days. A persistent CSF leak eventually required a reoperation. Two patients (4%) described low-pressure headaches during treatment. Both responded to temporarily suspending or reducing the drainage rate. We saw no complications. Required nursing interventions were minimal.  Conclusions: The FlowSafe system was safe and effective. In our experience, there were fewer complications compared to currently available ELD systems. The FlowSafe was well tolerated by our patients. The near elimination of nursing interventions should allow lumbar drainage to be delivered in less costly, non-intensive care unit settings. Larger trials will be needed. PMID:28331772

Factors associated with tracheotomy and decannulation in pediatric bilateral vocal fold immobility.

PubMed

Funk, Ryan T; Jabbour, Jad; Robey, Thomas

2015-06-01

Describe the natural history of all-cause bilateral vocal fold immobility (BVFI) in pediatric patients and analyze factors associated with tracheotomy and subsequent decannulation. This is a retrospective review of all patients diagnosed with complete or partial BVFI at a metropolitan private pediatric otolaryngology practice between 2001 and 2012. Records were reviewed for data on demographics, etiologies, vocal fold position, and BVFI resolution. Patients requiring tracheotomy were further investigated for tracheotomy duration and associated complications and procedures. One hundred two patients were included, with a median (range) follow-up of 32.9 (0.3-124.2) months. Of these, 68.6% required tracheotomy. Tracheotomies were more likely in those with concomitant airway disease (p = 0.005) and paramedian vocal fold position compared to lateral position (p = 0.02). Among patients requiring tracheotomy, 64.3% underwent decannulation during follow up. Decannulation was more likely in those who demonstrated VFI resolution (p = 0.002) and those with idiopathic compared to neurogenic etiologies (p = 0.003). Median duration of cannulation was 30.6 (0.5-297.3) months. The most common tracheotomy-related complication requiring medical attention was tracheal and stomal granuloma formation (77.1%), while the most frequent associated procedures included granuloma excision (47.1%) and airway reconstruction (31.4%). Of those who avoided tracheotomy, 40.6% did not demonstrate BVFI resolution during median follow up of 13.4 (0.6-44.4) months. Most pediatric BVFI patients require tracheotomy, with the majority of those undergoing eventual decannulation. A better understanding of the factors associated with tracheotomy and subsequent decannulation improves the otolaryngologist's ability to counsel parents and caregivers of children with BVFI. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

77 FR 61542 - Airworthiness Directives; The Boeing Company Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-10

... flange of the inboard track at the rear spar attachment of each outboard flap, and eventual rework of the... inboard track at the rear spar attachment of each outboard flap, and eventual rework of the flap track... required by paragraph (g) of this AD, before further flight, repair or rework the flap track per the...

Anesthesiology training using 3D imaging and virtual reality

NASA Astrophysics Data System (ADS)

Blezek, Daniel J.; Robb, Richard A.; Camp, Jon J.; Nauss, Lee A.

1996-04-01

Current training for regional nerve block procedures by anesthesiology residents requires expert supervision and the use of cadavers; both of which are relatively expensive commodities in today's cost-conscious medical environment. We are developing methods to augment and eventually replace these training procedures with real-time and realistic computer visualizations and manipulations of the anatomical structures involved in anesthesiology procedures, such as nerve plexus injections (e.g., celiac blocks). The initial work is focused on visualizations: both static images and rotational renderings. From the initial results, a coherent paradigm for virtual patient and scene representation will be developed.

Impact of supply problems of preservative-free glaucoma medications on patients and hospital staff.

PubMed

Shah, Shima; Theodossiades, Julia; Chapman, Kristin; Murdoch, Ian

2015-03-01

Glaucoma is a chronic ocular disease, which is usually managed with long-term daily medical therapy, in the form of eye drops. Patients who are intolerant to preservatives in topical medicines require preservative-free versions. From early 2011 patients attending Moorfields Eye Hospital, London, UK, started to report recurring problems with the supply of the following preservative-free glaucoma medications: Timolol 0.25% (Timoptol 0.25%, MSD UK); Dorzolamide (Trusopt, MSD UK); Dorzolamide and Timolol 0.5% (Cosopt, MSD UK). This study investigates the impact of the supply problems of these medications at Moorfields Eye Hospital from a patient, administrative and clinical perspective. Information was sought by interviewing both patients and hospital staff, and by a retrospective case note review between April 2010 and May 2013. Many hospital roles, both administrative and clinical, were involved in attempting to resolve the impact of the supply problems. All staff reported a considerable increase in their workload. At the peak of the problem, the glaucoma secretaries received about 150 enquiries per week. A review of 83 sets of patient notes, retrieved from a random sample of 125 patients, showed that 22% encountered a supply problem. Of these, more than one-third attended Moorfields Eye Hospital Accident & Emergency (A&E) for repeat supplies and 89% eventually had their medication changed. In telephone interviews with 39 of a random sample of 50 patients (a subset of the 83 notes retrieved), 59% of the interviewees reported a supply problem. Of these, one-third attended Moorfields Eye Hospital A&E for repeat supplies and half eventually required an alternative medication. Some patients reported going to considerable lengths to obtain ongoing supplies in the community. This study shows that medication supply problems can have a major impact on patients and hospital services. Supply problems occur across many fields of medicine and with increasing frequency. The findings of this study highlight the importance of early communication of impending shortages between manufacturers and the Department of Health, as recommended in the best practice guidelines. In order to minimise the impact of medicine shortages on patients, clinicians and administrative staff, hospitals need immediate notification of potential supply problems and clear updates on supply resolution. In addition, hospitals should consider nominating an individual as a contact point for patient enquiries regarding medicine supply problems. © 2014 The Authors Ophthalmic & Physiological Optics © 2014 The College of Optometrists.

The long-term outcome of restorative operation in Crohn's disease: influence of location, prognostic factors and surgical guidelines.

PubMed Central

Trnka, Y M; Glotzer, D J; Kasdon, E J; Goldman, H; Steer, M L; Goldman, L D

1982-01-01

The course of all 113 patients with Crohn's disease whose initial procedure involved an anastomosis operated upon from 1942 to 1972 was followed through 1980. The calculated cumulative 30-year total mortality was 23.4%, 16.7% disease-related. The cumulative recurrence rate was 29% at five years, 52% at ten years, 64% at 15 years and 84% at 25 years, with no important differences between disease locations and types of operation. Sex, age, duration, granulomas, enteral or perirectal fistulas and length of the resection, the disease, and the proximal resection margin had no significant influence on the rates of development of recurrent disease or on functional outcome. By far the most common site of recurrence was the neo-terminal ileum, but in ileocolitis compared with ileitis, recurrence was 5.2 times more likely (p = 0.0001) to involve the adjacent or remote colon as well. Moreover, only 1/63 ileitis patients eventually required ileostomy, whereas 15/47 patients with ileocolitis or colitis ultimately required this procedure (p less than 0.001). The current status of the patients was excellent or good in 64% and unwell or dead related in 24%. Urolithiasis developed in 19%. PMID:7114939

Major lower extremity lawn mower injuries in children.

PubMed

Dormans, J P; Azzoni, M; Davidson, R S; Drummond, D S

1995-01-01

Between 1983 and 1993, 16 children with 18 lower extremity power lawn mower-related injuries were treated at Children's Hospital of Philadelphia. Eleven of 16 patients (69%) were bystanders or nonoperators. The average age at injury was 4 years 9 months. Length of follow-up averaged 3 years 10 months. There was an average of 4.9 procedures per patient. Fourteen of the 18 limbs injured required eventual amputation (78%). We propose a new classification of lawn mower injuries in children. The most common injury (16 of 18 limbs) was a shredding type injury and was either intercalary or distal. The second was a paucilaceration type (two of 18 limbs). Of the four salvaged limbs, there were two shredding type injuries, and on most recent follow-up are considered to have poor results. The two patients with the paucilaceration type injuries and limb salvage are considered to have excellent results. All patients with a shredding type injury ultimately required amputation or had poor results with the salvaged limb. Limb salvage surgery was associated with prolonged hospitalizations, a higher incidence of surgical problems, a longer treatment course, and more complications than early ablative procedures.

Recurrent implantation failure in IVF: features of cycles that eventually ended in conception.

PubMed

Bord, Ilia; Tamir, Belle; Harlev, Avraham; Har-Vardi, Iris; Lunenfeld, Eitan; Friger, Michael; Levitas, Eliahu

2016-04-01

To evaluate the characteristics of patients and IVF cycles with recurrent implantation failure who eventually succeeded to conceive compared to those who failed to do so. In a retrospective study, we explored our database for patients younger than 35 years old who underwent at least three unsuccessful fresh IVF cycles. The following parameters were analyzed: cause of infertility, FSH level, stimulation cycle characteristics, fertilization rate, the type of luteal support, and cycle outcome. Uterine cavity assessment was also included. The relationship between endometrial scratching and the outcome of the following IVF cycle was assessed for the subsequent pregnancy rate. The study included 184 patients who underwent 854 IVF cycles. There were no statistically significant differences between patients who eventually conceived and those who did not in terms of ovarian reserve and response to gonadotropin treatment. IVF cycles that eventually ended with conception were characterized by shorter stimulation (10.87 ± 2.17 versus 11.34 ± 2.33 days, p < 0.05), higher estrogen level on the day of hCG administration (1661 ± 667 versus 1472 ± 633 pg/ml, p = 0.009), more fertilized oocytes via ICSI (5.04 ± 4.29 versus 3.85 ± 3.45, p = 0.002), and more embryos available for transfer (5.98 ± 3.89 versus 5.12 ± 3.31, p = 0.002). Combined estrogen and progesterone luteal support combined with endometrial scratching prior to the subsequent IVF cycle has been positively related to increased pregnancy rates. Young patients with RIF having a normal ovarian reserve and satisfactory ovarian response to superovulation should be encouraged to pursue IVF, even though the probability to conceive is relatively low compared to the general IVF population.

Robot-assisted intracorporeal ileal conduit: Marionette technique and initial experience at Roswell Park Cancer Institute.

PubMed

Guru, Khurshid; Seixas-Mikelus, Stéfanie A; Hussain, Abid; Blumenfeld, Aaron J; Nyquist, John; Chandrasekhar, Rameela; Wilding, Gregory E

2010-10-01

To present our technique and initial experience with patients who underwent robot-assisted intracorporeal creation of ileal conduit and to compare them with patients who underwent extracorporeal ileal diversion after robot-assisted radical cystectomy. Twenty-six patients diagnosed with invasive transitional cell carcinoma of the bladder underwent a robot-assisted radical cystectomy with bilateral extended pelvic lymphadenectomy with ileal conduit diversion. Total intracorporeal ileal conduit creation was performed in the last 13 patients. Operative data and short-term outcomes between the 2 groups were assessed. The novel surgical technique for intracorporeal ileal conduit will be presented. The intracorporeal group (IC) included 2 female and 11 male patients (mean age 71 years). The extracorporeal group (EC) included 4 female and 9 male patients (mean age 66 years). No significant differences were noted between the groups in terms of patient age, BMI, sex, prior surgery, or pathologic stage. Overall operative time and intraoperative complications were similar. No significant differences were noted between the 2 groups in terms of diversion time or estimated blood loss. There were 4 complications recorded in IC patients, including nonspecific colitis, small bowel obstruction requiring exploratory laparotomy with lysis of adhesions, a urine leak that eventually resolved but required a temporary nephrostomy tube, and a fever of unknown origin that resolved without intervention. Robot-assisted intracorporeal ileal conduit can be accomplished safely with acceptable operative times even during early experience. Larger series with favorable results will be required to add this new paradigm to minimally invasive surgery for bladder cancer. Copyright © 2010 Elsevier Inc. All rights reserved.

CORTICOTROPIN (ACTH) AND CORTISONE—Newer Concepts of Their Use in Clinical Practice

PubMed Central

Kinsell, Laurance W.; Boling, Lenore; Partridge, John W.; Foreman, Nadine

1953-01-01

On the basis of three years' experience with corticotropin and cortisone, it seems probable that the place of these hormones in clinical medicine will be one of increasing importance. At present they may be used to attain certain specific objectives: 1. To return a large number of chronic invalids to a place of full activity in the community. This applies particularly to patients with rheumatoid arthritis and bronchial asthma. Many years of continuous therapy will be required in the majority of such patients. 2. As life-saving agents in patients with certain diseases of unknown etiologic delineation that almost always cause death. In some patients treated for some of those diseases, therapy may eventually be discontinued. 3. As life-saving agents (in conjunction with intensive antibiotic therapy) in patients with severe infections inadequately responsive to chemotherapy alone. Many of the untoward effects of hormonal therapy may be minimized or prevented by appropriate adjuvant measures. PMID:13059621

Evidence-based best practices for EGFR T790M testing in lung cancer in Canada.

PubMed

Stockley, T; Souza, C A; Cheema, P K; Melosky, B; Kamel-Reid, S; Tsao, M S; Spatz, A; Karsan, A

2018-04-01

Epidermal growth factor receptor (egfr) tyrosine kinase inhibitors (tkis) are recommended as first-line systemic therapy for patients with non-small-cell lung cancer (nsclc) having mutations in the EGFR gene. Resistance to tkis eventually occurs in all nsclc patients treated with such drugs. In patients with resistance to tkis caused by the EGFR T790M mutation, the third-generation tki osimertinib is now the standard of care. For optimal patient management, accurate EGFR T790M testing is required. A multidisciplinary working group of pathologists, laboratory medicine specialists, medical oncologists, a respirologist, and a thoracic radiologist from across Canada was convened to discuss best practices for EGFR T790M mutation testing in Canada. The group made recommendations in the areas of the testing algorithm and the pre-analytic, analytic, and post-analytic aspects of clinical testing for both tissue testing and liquid biopsy circulating tumour dna testing. The recommendations aim to improve EGFR T790M testing in Canada and to thereby improve patient care.

Pyoderma gangrenosum in a patient with chronic granulomatous disease

PubMed Central

Nanoudis, Sideris; Tsona, Afroditi; Tsachouridou, Olga; Morfesis, Petros; Loli, Georgia; Georgiou, Adamantini; Zebekakis, Pantelis; Metallidis, Symeon

2017-01-01

Abstract Rationale: The simultaneous occurrence of pyoderma gangrenosum (PG) and chronic granulomatous disease (CGD) is uncommon and few cases have been reported worldwide. Patient concerns: PG is a rare, chronic, ulcerative, neutrophilic skin disease of unknown etiology that requires immunosuppressive treatment. CGD belongs to Primary Immune Deficiencies in which the main defect lies in an inability of the phagocytic cells to generate superoxide making patients susceptible to serious, potentially life-threatening bacterial and fungal infections. Diagnoses: In this manuscript, we present a case of ulcerative pyoderma gangrenosum in a 28-year-old man with recent diagnosis of chronic granulomatous disease during hospitalization for resistant pulmonary tuberculosis complicated with Aspergillus infection. Interventions: Second-line therapy with dapsone and intravenous immunoglobulin was initially administered but eventually corticosteroids were added to treatment because of disease progression and further ulceration. Outcomes: Patient's ulcers were gradually healed with no side effects. Lessons: Corticosteroids could be used under close monitoring for the treatment of PG in a patient with CGD, despite the increased risk for infections. PMID:28767612

Blood, sweat and tears: androgenic-anabolic steroid misuse and recurrent primary post-tonsillectomy haemorrhage

PubMed Central

Fox, Richard; Varadharajan, Kiran; Patel, Bhavesh; Beegun, Issa

2014-01-01

A 30-year-old male body builder and androgenic-anabolic steroid and insulin abuser was admitted for day case elective tonsillectomy (bipolar). He returned with primary post-tonsillectomy haemorrhage 18 h after the operation and required bipolar cautery to the multiple small bleeding points in the right and left tonsillar fossa. Thorough coagulation screen was normal. Recurrent primary haemorrhage occurred 3 h post-operatively requiring immediate surgical intervention, removal of the inferior poles, precautionary throat packs, intubation and observation on the intensive treatment unit (ITU). Re-examination in theatre revealed a bleeding left superior pole that was under-run to achieve haemostasis and the patient returned to ITU. Hypertensive episodes were noted in the emergency department and intraoperatively including one recording >200 mm Hg. Haemostasis was eventually achieved once the blood pressure was adequately controlled. A slow wean of steroids was also instigated and the patient was managed on a surgical ward for 2 weeks post-tonsillectomy. PMID:25398921

Blood, sweat and tears: androgenic-anabolic steroid misuse and recurrent primary post-tonsillectomy haemorrhage.

PubMed

Fox, Richard; Varadharajan, Kiran; Patel, Bhavesh; Beegun, Issa

2014-11-14

A 30-year-old male body builder and androgenic-anabolic steroid and insulin abuser was admitted for day case elective tonsillectomy (bipolar). He returned with primary post-tonsillectomy haemorrhage 18 h after the operation and required bipolar cautery to the multiple small bleeding points in the right and left tonsillar fossa. Thorough coagulation screen was normal. Recurrent primary haemorrhage occurred 3 h post-operatively requiring immediate surgical intervention, removal of the inferior poles, precautionary throat packs, intubation and observation on the intensive treatment unit (ITU). Re-examination in theatre revealed a bleeding left superior pole that was under-run to achieve haemostasis and the patient returned to ITU. Hypertensive episodes were noted in the emergency department and intraoperatively including one recording >200 mm Hg. Haemostasis was eventually achieved once the blood pressure was adequately controlled. A slow wean of steroids was also instigated and the patient was managed on a surgical ward for 2 weeks post-tonsillectomy. 2014 BMJ Publishing Group Ltd.

Sonographic Characteristics and Interval Changes of Subacute Thyroiditis.

PubMed

Lee, Yoo Jin; Kim, Dong Wook

2016-08-01

This study aimed to assess the sonographic characteristics and interval changes of subacute thyroiditis using follow-up sonography. From January 2008 to December 2014, 85 patients with clinically suspected subacute thyroiditis underwent sonographic examinations by a single radiologist. Subacute thyroiditis was confirmed on the basis of the clinical, sonographic, and cytohistopathologic findings. On the initial and follow-up sonograms, the individual sonographic findings and interval changes were retrospectively investigated by the same radiologist. According to the sonographic configuration, subacute thyroiditis lesions were categorized as nodular or non-nodular. The interval changes in the lesions were classified as follows: "disappeared," "decreased," "increased," "eventually smaller," "eventually larger," or "no interval change." Subacute thyroiditis was confirmed in 64 of the 85 patients. In these 64 patients, nodular (n = 39) and non-nodular (n = 35) lesions were found; 10 patients had both nodular and non-nodular lesions. Of the 64 patients, 41 underwent sonographic follow-up. In both nodular and non-nodular lesions, the common interval changes included disappeared, decreased, and eventually smaller patterns. Although the increased pattern was found only in 4 nodular lesions, there was no significant difference in the interval changes between nodular and non-nodular lesions. On follow-up sonography, a new lesion was detected in 6 patients. The prevalence rate of nodular subacute thyroiditis lesions on sonography was high, and the interval changes in the lesions were variable.

Alectinib salvages CNS relapses in ALK-positive lung cancer patients previously treated with crizotinib and ceritinib.

PubMed

Gainor, Justin F; Sherman, Carol A; Willoughby, Kathryn; Logan, Jennifer; Kennedy, Elizabeth; Brastianos, Priscilla K; Chi, Andrew S; Shaw, Alice T

2015-02-01

Leptomeningeal metastases (LM) are an increasingly frequent and devastating complication of anaplastic lymphoma kinase (ALK)-rearranged non-small-cell lung cancer (NSCLC). Currently, the optimal management of LM in ALK-positive patients remains poorly understood as these patients have been routinely excluded from clinical trials. We describe four ALK-positive patients with LM who were treated with the next-generation ALK inhibitor alectinib through single-patient, compassionate use protocols at two institutions. All patients had previously been treated with both FDA-approved ALK inhibitors--crizotinib and ceritinib. Patients received alectinib at a starting dose of 600 mg twice daily. Four ALK-positive NSCLC patients with symptomatic leptomeningeal disease were identified. Three of four patients experienced significant clinical and radiographic improvements in LM upon treatment with alectinib. A fourth patient had stable intracranial disease for 4 months before eventual systemic disease progression. Overall, alectinib was well tolerated. One patient required dose reduction due to grade 2 hyperbilirubinemia. Alectinib is active in ALK-rearranged NSCLC patients with LM, including in patients previously treated with crizotinib and ceritinib. Additional prospective studies of alectinib in ALK-positive patients with LM are warranted.

Alectinib Salvages CNS Relapses in ALK-Positive Lung Cancer Patients Previously Treated with Crizotinib and Ceritinib

PubMed Central

Gainor, Justin F.; Sherman, Carol A.; Willoughby, Kathryn; Logan, Jennifer; Kennedy, Elizabeth; Brastianos, Priscilla K.; Chi, Andrew S.; Shaw, Alice T.

2014-01-01

Background Leptomeningeal metastases (LM) are an increasingly frequent and devastating complication of anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer (NSCLC). Currently, the optimal management of LM in ALK-positive patients remains poorly understood as these patients have been routinely excluded from clinical trials. Methods We describe four ALK-positive patients with LM who were treated with the next-generation ALK inhibitor alectinib through single-patient, compassionate use protocols at two institutions. All patients had previously been treated with both FDA-approved ALK inhibitors—crizotinib and ceritinib. Patients received alectinib at a starting dose of 600 mg twice daily. Results Four ALK-positive NSCLC patients with symptomatic leptomeningeal disease were identified. Three of four patients experienced significant clinical and radiographic improvements in LM upon treatment with alectinib. A fourth patient had stable intracranial disease for four months before eventual systemic disease progression. Overall, alectinib was well tolerated. One patient required dose reduction due to grade 2 hyperbilirubinemia. Conclusions Alectinib is active in ALK-rearranged NSCLC patients with LM, including in patients previously treated with crizotinib and ceritinib. Additional prospective studies of alectinib in ALK-positive patients with LM are warranted. PMID:25526238

Multidisciplinary approach to the management of a case of classical respiratory diphtheria requiring percutaneous endoscopic gastrostomy feeding.

PubMed

Haywood, Matthew James; Vijendren, Ananth; Acharya, Vikas; Mulla, Rohinton; Panesar, Miss Jaan

2017-03-06

We present a case of a Caucasian woman aged 67 years referred with a 4-day history of sore throat, dysphagia, fever and nasal blockage. Examination revealed a swollen neck and pharyngeal pseudomembrane. A throat swab was positive on culture for Corynebacterium ulcerans , with toxin expression confirmed on PCR and Elek testing. A diagnosis of classical respiratory diphtheria was made, with subsequent confirmation of the patient's domesticated dog as the source of infection. The dog had recently been attacked by a wild badger and was being treated for an ear infection. The patient made a good recovery with intravenous antimicrobial and supportive therapy; however, she subsequently developed a diphtheritic polyneuropathy in the form of a severe bulbar palsy with frank aspiration necessitating percutaneous endoscopic gastrostomy feeding. A mild sensorimotor peripheral neuropathy was also diagnosed. The patient eventually made an almost complete recovery. 2017 BMJ Publishing Group Ltd.

Clinical pancreatic islet transplantation.

PubMed

Shapiro, A M James; Pokrywczynska, Marta; Ricordi, Camillo

2017-05-01

Clinical pancreatic islet transplantation can be considered one of the safest and least invasive transplant procedures. Remarkable progress has occurred in both the technical aspects of islet cell processing and the outcomes of clinical islet transplantation. With >1,500 patients treated since 2000, this therapeutic strategy has moved from a curiosity to a realistic treatment option for selected patients with type 1 diabetes mellitus (that is, those with hypoglycaemia unawareness, severe hypoglycaemic episodes and glycaemic lability). This Review outlines the techniques required for human islet isolation, in vitro culture before the transplant and clinical islet transplantation, and discusses indications, optimization of recipient immunosuppression and management of adjunctive immunomodulatory and anti-inflammatory strategies. The potential risks, long-term outcomes and advances in treatment after the transplant are also discussed to further move this treatment towards becoming a more widely available option for patients with type 1 diabetes mellitus and eventually a potential cure.

Transient Hypothyroidism after Radioiodine for Graves' Disease: Challenges in Interpreting Thyroid Function Tests.

PubMed

Sheehan, Michael T; Doi, Suhail A R

2016-03-01

Graves' disease is the most common cause of hyperthyroidism and is often managed with radioactive iodine (RAI) therapy. With current dosing schemes, the vast majority of patients develop permanent post-RAI hypothyroidism and are placed on life-long levothyroxine therapy. This hypothyroidism typically occurs within the first 3 to 6 months after RAI therapy is administered. Indeed, patients are typically told to expect life-long thyroid hormone replacement therapy to be required within this timeframe and many providers expect this post-RAI hypothyroidism to be complete and permanent. There is, however, a small subset of patients in whom a transient post-RAI hypothyroidism develops which, initially, presents exactly as the typical permanent hypothyroidism. In some cases the transient hypothyroidism leads to a period of euthyroidism of variable duration eventually progressing to permanent hypothyroidism. In others, persistent hyperthyroidism requires a second dose of RAI. Failure to appreciate and recognize the possibility of transient post-RAI hypothyroidism can delay optimal and appropriate treatment of the patient. We herein describe five cases of transient post-RAI hypothyroidism which highlight this unusual sequence of events. Increased awareness of this possible outcome after RAI for Graves' disease will help in the timely management of patients. © 2016 Marshfield Clinic.

Reading tarot cards.

PubMed

Edmunds, L Henry

2004-02-01

In some patients acute myocardial infarction and/or infarct expansion induces progressive left ventricular dilatation that eventually leads to heart failure and death. The five year mortality after onset of heart failure is 50%. Chronically stretched viable myocardium adjacent to or remote from an expanding infarction initiates a myopathic process that leads to progressive myocyte apoptosis and adverse postinfarction remodeling. Revascularization of stunned or hibernating myocardium restores contractility and benefits patients in heart failure; however, revascularization does not restore contractility to myopathic, remodeling myocardium. Contemporary operations for heart failure temporarily reduce ventricular wall stress, but fail to reverse stretch induced myocyte apoptosis, which may not be reversible. Logically, prevention of this myopathic process after acute infarction seems required to extend survival. It follows that surgeons should operate before adverse postinfarction left ventricular remodeling occurs, using new operations, rather than afterwards.

US FDA perspective on regulatory issues affecting circulatory assist devices.

PubMed

Sapirstein, Wolf; Chen, Eric; Swain, Julie; Zuckerman, Bram

2006-11-01

There has been a rapid development in mechanical circulatory support systems in the decade since the US FDA first approved a mechanical device to provide the circulatory support lacking from a failing heart. Devices are presently approved for marketing by the FDA to replace a failing ventricle, the Ventricular Assist Device or the entire heart, Total Artificial Heart. Contemporaneous with, and permitted by, improvement in technology and design, devices have evolved from units located extracorporeally to paracorporeal systems and totally implanted devices. Clinical studies have demonstrated a parallel improvement in the homeostatic adequacy of the circulatory support provided. Thus, while the circulatory support was initially tolerated for short periods to permit recovery of cardiac function, this technology eventually provided effective circulatory support for increasing periods that permitted the FDA to approve devices for bridging patients in end-stage cardiac failure awaiting transplant and eventually a device for destination therapy where patients in end-stage heart failure are not cardiac transplant candidates. The approved devices have relied on displacement pumps that mimic the pulsatility of the physiological system. Accelerated development of more compact devices that rely on alternative pump mechanisms have challenged both the FDA and device manufacturers to assure that the regulatory requirements for safety and effectiveness are met for use of mechanical circulatory support systems in expanded target populations. An FDA regulatory perspective is reviewed of what can be a potentially critical healthcare issue.

Clinical Features of Early and Late Postoperative Hypothyroidism After Lobectomy.

PubMed

Park, Suyeon; Jeon, Min Ji; Song, Eyun; Oh, Hye-Seon; Kim, Mijin; Kwon, Hyemi; Kim, Tae Yong; Hong, Suck Joon; Shong, Young Kee; Kim, Won Bae; Sung, Tae-Yon; Kim, Won Gu

2017-04-01

Lobectomy is preferred in thyroid cancer to decrease surgical complications and avoid lifelong thyroid-hormone replacement. However, postoperative hypothyroidism, requiring thyroid-hormone replacement, may occur. We aimed to identify the incidence and risk factors of postoperative hypothyroidism to develop a surveillance strategy after lobectomy for papillary thyroid microcarcinoma (PTMC). This historical cohort study involved 335 patients with PTMC treated by lobectomy. Postoperative thyroid functions were measured regularly, and patients were prescribed levothyroxine according to specific criteria. Patients not satisfying hormone-replacement criteria were closely followed up. Postoperative hypothyroidism occurred in 215 patients (64.2%) including 5 (1.5%) with overt hypothyroidism and 210 (62.7%) with subclinical hypothyroidism. Forty patients (11.9%) were required thyroid hormone replacement. One hundred nineteen patients (33.5%) experienced temporary hypothyroidism and spontaneously recovered to euthyroid state. High preoperative thyroid-stimulating hormone (TSH) was the most important factor predicting postoperative hypothyroidism and failure of recover from hypothyroidism (odds ratio [OR], 2.82 and 1.77; 95% confidence interval [CI], 2.07 to 3.95 and 1.22 to 2.63; P < 0.001 and 0.002, respectively). Of the 215 patients eventually developing postoperative hypothyroidism, 70 (32.6%) developed hypothyroidism after the first postoperative year. Postoperative 1-year TSH levels were able to differentiate patients developing late hypothyroidism or euthyroidism (OR, 2.29; 95% CI, 1.68 to 3.26; P < 0.001). Preoperative and postoperative TSH levels might be predictive for patients who develop postlobectomy hypothyroidism and identify those requiring long-term surveillance for hypothyroidism. Additionally, mild postoperative hypothyroidism cases should be followed up without immediate levothyroxine replacement with the expectation of spontaneous recovery. Copyright © 2017 by the Endocrine Society

Long-term Follow-up of Patients After Antegrade Continence Enema Procedure

PubMed Central

Siddiqui, Anees A.; Fishman, Steven J.; Bauer, Stuart B.; Nurko, Samuel

2013-01-01

Background Antegrade continence enema (ACE) has become an important therapeutic modality in the treatment of intractable constipation and fecal incontinence. There are little data available on the long-term performance of the ACE procedure in children. Methods A retrospective review of patients who underwent the ACE procedure was conducted. Irrigation characteristics and complications were noted. Outcome was assessed for individual encounters based on frequency of bowel movements, incontinence, pain, and predictability. Results One hundred seventeen patients underwent an ACE. One hundred five patients had at least 6 months of follow-up, and were included in the analysis. Diagnoses included myelodysplasia (39%), functional intractable constipation (26%), anorectal malformations (21%), nonrelaxing internal anal sphincter (7%), cerebral palsy (3%), and other diagnoses (4%). The average follow-up was 68 months (range 7–178 months). At the last follow-up, 69% of patients had successful bowel management. Of the 31% of patients who did not have successful bowel management, 20% were using the ACE despite suboptimal results, 10% required surgical removal, and 2% were not using the ACE because of behavioral opposition to it. Patients were started on normal saline, but were switched to GoLYTELY (PEG-3350 and electrolyte solution) if there was an inadequate response (61% at final encounter). Additives were needed in 34% of patients. The average irrigation dose was 23 ± 0.7mL/kg. The average toilet sitting time was 51.7 ± 3.5minutes, with infusions running for 12.1 ± 1.2minutes. Stomal complications occurred in 63% (infection, leakage, and stenosis) of patients, 33% required surgical revision and 6% eventually required diverting ostomies. Conclusions Long-term use of the ACE gives successful results in 69% of patients, whereas 63% had a stoma-related complication and 33% required surgical revision of the stoma. PMID:21502828

Temporomandibular joint involvement as a positive clinical prognostic factor in necrotising external otitis.

PubMed

Yeheskeli, E; Eta, R Abu; Gavriel, H; Kleid, S; Eviatar, E

2016-05-01

Necrotising otitis externa is associated with high morbidity and mortality rates. This study investigated whether temporomandibular joint involvement had any prognostic effect on the course of necrotising otitis externa in patients who had undergone hyperbaric oxygen therapy after failed medical and sometimes surgical therapy. A retrospective case series was conducted of patients in whom antibiotic treatment and surgery had failed, who had been hospitalised for further treatment and hyperbaric oxygen therapy. Twenty-three patients with necrotising otitis externa were identified. The temporomandibular joint was involved in four patients (17 per cent); these patients showed a constant gradual improvement in C-reactive protein and were eventually discharged free of disease, except one patient who was lost to follow up. Four patients (16 per cent) without temporomandibular joint involvement died within 90 days of discharge, while all patients with temporomandibular joint involvement were alive. Three patients (13 per cent) without temporomandibular joint involvement needed recurrent hospitalisation including further hyperbaric oxygen therapy; no patients with temporomandibular joint involvement required such treatment. Patients with temporomandibular joint involvement had lower rates of recurrent disease and no mortality. Therefore, we suggest considering temporomandibular joint involvement as a positive prognostic factor in necrotising otitis externa management.

Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis.

PubMed

Juhl, Alexander Andersen; Hody, Sofie; Videbaek, Tina Senholt; Damsgaard, Tine Engberg; Nielsen, Per Hostrup

2017-04-20

The present study aimed to compare the clinical outcome for patients with or without muscle flap reconstruction after deep sternal wound infection due to open-heart surgery. The study was a retrospective cohort study, including patients who developed deep sternal wound infection after open-heart surgery in the Western Denmark Region from 1999 to 2011. Journals of included patients were reviewed for clinical data regarding the treatment of their sternal defect. Patients were divided into two groups depending on whether they received a muscle-flap-based sternal reconstruction or traditional rewiring of the sternum. A total of 130 patients developed deep sternal wound infection in the study period. In all, 12 patients died before being discharged, leaving a total of 118 patients for analysis. Of these, 50 (42%) patients received muscle flap reconstruction. Muscle flap recipients had significantly longer total hospital stays (p <0.001). However, after receiving muscle flap reconstruction, patients were discharged after a median of 14 days, with 74% not needing additional surgery. It is difficult to predict which patients eventually require muscle flap reconstruction after deep sternal wound infection. Although patients receiving muscle flap reconstructions have longer hospital stays, they are quickly discharged after the reconstruction.

Managing Alzheimer dementia tomorrow.

PubMed

Rosenthal, Thomas C; Khotianov, Natan

2003-01-01

Acetylcholinesterase inhibitors are the first drugs to alter the devastating effects of Alzheimer disease. The next generation of drugs will prevent the beta-amyloid plaques and neurofibrillary tangles or block enzymes that lead to neuron destruction. Effective use of these medications will require early identification of patients at risk. Using the PubMed service of the National Library of Medicine, all English language articles published in 2000, 2001 and the first half of 2002 with a key word of 'dementia' were reviewed for articles that described the emerging pathophysiologic model for Alzheimer disease. Standardized clinical screening tools, such as the mini-mental status examination and the clock test, administered longitudinally and correlated with family observations, can identify many at-risk patients. Genetic testing can identify a known mutation in 70% of patients who have a high family incidence of Alzheimer disease but awaits effective prevention before being useful. The molecular mechanisms of Alzheimer disease will eventually lead to prevention. Today, these patients benefit from nutritional support and lifestyle enhancement encouraged through a continuous primary care relationship.

Thyroid nodules and differentiated thyroid cancer: update on the Brazilian consensus.

PubMed

Rosário, Pedro Weslley; Ward, Laura S; Carvalho, Gisah A; Graf, Hans; Maciel, Rui M B; Maciel, Léa Maria Z; Maia, Ana Luiza; Vaisman, Mário

2013-06-01

Thyroid nodules are frequent findings, especially when sensitive imaging methods are used. Although thyroid cancer is relatively rare, its incidence is increasing, particularly in terms of small tumors, which have an uncertain clinical relevance. Most patients with differentiated thyroid cancer exhibit satisfactory clinical outcomes when treatment is appropriate, and their mortality rate is similar to that of the overall population. However, relapse occurs in a considerable fraction of these patients, and some patients stop responding to conventional treatment and eventually die from their disease. Therefore, the challenge is how to identify the individuals who require more aggressive disease management while sparing the majority of patients from unnecessary treatments and procedures. We have updated the Brazilian Consensus that was published in 2007, emphasizing the diagnostic and therapeutic advances that the participants, representing several Brazilian university centers, consider most relevant in clinical practice. The formulation of the present guidelines was based on the participants' experience and a review of the relevant literature.

Diagnosis and treatment of cardiac iron overload in transfusion-dependent thalassemia patients.

PubMed

Siri-Angkul, Natthaphat; Chattipakorn, Siriporn C; Chattipakorn, Nipon

2018-05-18

Thalassemia is among the most common genetic diseases. Patients with severe forms of the disease are transfusion-dependent, leading to iron overload. A condition which can eventually develop in the iron-loaded heart is iron overload cardiomyopathy, a debilitating disease that accounts for the majority of deaths in thalassemia patients. Areas covered: This review article provides a comprehensive summary of the diagnosis and treatment of cardiac iron overload in transfusion-dependent thalassemia patients, with discussion covering current weak points and potential improvements of the relevant diagnostic and therapeutic strategies. Expert commentary: Current limitations of various diagnostic techniques for iron overload cardiomyopathy include suboptimal accuracy, untimely detection, or inadequate accessibility, and novel modalities are required to overcome these shortcomings. Treatment should address key pathophysiologic mechanisms of iron overload cardiomyopathy, which include cardiac iron mishandling and iron-induced oxidative injury. Apart from the promotion of iron removal by chelators, prevention of cardiac iron deposition and attenuation of oxidative damage should also be rigorously investigated on a cell-to-bedside basis.

Pyoderma gangrenosum in a patient with chronic granulomatous disease: A case report.

PubMed

Nanoudis, Sideris; Tsona, Afroditi; Tsachouridou, Olga; Morfesis, Petros; Loli, Georgia; Georgiou, Adamantini; Zebekakis, Pantelis; Metallidis, Symeon

2017-08-01

The simultaneous occurrence of pyoderma gangrenosum (PG) and chronic granulomatous disease (CGD) is uncommon and few cases have been reported worldwide. PG is a rare, chronic, ulcerative, neutrophilic skin disease of unknown etiology that requires immunosuppressive treatment. CGD belongs to Primary Immune Deficiencies in which the main defect lies in an inability of the phagocytic cells to generate superoxide making patients susceptible to serious, potentially life-threatening bacterial and fungal infections. In this manuscript, we present a case of ulcerative pyoderma gangrenosum in a 28-year-old man with recent diagnosis of chronic granulomatous disease during hospitalization for resistant pulmonary tuberculosis complicated with Aspergillus infection. Second-line therapy with dapsone and intravenous immunoglobulin was initially administered but eventually corticosteroids were added to treatment because of disease progression and further ulceration. Patient's ulcers were gradually healed with no side effects. Corticosteroids could be used under close monitoring for the treatment of PG in a patient with CGD, despite the increased risk for infections.

The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients

PubMed Central

2010-01-01

Objective To assess the incidence of total hip arthroplasty (THA) in osteoarthritic patients who were treated by arthroscopic debridement and to evaluate factors that might influence the time interval from the first hip arthroscopy to THA. Design Retrospective clinical series Methods Follow-up data and surgical reports were retrieved from 564 records of osteoarthritic patients that have had hip arthroscopy between the years 2002 to 2009 with a mean follow-up time of 3.2 years (range, 1-6.4 years). The time interval between the first hip arthroscopy to THA was modelled as a function of patient age; level of cartilage damage; procedures performed and repeated arthroscopies with the use of multivariate regression analysis. Results Ninety (16%) of all participants eventually required THA. The awaiting time from the first arthroscopy to a hip replacement was found to be longer in patients younger than 55 years and in a milder osteoarthritic stage. Patients that experienced repeated hip scopes had a longer time to THA than those with only a single procedure. Procedures performed concomitant with debridement and lavage did not affect the time interval to THA. Conclusions In our series of arthroscopic treatment of hip osteoarthritis, 16% required THA over a period of 7 years. Factors that influence the time to arthroplasty were age, degree of osteoarthritis and recurrent procedures. PMID:20670440

Postprostatectomy Erectile Dysfunction: A Review

PubMed Central

Salonia, Andrea; Briganti, Alberto; Montorsi, Francesco

2016-01-01

In the current era of the early diagnosis of prostate cancer (PCa) and the development of minimally invasive surgical techniques, erectile dysfunction (ED) represents an important issue, with up to 68% of patients who undergo radical prostatectomy (RP) complaining of postoperative erectile function (EF) impairment. In this context, it is crucial to comprehensively consider all factors possibly associated with the prevention of post-RP ED throughout the entire clinical management of PCa patients. A careful assessment of both oncological and functional baseline characteristics should be carried out for each patient preoperatively. Baseline EF, together with age and the overall burden of comorbidities, has been strongly associated with the chance of post-RP EF recovery. With this goal in mind, internationally validated psychometric instruments are preferable for ensuring proper baseline EF evaluations, and questionnaires should be administered at the proper time before surgery. Careful preoperative counselling is also required, both to respect the patient's wishes and to avoid false expectations regarding eventual recovery of baseline EF. The advent of robotic surgery has led to improvements in the knowledge of prostate surgical anatomy, as reflected by the formal redefinition of nerve-sparing techniques. Overall, comparative studies have shown significantly better EF outcomes for robotic RP than for open techniques, although data from prospective trials have not always been consistent. Preclinical data and several prospective randomized trials have demonstrated the value of treating patients with oral phosphodiesterase 5 inhibitors (PDE5is) after surgery, with the concomitant potential benefit of early re-oxygenation of the erectile tissue, which appears to be crucial for avoiding the eventual penile structural changes that are associated with postoperative neuropraxia and ultimately result in severe ED. For patients who do not properly respond to PDE5is, proper counselling regarding intracavernous treatment should be considered, along with the further possibility of surgical treatment for ED involving the implantation of a penile prosthesis. PMID:27574591

Transition of pediatric to adult care in inflammatory bowel disease: Is it as easy as 1, 2, 3?

PubMed

Afzali, Anita; Wahbeh, Ghassan

2017-05-28

Inflammatory bowel disease (IBD) is a heterogeneous group of chronic diseases with a rising prevalence in the pediatric population, and up to 25% of IBD patients are diagnosed before 18 years of age. Adolescents with IBD tend to have more severe and extensive disease and eventually require graduation from pediatric care toadult services. The transition of patients from pediatric to adult gastroenterologists requires careful preparation and coordination, with involvement of all key players to ensure proper collaboration of care and avoid interruption in care. This can be challenging and associated with gaps in delivery of care. The pediatric and adult health paradigms have inherent differences between health care models, as well as health care priorities in IBD. The readiness of the young adult also influences this transition of care, with often times other overlaps in life events, such as school, financial independence and moving away from home. These patients are therefore at higher risk for poorer clinical disease outcomes. The aim of this paper is to review concepts pertinent to transition of care of young adults with IBD to adult care, and provides resources appropriate for an IBD pediatric to adult transition of care model.

Implementation of an Analytical Model for Leakage Neutron Equivalent Dose in a Proton Radiotherapy Planning System

PubMed Central

Eley, John; Newhauser, Wayne; Homann, Kenneth; Howell, Rebecca; Schneider, Christopher; Durante, Marco; Bert, Christoph

2015-01-01

Equivalent dose from neutrons produced during proton radiotherapy increases the predicted risk of radiogenic late effects. However, out-of-field neutron dose is not taken into account by commercial proton radiotherapy treatment planning systems. The purpose of this study was to demonstrate the feasibility of implementing an analytical model to calculate leakage neutron equivalent dose in a treatment planning system. Passive scattering proton treatment plans were created for a water phantom and for a patient. For both the phantom and patient, the neutron equivalent doses were small but non-negligible and extended far beyond the therapeutic field. The time required for neutron equivalent dose calculation was 1.6 times longer than that required for proton dose calculation, with a total calculation time of less than 1 h on one processor for both treatment plans. Our results demonstrate that it is feasible to predict neutron equivalent dose distributions using an analytical dose algorithm for individual patients with irregular surfaces and internal tissue heterogeneities. Eventually, personalized estimates of neutron equivalent dose to organs far from the treatment field may guide clinicians to create treatment plans that reduce the risk of late effects. PMID:25768061

Implementation of an analytical model for leakage neutron equivalent dose in a proton radiotherapy planning system.

PubMed

Eley, John; Newhauser, Wayne; Homann, Kenneth; Howell, Rebecca; Schneider, Christopher; Durante, Marco; Bert, Christoph

2015-03-11

Equivalent dose from neutrons produced during proton radiotherapy increases the predicted risk of radiogenic late effects. However, out-of-field neutron dose is not taken into account by commercial proton radiotherapy treatment planning systems. The purpose of this study was to demonstrate the feasibility of implementing an analytical model to calculate leakage neutron equivalent dose in a treatment planning system. Passive scattering proton treatment plans were created for a water phantom and for a patient. For both the phantom and patient, the neutron equivalent doses were small but non-negligible and extended far beyond the therapeutic field. The time required for neutron equivalent dose calculation was 1.6 times longer than that required for proton dose calculation, with a total calculation time of less than 1 h on one processor for both treatment plans. Our results demonstrate that it is feasible to predict neutron equivalent dose distributions using an analytical dose algorithm for individual patients with irregular surfaces and internal tissue heterogeneities. Eventually, personalized estimates of neutron equivalent dose to organs far from the treatment field may guide clinicians to create treatment plans that reduce the risk of late effects.

Development of an algorithm to plan and simulate a new interventional procedure.

PubMed

Fujita, Buntaro; Kütting, Maximilian; Scholtz, Smita; Utzenrath, Marc; Hakim-Meibodi, Kavous; Paluszkiewicz, Lech; Schmitz, Christoph; Börgermann, Jochen; Gummert, Jan; Steinseifer, Ulrich; Ensminger, Stephan

2015-07-01

The number of implanted biological valves for treatment of valvular heart disease is growing and a percentage of these patients will eventually undergo a transcatheter valve-in-valve (ViV) procedure. Some of these patients will represent challenging cases. The aim of this study was to develop a feasible algorithm to plan and in vitro simulate a new interventional procedure to improve patient outcome. In addition to standard diagnostic routine, our algorithm includes 3D printing of the annulus, hydrodynamic measurements and high-speed analysis of leaflet kinematics after simulation of the procedure in different prosthesis positions as well as X-ray imaging of the most suitable valve position to create a 'blueprint' for the patient procedure. This algorithm was developed for a patient with a degenerated Perceval aortic sutureless prosthesis requiring a ViV procedure. Different ViV procedures were assessed in the algorithm and based on these results the best option for the patient was chosen. The actual procedure went exactly as planned with help of this algorithm. Here we have developed a new technically feasible algorithm simulating important aspects of a novel interventional procedure prior to the actual procedure. This algorithm can be applied to virtually all patients requiring a novel interventional procedure to help identify risks and find optimal parameters for prosthesis selection and placement in order to maximize safety for the patient. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Mouthpiece ventilation in Duchenne muscular dystrophy: a rescue strategy for noncompliant patients

PubMed Central

Fiorentino, Giuseppe; Annunziata, Anna; Cauteruccio, Rosa; Frega, Gianfranco Scotto di; Esquinas, Antonio

2016-01-01

ABSTRACT Objective: To evaluate mouthpiece ventilation (MPV) in patients with Duchenne muscular dystrophy (DMD) who are noncompliant with noninvasive ventilation (NIV). Methods: We evaluated four young patients with DMD who had previously refused to undergo NIV. Each patient was reassessed and encouraged to try MPV. Results: The four patients tolerated MPV well and were compliant with NIV at home. MPV proved to be preferable and more comfortable than NIV with any other type of interface. Two of the patients required overnight NIV and eventually agreed to use a nasal mask during the night. Conclusions: The advantages of MPV over other types of NIV include fewer speech problems, better appearance, and less impact on the patient, eliminating the risk of skin breakdown, gastric distension, conjunctivitis, and claustrophobia. The use of a mouthpiece interface should be always considered in patients with DMD who need to start NIV, in order to promote a positive approach and a rapid acceptance of NIV. Using MPV during the daytime makes patients feel safe and more likely to use NIV at night. In addition, MPV increases treatment compliance for those who refuse to use other types of interfaces. PMID:28117478

Outcome of metronidazole therapy for Clostridium difficile disease and correlation with a scoring system.

PubMed

Belmares, Jaime; Gerding, Dale N; Parada, Jorge P; Miskevics, Scott; Weaver, Frances; Johnson, Stuart

2007-12-01

To determine the response rate of Clostridium difficile disease (CDD) to treatment with metronidazole and assess a scoring system to predict response to treatment with metronidazole when applied at the time of CDD diagnosis. Retrospective review of patients with CDD who received primary treatment with metronidazole. We defined success as diarrhea resolution within 6 days of therapy. A CDD score was defined prospectively using variables suggested to correlate with disease severity. Among 102 evaluable patients, 72 had a successful response (70.6%). Twenty-one of the remaining 30 patients eventually responded to metronidazole, but required longer treatment, leaving 9 'true failures'. The mean CDD score was higher among true failures (2.89+/-1.4) than among all metronidazole responders (0.77+/-1.0) (p<.0001). The score was greater than 2 in 67% of true failures and 2 or less in 94% of metronidazole responders. Leukocytosis and abnormal CT scan findings were individual factors associated with a higher risk of metronidazole failure. Only 71% of CDD patients responded to metronidazole within 6 days, but the overall response rate was 91%. A CDD score greater than 2 was associated with metronidazole failure in 6 of 9 true failures. The CDD score will require prospective validation.

Clinical requirements for closed-loop control systems.

PubMed

Clarke, William L; Renard, Eric

2012-03-01

Closed-loop (CL) therapy systems should be safe, efficacious, and easily manageable for type 1 diabetes mellitus patient use. For the first two clinical requirements, noninferiority and superiority criteria must be determined based on current conventional and intensive therapy outcomes. Current frequencies of hypoglycemia and diabetic ketoacidosis are reviewed and safety expectations for CL therapy systems are proposed. Glycosylated hemoglobin levels lower than current American Diabetes Association recommendations for different age groups are proposed as superiority criteria. Measures of glycemic variability are described and the recording of blood glucose levels as percentages within, above, and below a target range are suggested as reasonable alternatives to sophisticated statistical analyses. It is also suggested that Diabetes Quality of Life and Fear of Hypoglycemia surveys should be used to track psychobehavioral outcomes. Manageability requirements for safe and effective clinical management of CL systems are worth being underscored. The weakest part of the infusion system remains the catheter, which is exposed to variable and under-delivery incidents. Detection methods are needed to warn both the system and the patient about altered insulin delivery, including internal pressure and flow alarms. Glucose monitor sensor accuracy is another requirement; it includes the definition of conditions that lead to capillary glucose measurement, eventually followed by sensor recalibration or replacement. The crucial clinical requirement will be a thorough definition of the situations when the patient needs to move from CL to manual management of insulin delivery, or inversely can switch back to CL after a requested interruption. Instructions about these actions will constitute a major part of the education process of the patients before using CL systems and contribute to the manageability of these systems. © 2012 Diabetes Technology Society.

Nephrocalcinosis (Enamel Renal Syndrome) Caused by Autosomal Recessive FAM20A Mutations

PubMed Central

Jaureguiberry, Graciana; De la Dure-Molla, Muriel; Parry, David; Quentric, Mickael; Himmerkus, Nina; Koike, Toshiyasu; Poulter, James; Klootwijk, Enriko; Robinette, Steven L.; Howie, Alexander J.; Patel, Vaksha; Figueres, Marie-Lucile; Stanescu, Horia C.; Issler, Naomi; Nicholson, Jeremy K.; Bockenhauer, Detlef; Laing, Christopher; Walsh, Stephen B.; McCredie, David A.; Povey, Sue; Asselin, Audrey; Picard, Arnaud; Coulomb, Aurore; Medlar, Alan J.; Bailleul-Forestier, Isabelle; Verloes, Alain; Le Caignec, Cedric; Roussey, Gwenaelle; Guiol, Julien; Isidor, Bertrand; Logan, Clare; Shore, Roger; Johnson, Colin; Inglehearn, Christopher; Al-Bahlani, Suhaila; Schmittbuhl, Matthieu; Clauss, François; Huckert, Mathilde; Laugel, Virginie; Ginglinger, Emmanuelle; Pajarola, Sandra; Spartà, Giuseppina; Bartholdi, Deborah; Rauch, Anita; Addor, Marie-Claude; Yamaguti, Paulo M.; Safatle, Heloisa P.; Acevedo, Ana Carolina; Martelli-Júnior, Hercílio; dos Santos Netos, Pedro E.; Coletta, Ricardo D.; Gruessel, Sandra; Sandmann, Carolin; Ruehmann, Denise; Langman, Craig B.; Scheinman, Steven J.; Ozdemir-Ozenen, Didem; Hart, Thomas C.; Hart, P. Suzanne; Neugebauer, Ute; Schlatter, Eberhard; Houillier, Pascal; Gahl, William A.; Vikkula, Miikka; Bloch-Zupan, Agnès; Bleich, Markus; Kitagawa, Hiroshi; Unwin, Robert J.; Mighell, Alan; Berdal, Ariane; Kleta, Robert

2013-01-01

Background/Aims Calcium homeostasis requires regulated cellular and interstitial systems interacting to modulate the activity and movement of this ion. Disruption of these systems in the kidney results in nephrocalcinosis and nephrolithiasis, important medical problems whose pathogenesis is incompletely understood. Methods We investigated 25 patients from 16 families with unexplained nephrocalcinosis and characteristic dental defects (amelogenesis imperfecta, gingival hyperplasia, impaired tooth eruption). To identify the causative gene, we performed genome-wide linkage analysis, exome capture, next-generation sequencing, and Sanger sequencing. Results All patients had bi-allelic FAM20A mutations segregating with the disease; 20 different mutations were identified. Conclusions This au-tosomal recessive disorder, also known as enamel renal syndrome, of FAM20A causes nephrocalcinosis and amelogenesis imperfecta. We speculate that all individuals with biallelic FAM20A mutations will eventually show nephrocalcinosis. PMID:23434854

Refractory gastro-oesophageal reflux disease: diagnosis and management.

PubMed

Liu, Julia J; Saltzman, John R

2009-10-01

Refractory gastro-oesophageal reflux disease (GORD) is described when reflux symptoms have not responded to 4-8 weeks of proton pump inhibitor therapy and occurs in a heterogeneous mixture of patients. The causes of refractory GORD include inadequate acid suppression, non-acid gastro-oesophageal reflux, and non-reflux causes of GORD symptoms including achalasia, gastroparesis and functional heartburn. Upper gastrointestinal tract endoscopy should initially be performed to identify the presence of oesophagitis, and exclude other diagnoses including eosinophilic oesophagitis and peptic ulcer disease. Patients with refractory symptoms but with a normal upper endoscopy are more difficult to diagnose and may require ambulatory pH monitoring, impedance testing, oesophageal motility tests and gastric emptying scans. The primary goal of treatment is symptom reduction and eventual elimination, which can be achieved with proper identification of the underlying cause of the symptoms.

Local morbidity from red-bellied black snake (Pseudechis porphyriacus, Elapidae) envenoming: Two cases and a brief review of management.

PubMed

Weinstein, Scott A; Mirtschin, Peter J; Tristram, Hamish; Lawton, Luke; White, Julian

2018-02-01

The red-bellied black snake (Pseudechis porphyriacus, Elapidae) is one of several species of venomous snakes most commonly implicated in human and domestic animal envenoming in Australia. Human systemic envenoming can present with myotoxicity that may include myoglobinuria; hemoglobinuria and intravascular hemolysis; thrombocytopenia, anticoagulant coagulopathy, and, rarely, mild cranial nerve palsies. Pseudechis porphyriacus envenoming can also feature significant local morbidity such as ecchymoses, bleeding, pain and necrosis. Some envenomed patients may develop progressive thickness necrosis independent of secondary infection, and occasionally require surgical debridement. Uncommonly, some digital envenoming may cause more severe deeper tissue pathology that justifies dermotomy and/or distal phalangeal amputation. Presented are two patients with significant local morbidity from P. porphyriacus envenoming. An 18-month old girl received a protracted envenoming on her right foot, while a 38-year old male professional zoologist was envenomed on the third digit of his right hand. Each patient experienced myotoxicity, one had anticoagulant coagulopathy, and both developed clinically significant local morbidity including persistent bleeding, ecchymoses, local necrosis and pain; each required extensive treatment and variably prolonged admission. Noted also were transiently elevated D-dimer with low-normal or normal fibrinogen levels. The progressive necrosis and subsequent chronic pathologic changes with ischemia of the latter patient's digit eventually required a dermotomy and amputation of the distal phalanx. The pediatric patient did not require extensive wound debridement, but experienced prolonged difficulty in ambulation because of slowly resolving wound discomfort. Factors that may contribute to the severity of local morbidity of P. porphyriacus envenoming are considered, and management of envenoming by this taxon is briefly reviewed. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Profile of hospitalisation and death in the first year after diagnosis of end-stage renal disease in a multi-ethnic Asian population.

PubMed

Teo, Boon Wee; Ma, Valerie; Xu, Hui; Li, Jialiang; Lee, Evan J

2010-02-01

The increasing prevalence of end-stage renal disease (ESRD) is an important public health issue due to the high costs of kidney replacement therapies. We examined the impact of ethnicity and other factors in ESRD management and hospitalisation in a multiracial Asian population in the fi rst year after diagnosis. We analysed a prospectively collected database of 168 new ESRD patients from the National University Hospital, Singapore (NUH) in 2005. Univariate and multivariate analyses were performed to assess factors for mortality and hospitalisation. Sixteen patients eventually chose conservative treatment, 102 haemodialysis, 41 peritoneal dialysis and 9 patients underwent kidney transplantation for their long-term treatment. Although more Chinese patients had dialysis plans (56.7% vs 36.8%, P = 0.022), many still required urgent dialysis initiation via catheters (61.3%). These dialysed patients who required urgent treatment had more admissions (3.6 vs 2.6, P = 0.023) and longer length of stay (9.3 days, P = 0.014). Approximately 40 (7.4%) admissions were related to vascular access complications (thromboses, dislodgements and infections), and 15 (2.8%) were for new tunnelled catheter insertions. Deaths were 23.8% in the fi rst year after diagnosis and median survival was 125 days. Age, fi nal treatment modality, type of therapy centre, history of coronary artery disease, left ventricular ejection fraction (LVEF) <50%, and having no plans for dialysis were associated with mortality. The care of ESRD patients requires substantial commitment of healthcare resources particularly in the fi rst year after diagnosis. Steps to reduce urgent initiation of dialysis will help reduce resource utilisation and improve patient outcomes.

The economic burden of gallstone lithotripsy. Will cost determine its fate?

PubMed Central

Nealon, W H; Urrutia, F; Fleming, D; Thompson, J C

1991-01-01

Gallstone lithotripsy (LITHO) was performed on 52 patients who underwent 107 procedures. Two hundred sixty-seven gallstone patients were screened and 215 (81%) were excluded. Excessive stone burden and nonvisualization by oral cholecystogram (OCG) were the most common reasons for exclusion. The hospital course of 100 excluded patients who later underwent elective cholecystectomy was evaluated for length of hospital stay (2.3 days) and total cost of treatment ($3685.00). Successful fragmentation to less than 5 mm was achieved in 43 LITHO patients (83%). Five LITHO patients (10%) required conversion to operative management. Complications of LITHO included acute cholecystitis (1 of 52 patients) and biliary colic (17 of 52 patients, or 33%). Multiple procedures in one patient were common. Costs for LITHO were calculated in two ways: first the individual cost for each of the 52 candidates; second the cost for successful LITHO was calculated by excluding five patients who required operation as well as five patients (10%) who are predicted failures of LITHO. Including the preoperative evaluation, treatment, recovery room, and follow-up, the individual LITHO cost for 52 patients was $8275.00. If the same total expenditure is calculated after excluding patients who required operation and those predicted to fail, the cost per 'successful' LITHO procedure was $10,245. The cost of 1 year of bile acid therapy is $1949.00 or $2413.00 per 'successful' procedure. Follow-up costs were $1232.00 per patient or $1525.00 per 'successful' procedure. The added LITHO cost incurred by screening eventual noncandidates was $904.00 per successful procedure. The sum of these individual costs was $15,087.00 per success, as compared to $3685.00 for cholecystectomy. No allowance was made for cost of stone recurrence. Lithotripsy costs appear to be sufficiently high to render the procedure unlikely to emerge as the treatment of choice. PMID:2039296

The economic burden of gallstone lithotripsy. Will cost determine its fate?

PubMed

Nealon, W H; Urrutia, F; Fleming, D; Thompson, J C

1991-06-01

Gallstone lithotripsy (LITHO) was performed on 52 patients who underwent 107 procedures. Two hundred sixty-seven gallstone patients were screened and 215 (81%) were excluded. Excessive stone burden and nonvisualization by oral cholecystogram (OCG) were the most common reasons for exclusion. The hospital course of 100 excluded patients who later underwent elective cholecystectomy was evaluated for length of hospital stay (2.3 days) and total cost of treatment ($3685.00). Successful fragmentation to less than 5 mm was achieved in 43 LITHO patients (83%). Five LITHO patients (10%) required conversion to operative management. Complications of LITHO included acute cholecystitis (1 of 52 patients) and biliary colic (17 of 52 patients, or 33%). Multiple procedures in one patient were common. Costs for LITHO were calculated in two ways: first the individual cost for each of the 52 candidates; second the cost for successful LITHO was calculated by excluding five patients who required operation as well as five patients (10%) who are predicted failures of LITHO. Including the preoperative evaluation, treatment, recovery room, and follow-up, the individual LITHO cost for 52 patients was $8275.00. If the same total expenditure is calculated after excluding patients who required operation and those predicted to fail, the cost per 'successful' LITHO procedure was $10,245. The cost of 1 year of bile acid therapy is $1949.00 or $2413.00 per 'successful' procedure. Follow-up costs were $1232.00 per patient or $1525.00 per 'successful' procedure. The added LITHO cost incurred by screening eventual noncandidates was $904.00 per successful procedure. The sum of these individual costs was $15,087.00 per success, as compared to $3685.00 for cholecystectomy. No allowance was made for cost of stone recurrence. Lithotripsy costs appear to be sufficiently high to render the procedure unlikely to emerge as the treatment of choice.

Multiple polyps and colorectal cancer.

PubMed

Alecu, M; Simion, L; Straja, Nd; Brătucu, E

2014-01-01

Malignant degeneration as a possible course of evolution of colorectal polyps renders their diagnosis and therapeutic management a prophylactic act in the prevention of colorectal cancer (CRC). The study was conducted over a period of 3 years (2008-2011), during which 1,368 colonoscopies were performed in our service. The aim of the study was to identify patients presenting multiple colorectal polyps and to determine their risk factors for developing CRC, as well as to establish the appropriate therapeutic conduct. Presence of multiple polyps was recorded in over 40% of the patients identified with colorectal polyps of any kind. Dysplastic modifications observed during the histopathology exam presented a high incidence in the case of patients with multiple polyps, ranging from low-grade dysplasia to incipient CRC. Dysplastic modifications and carcinomatous foci were identified mostly among patients with multiple polyps.Only benign lesions or in situ carcinomas benefited from endoscopic treatment, poorly differentiated carcinomas or those invading the submucosa being treated by conventional surgery. Patients diagnosed with colorectal polyps require a rigorous post-therapy follow-up protocol, able to identify any eventual polyposis recurrence. Celsius.

[Economic impact of Losartan use in type 2 diabetic patients with nephropathy].

PubMed

González F, Fernando; Fuentes C, Verónica; Castro H, Catalina; Santelices L, Juan Pablo; Lorca H, Eduardo

2009-05-01

The study RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) demonstrated that Losartan was more effective lo reduce the progression of kidney disease in diabetic patients with proteinuria and a reduction in glomerular filtration rate. To perform a cost benefit analysis of Losartan use from provider and payer points of view. Published data of the RENAAL study was analyzed. The costs of the use or not use of Losartan in patients with diabetic nephropathy were compared in terms of total costs of the disease including medications, hospital admissions for myocardial infarction, cerebrovascular accidents and congestive cardiac failure and the costs of chronic hemodialysis. The reduction in antihypertensive medication use, hospital admissions, and the delay in dialysis requirement from a mean of 65 to 79 months induced by Losartan use, results in net savings of $7,576,135 per patient, at 3.5 years of intervention. The figure does not change using different sensitivity scenarios. The eventual use of Losartan in type 2 diabetic patients results in important savings.

Extracorporeal Life Support Bridge to Ventricular Assist Device: The Double Bridge Strategy.

PubMed

Marasco, Silvana F; Lo, Casey; Murphy, Deirdre; Summerhayes, Robyn; Quayle, Margaret; Zimmet, Adam; Bailey, Michael

2016-01-01

In patients requiring left ventricular assist device (LVAD) support, it can be difficult to ascertain suitability for long-term mechanical support with LVAD and eventual transplantation. LVAD implantation in a shocked patient is associated with increased morbidity and mortality. Interest is growing in the utilization of extracorporeal life support (ECLS) as a bridge-to-bridge support for these critically unwell patients. Here, we reviewed our experience with ECLS double bridging. We hypothesized that ECLS double bridging would stabilize end-organ dysfunction and reduce ventricular assist device (VAD) implant perioperative mortality. We conducted a retrospective review of prospectively collected data for 58 consecutive patients implanted with a continuous-flow LVAD between January 2010 and December 2013 at The Alfred Hospital, Melbourne, Victoria, Australia. Twenty-three patients required ECLS support pre-LVAD while 35 patients underwent LVAD implantation without an ECLS bridge. Preoperative morbidity in the ECLS bridge group was reflected by increased postoperative intensive care duration, blood loss, blood product use, and postoperative renal failure, but without negative impact upon survival when compared with the no ECLS group. ECLS stabilization improved end-organ function pre-VAD implant with significant improvements in hepatic and renal dysfunction. This series demonstrates that the use of ECLS bridge to VAD stabilizes end-organ dysfunction and reduces VAD implant perioperative mortality from that traditionally reported in these "crash and burn" patients. Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Management of inflammatory bowel disease.

PubMed

Nayar, M; Rhodes, J M

2004-04-01

Ulcerative colitis and Crohn's disease result from an interaction between genetic and environmental factors. Only one gene, NOD2/CARD15, has been clearly identified; a minority of people with alteration of this gene develop Crohn's disease. The NOD2/CARD15 protein is thought to be involved in defence against intracellular bacteria. This supports the idea that Crohn's disease and ulcerative colitis result from altered immunological responses to the normal intestinal flora. Life expectancy is normal in ulcerative colitis and nearly so in Crohn's disease, but both conditions cause considerable morbidity. Approximately 80% of patients with Crohn's disease eventually require surgery, and about 25% of patients with ulcerative colitis require colectomy. Treatment of ulcerative colitis is generally by corticosteroids for acute disease and mesalazine for maintenance, but the range of therapies for Crohn's disease is expanding. Alternative therapies include immunosuppressives, enteral nutrition, antibiotics, anti-TNF antibody (infliximab), corticosteroids, and surgery. High dosages of corticosteroids may provide symptomatic relief in Crohn's disease but do not affect the long term natural history of the disease, and management strategies should avoid using steroids whenever possible.

Anaesthesia for laparoscopic surgery: General vs regional anaesthesia

PubMed Central

Bajwa, Sukhminder Jit Singh; Kulshrestha, Ashish

2016-01-01

The use of laparoscopy has revolutionised the surgical field with its advantages of reduced morbidity with early recovery. Laparoscopic procedures have been traditionally performed under general anaesthesia (GA) due to the respiratory changes caused by pneumoperitoneum, which is an integral part of laparoscopy. The precise control of ventilation under controlled conditions in GA has proven it to be ideal for such procedures. However, recently the use of regional anaesthesia (RA) has emerged as an alternative choice for laparoscopy. Various reports in the literature suggest the safety of the use of spinal, epidural and combined spinal-epidural anaesthesia in laparoscopic procedures. The advantages of RA can include: Prevention of airway manipulation, an awake and spontaneously breathing patient intraoperatively, minimal nausea and vomiting, effective post-operative analgesia, and early ambulation and recovery. However, RA may be associated with a few side effects such as the requirement of a higher sensory level, more severe hypotension, shoulder discomfort due to diaphragmatic irritation, and respiratory embarrassment caused by pneumoperitoneum. Further studies may be required to establish the advantage of RA over GA for its eventual global use in different patient populations. PMID:26917912

Factors Associated with Acute and Chronic Hydrocephalus in Nonaneurysmal Subarachnoid Hemorrhage.

PubMed

Kang, Peter; Raya, Amanda; Zipfel, Gregory J; Dhar, Rajat

2016-02-01

Hydrocephalus requiring external ventricular drain (EVD) or shunt placement commonly complicates aneurysmal subarachnoid hemorrhage (SAH), but its frequency is not as well known for nonaneurysmal SAH (NA-SAH). Those with diffuse bleeding may have greater risk of hydrocephalus compared to those with a perimesencephalic pattern. We evaluated the frequency of hydrocephalus in NA-SAH and whether imaging factors could predict the need for EVD and shunting. We collected admission clinical and imaging variables for 105 NA-SAH patients, including bicaudate index (BI), Hijdra sum score (HSS), intraventricular hemorrhage (IVH) score, modified Fisher scale (mFS), and bleeding pattern. Hydrocephalus was categorized as acute (need for EVD) or chronic (shunt). We applied logistic regression to determine whether hydrocephalus risk was independently related to bleeding pattern or mediated through blood volume or ventriculomegaly. Acute hydrocephalus was seen in 26 (25%) patients but was more common with diffuse (15/28, 54%) versus perimesencephalic (10/59, 17%, p < 0.001) bleeding. Patients developing acute hydrocephalus had worse clinical grade and higher BI, HSS, and IVH scores. Adjusting the relationship between hydrocephalus and diffuse bleeding for HSS (but not BI) nullified this association. Nine (35%) patients requiring EVD eventually required shunting for chronic hydrocephalus, which was associated with greater blood burden but not poor clinical grade. Acute hydrocephalus occurs in one-quarter of NA-SAH patients. The greater risk in diffuse bleeding appears to be mediated by greater cisternal blood volume but not by greater ventriculomegaly. Imaging characteristics may aid in anticipatory management of hydrocephalus in NA-SAH.

Renal impairment in stroke patients: A comparison between the haemorrhagic and ischemic variants.

PubMed

Shrestha, Pratyush; Thapa, Shalima; Shrestha, Shikher; Lohani, Subash; Bk, Suresh; MacCormac, Oscar; Thapa, Lekhjung; Devkota, Upendra Prasad

2017-01-01

Background: Renal impairment is regularly seen in hospitalized stroke patients, affecting the outcome of patients, as well as causing difficulties in their management. A prospective cohort study was conducted to assess the trend of renal function in hospitalized ischemic and haemorrhagic stroke patients. The incidence of renal impairment in these subgroups, the contributing factors and the need for renal replacement in renal impaired patients was evaluated. Methods: Alternate day renal function testing was performed in hospitalized stroke patients. Estimated glomerular filtration rate (e-GFR) was calculated and the trend of renal function in the two stroke subgroups (haemorrhagic and ischemic) was assessed, with renal impairment defined as e-GFR < 60mL/ minute per 1.73m 2 . Results: Among 52 patients, 25 had haemorrhagic stroke (mean age 59.81 ± 14.67) and 27 had ischemic stroke (mean age 56.12 ± 13.08). The mean e-GFR (mL/minute per 1.732m 2 ) at admission in the haemorrhagic stroke subgroup was 64.79 ± 25.85 compared to 86.04 ± 26.09 in the ischemic stroke subgroup (p=0.005). Sixteen out of 25 (64%) patients in the haemorrhagic stroke subgroup and 9 out of 27 (33.3%) patients in the ischemic subgroup developed renal impairment (p=0.027). The location of the bleed (p=0.8), volume of hematoma (p=0.966) and surgical intervention (p=0.4) did not predispose the patients to renal impairment. One out of 16 patients with haemorrhagic stroke (who eventually died), and 2 out of 9 patients with ischemic stroke required renal replacement. Conclusion : Renal impairment is commonly seen in stroke patients, more so in patients who suffered haemorrhagic strokes.  The impairment, however, is transient and rarely requires renal replacement therapy.

Shoulder fusion after a self-inflicted gunshot wound: an injury pattern and treatment option.

PubMed

Zsoldos, C M; Basamania, C J; Bal, G K

2013-06-01

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as 'suicide shoulder' caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.

What Incentives Are Created by Medicare Payments for Total Hip Arthroplasty?

PubMed

Clement, R Carter; Soo, Adrianne E; Kheir, Michael M; Derman, Peter B; Flynn, David N; Levin, L Scott; Fleisher, Lee A

2016-09-01

Differences in profitability and contribution margin (CM) between various patient populations may make certain patients particularly attractive (or unattractive) to providers. This study seeks to identify patient characteristics associated with increased profit and CM among Medicare patients undergoing total hip arthroplasty (THA). The expected Medicare reimbursement for consecutive patients of Medicare-eligible age (65+ years) undergoing primary unilateral elective THA (n = 498) was calculated in accordance with Center for Medicare and Medicaid Services policy. Costs were derived from the hospital's cost accounting system. Profit and CM were calculated for each patient as reimbursement less total and variable costs, respectively. Patients were compared based on clinical and demographic factors by univariate and multivariate analyses. Medicare patients undergoing THA generated negative average profits but substantial positive CMs. Lower profit and CM were associated with higher American Society of Anesthesiologists Physical Status Classification (P < .01, P = .03), older age (P < .01), and longer length of stay (P < .01, P = .03). No association was found with gender, body mass index, or race. If our results are generalizable, Medicare patients requiring THA are currently financially attractive, but institutions have a long-term incentive to shift resources to more profitable patients and service lines, which may eventually restrict access to care for this population. THA providers have a financial incentive to favor Medicare patients with younger age, lower American Society of Anesthesiologists Physical Status Classification, and those who can be expected to require relatively short admissions. The Center for Medicare and Medicaid Services must strive to accurately match reimbursement rates to provider costs to avoid inequitable payments to providers and financial incentives discouraging treatment of high-risk patients or other patient subpopulations. Copyright © 2016 Elsevier Inc. All rights reserved.

The therapeutic action of psychoanalysis: abstinence and informative experiences.

PubMed

Chused, J F

1996-01-01

In recent years a number of analytic concepts have been subject to scrutiny, with the value of interpretations, the usefulness of abstinence, the possibility of neutrality, all questioned. One reason for the skepticism about interpretations, in particular, is that before a patient can use an interpretation for psychic change, his perceptual frame must change, a process that is rarely initiated by the verbal content of an interpretation alone. Instead, alterations in perception usually require experiences which are discordant with expectations. In this paper the author demonstrates how the nonverbal elements of an intervention, the action communications, provide informative experiences, creating the dissonance between expectation and eventuality which makes psychic change possible. Case vignettes are presented to illustrate this point as well as to support the idea that when nonverbal experiences contribute to lasting change within a patient, the therapeutic benefit does not accrue primarily from the gratification provided by the experience, but from how the experience informs the patient about his mode of thinking, perceiving, and reacting.

Successful management of severe neuroinvasive eastern equine encephalitis.

PubMed

Wendell, Linda C; Potter, N Stevenson; Roth, Julie L; Salloway, Stephen P; Thompson, Bradford B

2013-08-01

Eastern Equine Encephalitis (EEE) virus is an arbovirus that mostly causes asymptomatic infection in humans; however, some people can develop a neuroinvasive infection associated with a high mortality. We present a case of a patient with severe neuroinvasive EEE. A 21-year-old man initially presented with headache, fever, and vomiting and was found to have a neutrophilic pleocytosis in his cerebrospinal fluid. He eventually was diagnosed with EEE, treated with high-dose methylprednisolone and intravenous immunoglobulin. His course in the NeuroIntensive Care Unit was complicated by cerebral edema and intracranial hypertension, requiring osmotherapy, pentobarbital and placement of an external ventricular device, and subclinical seizures, necessitating multiple anti-epileptic drugs A multifaceted approach including aggressive management of cerebral edema and ICP as well as treatment with immunomodulating agents and cessation of seizures may prevent brain herniation, secondary neurologic injury and death in patients with EEE. Effective management and treatment in our patient contributed to a dramatic recovery and ultimate good outcome.

Microcontrolled air-mattress for ulcer by pressure prevention

NASA Astrophysics Data System (ADS)

Pasluosta, Cristian F.; Fontana, Juan M.; Beltramone, Diego A.; Taborda, Ricardo A. M.

2007-11-01

An ulcer by pressure is produced when a constant pressure is exerted over the skin. This generates the collapse of the blood vessels and, therefore, a lack in the contribution of the necessary nutrients for the affected zone. As a consequence, the skin deteriorates, eventually causing an ulcer. In order to prevent it, a protocol must be applied to the patient, which is reflected on time and cost of treatment. There are some air mattresses available for this purpose, but whose performance does not fulfill all requirements. The prototype designed in our laboratory is based on the principle of the air mattress. Its objective is to improve on existing technologies and, due to an increased automation, reduce time dedication for personnel in charge of the patient. A clinical experience was made in the local Emergencies Hospital and also in an institution dedicated to aged patients care. In both cases, the results obtained and the comments from the personnel involved were favorable.

Ahmed glaucoma valve in children: A review☆

PubMed Central

Nassiri, Nariman; Nouri-Mahdavi, Kouros; Coleman, Anne L.

2011-01-01

Pediatric glaucoma is potentially a blinding disease. Although goniotomy and trabeculotomy are associated with good early success rates, eventually 20% of these procedures fail and many children will require additional surgery to control the IOP in the long-term. In this review, we reported that adequate IOP control can be achieved with the placement of Ahmed glaucoma valve and can last 5 or more years. However, most patients will need one or more glaucoma medications at some point after surgery. In addition, the implants may be associated with pupillary irregularities, lenticular opacification as well as tube-related complications, particularly in the first year of life, as the globe is enlarging with age. PMID:23960945

Predictive factors for outcomes of patients undergoing endoscopic therapy for bile leak after hepatobiliary surgery.

PubMed

Yabe, Shuntaro; Kato, Hironari; Mizukawa, Sho; Akimoto, Yutaka; Uchida, Daisuke; Seki, Hiroyuki; Tomoda, Takeshi; Matsumoto, Kazuyuki; Yamamoto, Naoki; Horiguchi, Shigeru; Tsutsumi, Koichiro; Okada, Hiroyuki

2017-05-01

Endoscopic procedures are used as first-line treatment for bile leak after hepatobiliary surgery. Advances have been made in endoscopic techniques and devices, but few reports have described the effectiveness of endoscopic procedures and the management principles based on severity of bile leak. We evaluated the effectiveness of an endoscopic procedure for the treatment of bile leak after hepatobiliary surgery. Fifty-eight patients underwent an endoscopic procedure for suspected bile leak after hepatobiliary surgery; the presence of bile leak on endoscopic retrograde cholangiopancreatography (ERCP) was evaluated retrospectively. Two groups were created based on bile leak severity at ERCP. We defined success as follows: technical, successful placement of the plastic stent at the intended bile duct; clinical, improvement in symptoms of bile leak; and eventual, disappearance of bile leak at ERCP. We evaluated several factors that influenced the success of the endoscopic procedure and the differences between bile leak severity. Success rates were as follows: technical, 90%; clinical, 79%; and eventual, 71%. Median interval between first endoscopic procedure and achievement of eventual success was 135 days (IQR, 86-257 days). Bile leak severity was the only independent factor associated with eventual success (P = 0.01). Endoscopic therapy is safe and effective for postoperative bile leak. Bile leak severity is the most important factor influencing successful endoscopic therapy. © 2016 Japan Gastroenterological Endoscopy Society.

Comprehensive obesity evaluation and treatment of three adolescents: a case series.

PubMed

Taylor, Sharonda J Alston; Peterson, Mitchell A; Garland, Beth H; Hastings, Elisabeth S

2016-02-01

Adolescent obesity is a chronic disease that is impacted from each patient's biopsychosocial milieu. Successfully treating pediatric obesity requires long-term, innovative, systematic involvement to facilitate patient and family engagement and change. Extensive chart review was done for three obese adolescents who underwent comprehensive weight management in an adolescent clinic seen within the past 5 years. The charts were reviewed starting from the time of initial contact through the last visit in the clinic. The patients are no longer receiving care within the clinic. The patients presented with BMI>99th percentile, family history of obesity, severe psychosocial stressors, and multiple obesity-related comorbidities. Their treatment involved comprehensive multidisciplinary intervention in an adolescent weight management clinic within a tertiary care center. In addition to rigorous support through frequent office visits, these patients all eventually required temporary, alternative living arrangements to successfully implement recommendations. One patient resided with another family member; two went to inpatient weight management program care for 2-3 months. All subjects successfully lost weight when away from their primary residence, and they demonstrated improvement or resolution of comorbidities. This case series of three adolescents who underwent comprehensive obesity evaluation and treatment demonstrates multidisciplinary care across interconnected treatment programs and active engagement of family. Those who maintained successful weight loss reduced sedentary time, demonstrated family support (e.g., key members attending follow-up visits), and altered their living environment and were committed to their own health goals.

Normalization of Elevated Tumor Marker CA27-29 after Bilateral Lung Transplantation in a patient with Breast Cancer and Idiopathic Pulmonary Fibrosis.

PubMed

Copur, Mehmet Sitki; Wurdeman, Julie Marie; Nelson, Debra; Ramaekers, Ryan; Gauchan, Dron; Crockett, David

2017-12-11

Solid tumors involving glandular organs express mucin glycoprotein which is eventually shed into the circulation. As aresult these proteins can easily be measured in the serum and be used as potential tumor markers. The most commonly used tumor markers for breast cancer are CA 27-29 and CA 15-3, which both measure the glycoprotein product of the mucin-1 (MUC1) gene. CA 27-29 has been approved by the US Food and Drug Administration for monitoring disease activity in breast cancer patients. Most oncology clinical practice guidelines do not recommend the use of tumor markers for routine surveillance of early stage disease but recognize their utility in the metastatic setting. Herein, we present a patient with stage III-A breast cancer and pre-existing hypersensitivity pneumonitis who is found to have an elevated serum tumor marker CA 27-29. After successful curative intent treatment of her early stage breast cancer, she developed gradual and progressive worsening of her lung disease with eventual development of severe pulmonary fibrosis requiring bilateral lung transplantation. As part of the pre-transplant evaluation, she was found to have an elevation of serum tumor marker CA 27-29. While the diagnostic evaluation, including imaging studies was negative for the presence of recurrent disease, the serial serum tumor marker CA 27-29 levels remained persistently elevated. The decision was made for her to undergo bilateral lung transplantation. Shortly after surgery her CA27-29 tumor marker level returned to normal range, and it has continued to remain in the normal range with no evidence of breast cancer recurrence.

Is There Extra Cost of Institutional Care for MS Patients?

PubMed Central

Noyes, Katia; Bajorska, Alina; Weinstock-Guttman, Bianca

2013-01-01

Throughout life, patients with multiple sclerosis (MS) require increasing levels of support, rehabilitative services, and eventual skilled nursing facility (SNF) care. There are concerns that access to SNF care for MS patients is limited because of perceived higher costs of their care. This study compares costs of caring for an MS patient versus those of a typical SNF patient. We merged SNF cost report data with the 2001–2006 Nursing Home Minimum Data Set (MDS) to calculate percentage of MS residents-days and facility case-mix indices (CMIs). We estimated the average facility daily cost using hybrid cost functions, adjusted for facility ownership, average facility wages, CMI-adjusted number of SNF days, and percentage of MS residents-days. We describe specific characteristics of SNF with high and low MS volumes and examine any sources of variation in cost. MS patients were no longer more costly than typical SNF patients. A greater proportion of MS patients had no significant effect on facility daily costs (P = 0.26). MS patients were more likely to receive care in government-owned facilities (OR = 1.904) located in the Western (OR = 2.133) and Midwestern (OR = 1.3) parts of the USA (P < 0.05). Cost of SNF care is not a likely explanation for the perceived access barriers that MS patients face. PMID:24163769

Assessing changes in a patient's condition - perspectives of intensive care nurses.

PubMed

Kvande, Monica; Delmar, Charlotte; Lykkeslet, Else; Storli, Sissel Lisa

2017-03-01

To explore the phenomenon of assessing changes in patients' conditions in intensive care units from the perspectives of experienced intensive care nurses. Providing safe care for patients in intensive care units requires an awareness and perception of the signs that indicate changes in a patient's condition. Nurses in intensive care units play an essential role in preventing the deterioration of a patient's condition and in improving patient outcomes. This hermeneutic phenomenological study conducted close observations and in-depth interviews with 11 intensive care nurses. The nurses' experience ranged from 7 to 28 years in the intensive care unit. Data were collected at two intensive care units in two Norwegian university hospitals. The analysis was performed using the reflective methods of van Manen. An overarching theme of 'sensitive situational attention' was identified, in which the nurses were sensitive in relation to a patient and understood the significance of a given situation. This theme was further unfolded in four subthemes: (1) being sensitive and emotionally present, (2) being systematic and concentrating, (3) being physically close to the bedside and (4) being trained and familiar with the routines. Nurses understand each patient's situation and foresee clinical eventualities through a sensitive and attentive way of thinking and working. This requires nurses to be present at the bedside with both their senses (sight, hearing, smell and touch) and emotions and to work in a concentrated and systematic manner. Knowledge about the unique patient exists in interplay with past experiences and medical knowledge, which are essential for nurses to understand the situation. Clinical practice should develop routines that enable nurses to be present at the bedside and to work in a concentrated and systematic manner. Furthermore, providing safe care requires nurses to be sensitive and attentive to each patient's unique situation. © 2016 British Association of Critical Care Nurses.

Airway complications in the head injured.

PubMed

Woo, P; Kelly, G; Kirshner, P

1989-07-01

Fifty head-injured patients who had tracheostomy were followed during rehabilitation by video fiberoptic laryngoscopy examination. Complications of aspiration (23/50), airway stenosis (13/50), and phonation dysfunction (16/24) were followed. Spontaneous resolution of aspiration may require a prolonged course. A majority of patients (37/50) had improvement and could be decannulated. Prognostic factors correlated to eventual decannulation included age, level on the Glasgow Coma Outcome Scale, and type of head injury. Those with poor neurologic improvement and glottic incompetence (13/50) are poor candidates for decannulation. Significant airway stenosis can involve both laryngeal and tracheal sites. Neurologic dysfunction may complicate the decannulation process after airway anatomy has been restored by surgery. Dysphonia resulting from intubation, peripheral laryngeal and nerve injury, or central laryngeal movement dysfunction are common. Preventive maintenance with ongoing evaluation can avoid airway crises such as aspiration pneumonia, hemoptysis, and innominate artery.

MRI-guided robotics at the U of Houston: evolving methodologies for interventions and surgeries.

PubMed

Tsekos, Nikolaos V

2009-01-01

Currently, we witness the rapid evolution of minimally invasive surgeries (MIS) and image guided interventions (IGI) for offering improved patient management and cost effectiveness. It is well recognized that sustaining and expand this paradigm shift would require new computational methodology that integrates sensing with multimodal imaging, actively controlled robotic manipulators, the patient and the operator. Such approach would include (1) assessing in real-time tissue deformation secondary to the procedure and physiologic motion, (2) monitoring the tool(s) in 3D, and (3) on-the-fly update information about the pathophysiology of the targeted tissue. With those capabilities, real time image guidance may facilitate a paradigm shift and methodological leap from "keyhole" visualization (i.e. endoscopy or laparoscopy) to one that uses a volumetric and informational rich perception of the Area of Operation (AoO). This capability may eventually enable a wider range and level of complexity IGI and MIS.

Analysis of Marine Corps Renewable Energy Planning to Meet Installation Energy Security Requirements

DTIC Science & Technology

2013-12-03

experimentation eventually gives way to the era of ferment . A few new technologies break through in the industry and are applied to a growing number of niche...experimentation and ferment eventually give way to an era of incremental change, where the industry down-selects to the most successful and efficient...clearly in the later part of the era of incremental change. Most renewables, however, are only just now moving into the second phase, the era of ferment

Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series.

PubMed

Banc-Husu, Anna M; Ahmad, Nuzhat A; Chandrasekhara, Vinay; Ginsberg, Gregory G; Jaffe, David L; Kochman, Michael L; Rajala, Michael W; Mamula, Petar

2017-04-01

Gastrointestinal bleeding is one of the most common indications for urgent endoscopy in the pediatric setting. The majority of these procedures are performed for control of variceal bleeding, with few performed for nonvariceal upper gastrointestinal (NVUGI) bleeding. The data on therapeutic endoscopy for NVUGI are sparse. The aims of our study were to review our experience with NVUGI bleeding, describe technical aspects and outcomes of therapeutic endoscopy, and determine gastroenterology fellows' training opportunities according to the national training guidelines. We performed a retrospective review of endoscopy database (Endoworks, Olympus Inc, Center Valley, PA) from January 2009 to December 2014. The search used the following keywords: bleeding, hematemesis, melena, injection, epinephrine, cautery, clip, and argon plasma coagulation. The collected data included demographics, description of bleeding lesion and medical/endoscopic therapy, rate of rebleeding, relevant laboratories, physical examination, and need for transfusion and surgery. The study was approved by the institutional review board. During the study period 12,737 upper endoscopies (esophagogastroduodenoscopies) were performed. A total of 15 patients underwent 17 esophagogastroduodenoscopies that required therapeutic intervention to control bleeding (1:750 procedures). The mean ± standard deviation (median) age of patients who required endoscopic intervention was 11.6 ± 6.0 years (14.0 years). Seven out of 17 patients received dual therapy to control the bleeding lesions. All but 3 patients received medical therapy with intravenous proton pump inhibitor, and 3 received octreotide infusions. Six of the patients experienced rebleeding (40%), with 4 out of 6 initially only receiving single modality therapy. Two of these patients eventually required surgical intervention to control bleeding and both patients presented with bleeding duodenal ulcers. There were no cases of aspiration, perforation, or deaths. There were a total of 24 fellows trained in our program during the study period. Less than 1 therapeutic endoscopy per fellow for NVUGI bleeding was performed. NVUGI bleeding requiring therapeutic endoscopic intervention is rare in pediatrics. A high rate (40%) of rebleeding was noted with a large proportion (66%) of patients receiving single modality therapy. Two patients required surgical intervention to control bleeding and both presented with bleeding duodenal ulcers. An insufficient number of therapeutic procedures is available for adequate fellow training requiring supplemental simulator and hands-on animal model, or adult endoscopy unit training.

Anatomical shoulder arthroplasty in epileptic patients with instability arthropathy and persistent seizures.

PubMed

Thangarajah, Tanujan; Falworth, Mark; Lambert, Simon M

2017-01-01

Epileptic seizures can cause shoulder dislocation, recurrent instability and eventually arthritis. The purpose of this study was to report the results, complications and rate of revision surgery following anatomical shoulder arthroplasty in epileptic patients with instability arthropathy. A consecutive series of eight patients with epilepsy underwent anatomical shoulder arthroplasty for recurrent shoulder instability and were retrospectively reviewed after a mean of 4.7 years (range, 2-7.5 years). These included three total shoulder replacements and five humeral resurfacing hemiarthroplasty procedures. Mean age of the cohort was 33 years (range, 17-44). All patients experienced post-operative grand mal seizures. Two patients with hemiarthroplasty required further surgery due to painful glenoid erosion. No residual cases of instability were noted. Mean active forward elevation and external rotation improved following surgery. The Oxford Shoulder Score improved from 15 pre-operatively (range, 7-22) to 26 post-operatively (range, 12-45) ( p = 0.031). This was accompanied by an increase in the mean Subjective Shoulder Value, which improved from 29 (range, 10-80) pre-operatively to 53 (range, 15-90) post-operatively ( p=0.042). Anatomical shoulder arthroplasty may offer a solution for the treatment of instability arthropathy in patients with epilepsy and persistent seizures.

Mini-extracorporeal circulation minimizes coagulation abnormalities and ameliorates pulmonary outcome in coronary artery bypass grafting surgery.

PubMed

Zeitani, J; Buccisano, F; Nardella, S; Flaminio, M; Prati, P; Chiariello, G; Venditti, A; Chiariello, L

2013-07-01

Hemostasis is impaired during CABG and coagulation abnormalities often result in clinically relevant organ dysfunctions, eventually increasing morbidity and mortality rates. Fifteen consecutive patients with coronary artery disease submitted to conventional extracorporeal circulation (cECC) have been compared with 15 matched patients, using mini-ECC (MECC). Postoperative lung function was evaluated according to gas exchange, intubation time and lung injury score. In the MECC group, thrombin-antithrombin complex levels (TaTc), prothrombin fragments (PF1+2) formation and thromboelastography (TEG) clotting times were lower compared to the cECC group (p=0.002 and p<0.001, respectively) whereas postoperative blood loss was higher in the cECC group (p=0.030) and more patients required blood transfusion (p=0.020). In the MECC group, postoperative gas exchange values were better, intubation time shorter and lung injury score lower (p<0.001 for all comparisons). Our study suggests that MECC induces less coagulation disorders, leading to lower postoperative blood loss and better postoperative lung function. This approach may be advantageous in high-risk patients.

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit.

PubMed

Silvestre, Julio; Montoya, Maria; Bruera, Eduardo; Elsayem, Ahmed

2015-12-01

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting. We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided. Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control. This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

Lung Transplantation for Cystic Fibrosis: Results, Indications, Complications, and Controversies

PubMed Central

Lynch, Joseph P.; Sayah, David M.; Belperio, John A.; Weigt, S. Sam

2016-01-01

Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (~50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed. PMID:25826595

[Social issues in the doctor's clinic].

PubMed

Vos, H

2017-01-01

Doctors are confronted with issues that arise in society. These social issues can affect patients' health. Solving these problems requires more than just prescribing a pill, as illustrated by the cases of three patients. The first patient is a 42-year-old male with cardiac symptoms, chronic lower back pain and an excessive use of tranquillizers. The welfare worker intervened and his demand for health care and use of tranquillizers diminished. The second patient is a 53-year-old female with symptoms of chronic back pain, migraine and depression. A labour dispute concerning her health eventually led to a referral to a project named 'social hospital', but actual assistance never took place due to the patient's alleged lack of time to participate. The third case concerns an 86-year-old female with postherpetic neuralgia who also suffered from loneliness. The patient's named welfare worker tried to get in touch with her, but the patient kept her at a distance. These three cases illustrate that it is very important to get to know the social network in a community in order to refer patients with social issues to the right person or place. Furthermore, prevention and early intervention strategies should be applied where possible. Doctors and local governments must act together in order to succeed in solving patient ill health as a result of social issues.

Cost and Business Analysis Module (CABAM). Revision A

NASA Technical Reports Server (NTRS)

Lee, Michael Hosung

1997-01-01

In the recent couple of decades, due to international competition, the US launchers lost a considerable amount of market share in the international space launch industry'. Increased international competition has continuously affected the US dominance to eventually place great pressure on future US space launch programs. To compete for future payload and passenger delivery markets, new launch vehicles must first be capable of reliably reaching a number of desired orbital destinations with customer-desired payload capacities. However, the ultimate success of a new launch vehicle program will depend on the launch price it is capable of offering it's customers. Extremely aggressive pricing strategies will be required for a new domestic launch service to compete with low-price international launchers. Low launch prices, then, naturally require a tight budget for the launch program economy. Therefore, budget constraints established by low-pricing requirements eventually place pressure on new launch vehicles to have unprecedentedly low Life Cycle Costs (LCC's).

Incorporating Research Findings into Standards and Requirements for Space Medicine

NASA Technical Reports Server (NTRS)

Duncan, J. Michael

2006-01-01

The Vision for Exploration has been the catalyst for NASA to refocus its life sciences research. In the future, life sciences research funded by NASA will be focused on answering questions that directly impact setting physiological standards and developing effective countermeasures to the undesirable physiological and psychological effects of spaceflight for maintaining the health of the human system. This, in turn, will contribute to the success of exploration class missions. We will show how research will impact setting physiologic standards, such as exposure limits, outcome limits, and accepted performance ranges. We will give examples of how a physiologic standard can eventually be translated into an operational requirement, then a functional requirement, and eventually spaceflight hardware or procedures. This knowledge will be important to the space medicine community as well as to vehicle contractors who, for the first time, must now consider the human system in developing and constructing a vehicle that can achieve the goal of success.

[Multiple colonic anastomoses in the surgical treatment of short bowel syndrome. A new technique].

PubMed

Robledo-Ogazón, Felipe; Becerril-Martínez, Guillermo; Hernández-Saldaña, Víctor; Zavala-Aznar, Marí Luisa; Bojalil-Durán, Luis

2008-01-01

Some surgical pathologies eventually require intestinal resection. This may lead to an extended procedure such as leaving 30 cm of proximal jejunum and left and sigmoid colon. One of the most important consequences of this type of resection is "intestinal failure" or short bowel syndrome. This complex syndrome leads to different metabolic and water and acid/base imbalances, as well as nutritional and immunological challenges along with the problem accompanying an abdomen subjected to many surgical procedures and high mortality. Many surgical techniques have been developed to improve quality of life of patients. We designed a non-transplant surgical approach and performed the procedure on two patients with postoperative short bowel syndrome with <40 cm of proximal jejunum and left colon. There are a variety of non-transplant surgical procedures that, due to their complex technique or high mortality rate, have not resolved this important problem. However, the technique we present in this work can be performed by a large number of surgeons. The procedure has a low morbimortality rate and offers the opportunity for better control of metabolic and acid/base balance, intestinal transit and proper nutrition. We consider that this technique offers a new alternative for the complex management required by patients with short bowel syndrome and facilitates their long-term nutritional control.

Transition of Intravenous Treprostinil to Oral Therapy in a Patient with Functional Class IV Chronic Thromboembolic Pulmonary Hypertension.

PubMed

Thurber, Kristina M; Williams, Breann M; Bates, Ruth E; Frantz, Robert P

2017-08-01

Chronic thromboembolic pulmonary hypertension (CTEPH) occurs when pulmonary emboli fail to resolve with anticoagulation. For patients with inoperable or residual CTEPH, riociguat is currently the only therapy approved by the United States Food and Drug Administration. However, some patients with CTEPH may require therapy beyond riociguat, such as intravenous prostacyclins, which can present significant administration challenges in patients with complex comorbid conditions. We describe a 42-year-old man with T12 paraplegia complicated by CTEPH (functional class IV with substantial right ventricular dysfunction) and severe pressure ulcers. In order to facilitate goals of care (hospital discharge to a skilled nursing facility where parenteral prostanoids could not be administered), he underwent rapid transition from intravenous treprostinil to oral selexipag in the form of a cross-taper over 6 days. The patient required readmission due to worsening symptoms and was transitioned back to intravenous treprostinil; he tolerated conversion to oral treprostinil for approximately 4 months, but it was subsequently discontinued due to nausea and modified goals of care. The patient underwent transition to hospice care 3 months later and eventually died from clinical deterioration. To our knowledge, this is the first report to describe transition from intravenous treprostinil to selexipag as well as conversion from parenteral treprostinil to oral treprostinil in a patient with CTEPH and illustrates the approaches to and potential issues with prostanoid transitions. Additional observations are necessary to better understand the relative roles of selexipag and oral treprostinil regarding comparative efficacy and tolerability. © 2017 Pharmacotherapy Publications, Inc.

The application of cure models in the presence of competing risks: a tool for improved risk communication in population-based cancer patient survival.

PubMed

Eloranta, Sandra; Lambert, Paul C; Andersson, Therese M-L; Björkholm, Magnus; Dickman, Paul W

2014-09-01

Quantifying cancer patient survival from the perspective of cure is clinically relevant. However, most cure models estimate cure assuming no competing causes of death. We use a relative survival framework to demonstrate how flexible parametric cure models can be used in combination with competing-risks theory to incorporate noncancer deaths. Under a model that incorporates statistical cure, we present the probabilities that cancer patients (1) have died from their cancer, (2) have died from other causes, (3) will eventually die from their cancer, or (4) will eventually die from other causes, all as a function of time since diagnosis. We further demonstrate how conditional probabilities can be used to update the prognosis among survivors (eg, at 1 or 5 years after diagnosis) by summarizing the proportion of patients who will not die from their cancer. The proposed method is applied to Swedish population-based data for persons diagnosed with melanoma, colon cancer, or acute myeloid leukemia between 1973 and 2007.

A case of atypical Bartonella henselae infection in a patient with methimazole-induced agranulocytosis

PubMed Central

Kaysin, Alexander; Viera, Anthony J

2015-01-01

Antithyroid medications such as methimazole and propylthiouracil are commonly used to treat hyperthyroid disorders. Thionamide-induced agranulocytosis is a rare but life-threatening potential side effect of these medicines. In addition to routine monitoring of blood counts, healthcare workers caring for patients on such medication need to be mindful of atypical presentations of acute agranulocytosis throughout the treatment course. The manifestations of underlying infectious aetiologies can be mistaken for more common illness and result in delayed diagnosis. We present a case of a 41-year-old woman receiving methimazole for Grave's disease, who presented to outpatient care with high fever, pharyngitis, lymphadenopathy and jaundice. After failing to respond to empiric antibiotics, a diagnosis of neutropenia was made and the patient was admitted for inpatient care with eventual recovery following a course of granulocyte colony-stimulating factor. A diagnosis of atypical Bartonella henselae was eventually made and treated appropriately. The patient was later discharged and underwent radioactive iodine ablation. PMID:26315358

Outcome of patients with relapsed diffuse large B-cell lymphoma who fail second-line salvage regimens in the International CORAL study.

PubMed

Van Den Neste, E; Schmitz, N; Mounier, N; Gill, D; Linch, D; Trneny, M; Milpied, N; Radford, J; Ketterer, N; Shpilberg, O; Dührsen, U; Ma, D; Brière, J; Thieblemont, C; Salles, G; Moskowitz, C H; Glass, B; Gisselbrecht, C

2016-01-01

Salvage chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard second-line treatment for relapsed and refractory diffuse large B-cell lymphoma (DLBCL). However, the strategy is less clear in patients who require third-line treatment. Updated outcomes of 203 patients who could not proceed to scheduled ASCT in the Collaborative Trial in Relapsed Aggressive Lymphoma (CORAL) are herein reviewed. In the intent-to-treat analysis, overall response rate to third-line chemotherapy was 39%, with 27% CR or CR unconfirmed, and 12% PR. Among the 203 patients, 64 (31.5%) were eventually transplanted (ASCT 56, allogeneic SCT 8). Median overall survival (OS) of the entire population was 4.4 months. OS was significantly improved in patients with lower tertiary International Prognostic Index (IPI), patients responding to third-line treatment and patients transplanted with a 1-year OS of 41.6% compared with 16.3% for the not transplanted (P<0.0001). In multivariate analysis, IPI at relapse (hazard ratio (HR) 2.409) and transplantation (HR 0.375) independently predicted OS. Third-line salvage chemotherapy can lead to response followed by transplantation and long-term survival in DLBCL patients. However, improvement of salvage efficacy is an urgent need with new drugs.

The probability of seizures during EEG monitoring in critically ill adults

PubMed Central

Westover, M. Brandon; Shafi, Mouhsin M.; Bianchi, Matt T.; Moura, Lidia M.V.R.; O’Rourke, Deirdre; Rosenthal, Eric S.; Chu, Catherine J.; Donovan, Samantha; Hoch, Daniel B.; Kilbride, Ronan D.; Cole, Andrew J.; Cash, Sydney S.

2014-01-01

Objective To characterize the risk for seizures over time in relation to EEG findings in hospitalized adults undergoing continuous EEG monitoring (cEEG). Methods Retrospective analysis of cEEG data and medical records from 625 consecutive adult inpatients monitored at a tertiary medical center. Using survival analysis methods, we estimated the time-dependent probability that a seizure will occur within the next 72-h, if no seizure has occurred yet, as a function of EEG abnormalities detected so far. Results Seizures occurred in 27% (168/625). The first seizure occurred early (<30 min of monitoring) in 58% (98/168). In 527 patients without early seizures, 159 (30%) had early epileptiform abnormalities, versus 368 (70%) without. Seizures were eventually detected in 25% of patients with early epileptiform discharges, versus 8% without early discharges. The 72-h risk of seizures declined below 5% if no epileptiform abnormalities were present in the first two hours, whereas 16 h of monitoring were required when epileptiform discharges were present. 20% (74/388) of patients without early epileptiform abnormalities later developed them; 23% (17/74) of these ultimately had seizures. Only 4% (12/294) experienced a seizure without preceding epileptiform abnormalities. Conclusions Seizure risk in acute neurological illness decays rapidly, at a rate dependent on abnormalities detected early during monitoring. This study demonstrates that substantial risk stratification is possible based on early EEG abnormalities. Significance These findings have implications for patient-specific determination of the required duration of cEEG monitoring in hospitalized patients. PMID:25082090

Outcome Assessment after Aptis Distal Radioulnar Joint (DRUJ) Implant Arthroplasty

PubMed Central

Kachooei, Amir Reza; Chase, Samantha M; Jupiter, Jesse B

2014-01-01

Background: Conventional treatments after complicated injuries of the distal radioulnar joint (DRUJ) such as Darrach and Kapandji-Sauvé procedures have many drawbacks, which may eventually lead to a painful unstable distal ulna. The development of DRUJ prosthesis has significantly evolved over the past years. In this study, we assessed the outcome results of patients after DRUJ implant arthroplasty using the Aptis (Scheker) prosthesis. Methods: We identified 13 patients with 14 prosthesis during the past 10 years. Patients underwent DRUJ arthroplasty due to persistent symptoms of instability, chronic pain, and stiffness. Records and follow-up visits were reviewed to find the final post-operative symptoms, pain, range of motion, and grip strength with a mean follow-up of 12 months (range: 2-25 months). Also, patients were contacted prospectively by phone in order to administer the disabilities of the arm shoulder and hand (DASH), patient rated wrist evaluation (PRWE), and visual analogue scale (VAS), and to interview regarding satisfaction and progress in daily activities. Eleven patients out of 13 could be reached with a median follow-up time of 60 months (range: 2 to 102 months). Results: No patient required removal of the prosthesis. Only two patients underwent secondary surgeries in which both required debridement of the screw tip over the radius. The median DASH score, PRWE score, VAS, and satisfaction were 1.3, 2.5, 0, and 10, respectively. The mean range of flexion, extension, supination, and pronation was 62, 54, 51, and 64, respectively. Conclusions: Distal radioulnar joint injuries are disabling and patients usually undergo one or more salvage surgeries prior to receiving an arthroplasty. The Scheker prosthesis has shown satisfactory results with 100% survival rate in all reports. The constrained design of this prosthesis gives enough stability to prevent painful subluxation. PMID:25386579

Patient-specific embryonic stem cells derived from human SCNT blastocysts.

PubMed

Hwang, Woo Suk; Roh, Sung Il; Lee, Byeong Chun; Kang, Sung Keun; Kwon, Dae Kee; Kim, Sue; Kim, Sun Jong; Park, Sun Woo; Kwon, Hee Sun; Lee, Chang Kyu; Lee, Jung Bok; Kim, Jin Mee; Ahn, Curie; Paek, Sun Ha; Chang, Sang Sik; Koo, Jung Jin; Yoon, Hyun Soo; Hwang, Jung Hye; Hwang, Youn Young; Park, Ye Soo; Oh, Sun Kyung; Kim, Hee Sun; Park, Jong Hyuk; Moon, Shin Yong; Schatten, Gerald

2005-06-17

Patient-specific, immune-matched human embryonic stem cells (hESCs) are anticipated to be of great biomedical importance for studies of disease and development and to advance clinical deliberations regarding stem cell transplantation. Eleven hESC lines were established by somatic cell nuclear transfer (SCNT) of skin cells from patients with disease or injury into donated oocytes. These lines, nuclear transfer (NT)-hESCs, grown on human feeders from the same NT donor or from genetically unrelated individuals, were established at high rates, regardless of NT donor sex or age. NT-hESCs were pluripotent, chromosomally normal, and matched the NT patient's DNA. The major histocompatibility complex identity of each NT-hESC when compared to the patient's own showed immunological compatibility, which is important for eventual transplantation. With the generation of these NT-hESCs, evaluations of genetic and epigenetic stability can be made. Additional work remains to be done regarding the development of reliable directed differentiation and the elimination of remaining animal components. Before clinical use of these cells can occur, preclinical evidence is required to prove that transplantation of differentiated NT-hESCs can be safe, effective, and tolerated.

Cancer disclosure: experiences of Iranian cancer patients.

PubMed

Valizadeh, Leila; Zamanzadeh, Vahid; Rahmani, Azad; Howard, Fuchsia; Nikanfar, Ali-Reza; Ferguson, Caleb

2012-06-01

This study explored Iranian patients' experiences of cancer disclosure, paying particular attention to the ways of disclosure. Twenty cancer patients were invited to participate in this qualitative inquiry by research staff in the clinical setting. In-depth, semistructured interview data were analyzed through content analysis. The rigor of the study was established by principles of credibility, transferability, dependability, and confirmability. Four themes emerged: the atmosphere of non-disclosure, eventual disclosure, distress in knowing, and the desire for information. Non-disclosure was the norm for participants, and all individuals involved made efforts to maintain an atmosphere of non-disclosure. While a select few were informed of their diagnosis by a physician or another patient, the majority eventually became aware of their diagnosis indirectly by different ways. All participants experienced distress after disclosure. The participants wanted basic information about their prognosis and treatments from their treating physicians, but did not receive this information, and encountered difficulty accessing information elsewhere. These challenges highlight the need for changes in current medical practice in Iran, as well as patient and healthcare provider education. © 2012 Blackwell Publishing Asia Pty Ltd.

A Prospective, Quantitative Evaluation of Fatty Infiltration Before and After Rotator Cuff Repair.

PubMed

Lansdown, Drew A; Lee, Sonia; Sam, Craig; Krug, Roland; Feeley, Brian T; Ma, C Benjamin

2017-07-01

Current evaluation of muscle fatty infiltration has been limited by subjective classifications. Quantitative fat evaluation through magnetic resonance imaging (MRI) may allow for an improved longitudinal evaluation of the effect of surgical repair on the progression of fatty infiltration. We hypothesized that (1) patients with isolated full-thickness supraspinatus tendon tears would have less progression in fatty infiltration compared with patients with full-thickness tears of multiple tendons and (2) patients with eventual failed repair would have higher baseline levels of fatty infiltration. Cohort study; Level of evidence, 2. Thirty-five patients with full-thickness rotator cuff tears were followed longitudinally. All patients received a shoulder MRI, including the iterative decomposition of echoes of asymmetric length (IDEAL) sequence for fat measurement, prior to surgical treatment and at 6 months after surgical repair. Fat fractions were recorded for all 4 rotator cuff muscles from measurements on 4 sagittal slices centered at the scapular-Y. Demographics and tear characteristics were recorded. Baseline and follow-up fat fractions were compared for patients with isolated supraspinatus tears versus multitendon tears and for patients with intact repairs versus failed repairs. Statistical significance was set at P < .05. The mean fat fractions were significantly higher at follow-up than at baseline for the supraspinatus (9.8% ± 7.0% vs 8.3% ± 5.7%; P = .025) and infraspinatus (7.4% ± 6.1% vs 5.7% ± 4.4%; P = .027) muscles. Patients with multitendon tears showed no significant change for any rotator cuff muscle after repair. Patients with isolated supraspinatus tears showed a significant progression in the supraspinatus fat fraction from baseline to follow-up (from 6.8% ± 4.9% to 8.6% ± 6.8%; P = .0083). Baseline supraspinatus fat fractions were significantly higher in patients with eventual failed repairs compared with those with intact repairs (11.7% ± 6.8% vs 7.1% ± 4.8%; P = .037). Contrary to our initial hypothesis, patients with isolated supraspinatus tears showed a significant progression of fatty infiltration. Patients with eventual repair failure had higher baseline fat fractions in the supraspinatus.

The Infection Returns: A Case of Pulmonary Sporotrichosis Relapse after Chemotherapy

PubMed Central

2018-01-01

Background Pulmonary sporotrichosis is a rare disease caused by a dimorphic fungus, Sporothrix schenckii. It is rarely found in association with malignancy. We present a case of pulmonary sporotrichosis recurrence after chemotherapy. Case Presentation A 44-year-old man, treated for pulmonary sporotrichosis in the past, presented with dysphagia and was found to have squamous cell carcinoma of the esophagus. After undergoing chemotherapy, extensive cavitary lesions were observed on thoracic computed tomography scan. A bronchoalveolar lavage revealed the presence of Sporothrix schenckii sensu lato. Despite treatment with itraconazole, he eventually required a left pneumonectomy for progressive destructive cavitary lesions involving the left lung. Conclusion This case highlights the importance of considering past fungal infections, albeit cured, in patients initiating immunosuppressive therapy. PMID:29559998

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure.

PubMed

Hagopian, Thomas M; Ghareeb, Paul A; Arslanian, Brian H; Moosavi, Benjamin L; Carlson, Grant W

2015-01-01

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction. © 2015 Wiley Periodicals, Inc.

Allografts about the Knee in Young Patients with High-Grade Sarcoma.

PubMed

Brigman, Brian E; Hornicek, Francis J; Gebhardt, Mark C; Mankin, Henry J

2004-04-01

Reconstruction after resections for high-grade sarcomas about the knee in children and adolescents is a challenging problem because of the large soft tissue and skeletal defects, the effects of adjuvant therapy, and the potential for long-term use of the limb. One hundred sixteen patients, all 18 years or younger, with osteosarcoma or Ewing's sarcoma located between the middle femur and middle tibia, were treated with chemotherapy, resection, and allograft reconstruction. One hundred three patients with osteosarcoma and 13 patients with Ewing's sarcoma had 105 Stage II and 11 Stage III tumors. There were 72 osteoarticular grafts (39 femur, 33 tibia), 28 intercalary grafts (19 femur), seven allograft-prosthetic composites (all femur,) and nine allograft-arthrodeses (seven femur, two tibia). At latest followup, 49% of all of the allograft reconstructions were rated good or excellent, 14% were rated as fair, and 37% were failures. Sixteen percent had an infection develop. Twenty-seven percent of patients had a fracture, 34% had a nonunion, and 14 patients eventually required amputation. Reconstruction of large bone defects about the knee in young patients who are being treated with chemotherapy is difficult. Although complications significantly affect outcome, allografts are a viable option for reconstruction in children with high-grade sarcomas about the knee.

3D printing materials and their use in medical education: a review of current technology and trends for the future

PubMed Central

Garcia, Justine; Yang, ZhiLin; Mongrain, Rosaire; Leask, Richard L; Lachapelle, Kevin

2018-01-01

3D printing is a new technology in constant evolution. It has rapidly expanded and is now being used in health education. Patient-specific models with anatomical fidelity created from imaging dataset have the potential to significantly improve the knowledge and skills of a new generation of surgeons. This review outlines five technical steps required to complete a printed model: They include (1) selecting the anatomical area of interest, (2) the creation of the 3D geometry, (3) the optimisation of the file for the printing and the appropriate selection of (4) the 3D printer and (5) materials. All of these steps require time, expertise and money. A thorough understanding of educational needs is therefore essential in order to optimise educational value. At present, most of the available printing materials are rigid and therefore not optimum for flexibility and elasticity unlike biological tissue. We believe that the manipuation and tuning of material properties through the creation of composites and/or blending materials will eventually allow for the creation of patient-specific models which have both anatomical and tissue fidelity. PMID:29354281

3D printing materials and their use in medical education: a review of current technology and trends for the future.

PubMed

Garcia, Justine; Yang, ZhiLin; Mongrain, Rosaire; Leask, Richard L; Lachapelle, Kevin

2018-01-01

3D printing is a new technology in constant evolution. It has rapidly expanded and is now being used in health education. Patient-specific models with anatomical fidelity created from imaging dataset have the potential to significantly improve the knowledge and skills of a new generation of surgeons. This review outlines five technical steps required to complete a printed model: They include (1) selecting the anatomical area of interest, (2) the creation of the 3D geometry, (3) the optimisation of the file for the printing and the appropriate selection of (4) the 3D printer and (5) materials. All of these steps require time, expertise and money. A thorough understanding of educational needs is therefore essential in order to optimise educational value. At present, most of the available printing materials are rigid and therefore not optimum for flexibility and elasticity unlike biological tissue. We believe that the manipuation and tuning of material properties through the creation of composites and/or blending materials will eventually allow for the creation of patient-specific models which have both anatomical and tissue fidelity.

Endoscopic ultrasound-guided transmural drainage of postoperative pancreatic collections.

PubMed

Tilara, Amy; Gerdes, Hans; Allen, Peter; Jarnagin, William; Kingham, Peter; Fong, Yuman; DeMatteo, Ronald; D'Angelica, Michael; Schattner, Mark

2014-01-01

Pancreatic leak is a major cause of morbidity after pancreatectomy. Traditionally, peripancreatic fluid collections have been managed by percutaneous or operative drainage. Data for endoscopic ultrasound (EUS)-guided drainage of postoperative fluid collections are limited. Here we report on the safety, efficacy, and timing of EUS-guided drainage of postoperative peripancreatic collections. This is a retrospective review of 31 patients who underwent EUS-guided drainage of fluid collections after pancreatic resection. Technical success was defined as successful transgastric deployment of at least one double pigtail plastic stent. Clinical success was defined as resolution of the fluid collection on follow-up CT scan and resolution of symptoms. Early drainage was defined as initial transmural stent placement within 30 days after surgery. Endoscopic ultrasound-guided drainage was performed effectively with a technical success rate of 100%. Clinical success was achieved in 29 of 31 patients (93%). Nineteen of the 29 patients (65%) had complete resolution of their symptoms and collection with the first endoscopic procedure. Repeat drainage procedures, including some with necrosectomy, were required in the remaining 10 patients, with eventual resolution of collection and symptoms. Two patients who did not achieve durable clinical success required percutaneous drainage by interventional radiology. Seventeen (55%) of 31 patients had successful early drainage completed within 30 days of their operation. Endoscopic ultrasound-guided drainage of fluid collections after pancreatic resection is safe and effective. Early drainage (<30 days) of postoperative pancreatic fluid collections was not associated with increased complications in this series. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Negative pressure wound therapy, staged excision and definitive closure with split-thickness skin graft for axillary hidradenitis suppurativa: a retrospective study.

PubMed

Pearce, F B; Richardson, K A

2017-01-02

Bilateral axillary hidradenitis is a chronic, suppurative, and scarring disease that is most effectively treated by complete excision of all hair-bearing tissues. We assessed our staged procedure for excision and placement of a split-thickness skin graft for bilateral axillary hidradenitis in terms of costs, outcomes, and timing of excision. An IRB approved retrospective case analysis was performed on patients that underwent bilateral axillary hidradenitis skin excision with eventual placement of split-thickness skin grafting using the current LSUHSC/University Health hidradenitis surgical treatment protocol. Using ICD-9 codes (705.83) and CPT codes (11041, 11042, 11451, 11600, 11601, 11602, 11603, 11604) we reviewed cases performed at our institution from 1 January 2008 to 24 Febuary 2014 and we selected patients based on bilateral axillary involvement (alone) and >1 year history of active disease. Patients were excluded if resection of tissue encompassed regions outside of the immediately adjacent axillary. A total of seven patients matching criteria for bilateral axillary hidradenitis were selected for analysis. Clinical course, cost and surgical techniques were assessed. Of the seven patients, six required admission throughout their treatment due to lack of funding making use of negative pressure wound therapy at home not possible. These patients stayed an average of 10 days with a mean hospital charge of $35,178 and a mean hospital provider charge of $10,019. No recurrence was demonstrated. All patients attained full range of motion, post grafting. No patient required a further operation due to graft failure. Split-thickness skin grafting without use of bilayer dermal regenerative templates yielded definitive results with acceptable cosmesis and functionality, without the added cost of treatments such as a bilayer dermal regenerative template.

[Systemic paracoccidioidomycosis with central nervous system involvement].

PubMed

Duarte, A L; Baruffa, G; Terra, H B; Renck, D V; de Moura, D; Petrucci, C

1999-01-01

A clinical case of a patient bearing systemic paracoccidioidomycosis with regional ganglionic and oral exposure and later pulmonary involvement is presented. The patient was treated with specific drugs (amphotericin B, itraconazole, sulfamethoxazole-trimethoprim) and followed throughout a 6-year period and eventually died showing an extensive involvement of the central nervous system.

Treatment Options in Gastrointestinal Cutaneous Fistulas

PubMed Central

Ashkenazi, Itamar; Turégano-Fuentes, Fernando; Olsha, Oded; Alfici, Ricardo

2017-01-01

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context. PMID:28825016

[Care and optimal management of the face- and neck-lift patients].

PubMed

Delay, E

2017-10-01

Surgical and case management for patients demanding a face- and neck-lift are very important. The purpose of this paper is to help the plastic surgeons with information and recommendations useful for the best medical care of patients requiring a face- and neck-lift. The first consultation is the most important contact with the patient. The preoperative discussion helps to define patient demands and to evaluate eventual contraindications for surgery. The clinical exam and patient requirements are useful in the construction of the therapeutic proposition. This proposition is then confronted with patients' expectations and demands. The confrontation between the surgical proposition and patients' expectations allows to evaluate if it is appropriate, or not, to operate. At the end of the first consultation, the patient receives the information sheets of the French Plastic Surgery Society (SOFCPRE) according to the proposed surgical treatment. The second consultation makes it possible to verify the pertinence of the surgical act, to reiterate the preoperative recommendations, to confirm that the information given to the patient was well understood and to obtain the written consent from the patient. The written consent should include the fact that the patient received the information sheets of the SOFCPRE, that they were read and understood, and that the surgeon has transmitted the necessary information in order for the patient to take an informed and free decision to pursue with the surgery. The follow-up after surgery is as important as the surgery itself. In some cases, cosmetic gestures can be performed in the following months to obtain the best results possible and the highest satisfaction. The face- and neck-lift is an "adventure" for the patients and the postoperative difficulties should not be underestimated. However, the caring and professional support of the plastic surgeon and the support of someone of the patients' entourage can help the patient overcome this stage, and obtain a maximum benefit after this operation. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

An unusual tachycardia.

PubMed

Hanon, Sam; Shapiro, Michael; Schweitzer, Paul

2004-07-01

The following article presents an unusual case of atrial tachycardia, initially misdiagnosed due to a lack of clear P waves. The diagnosis was eventually confirmed using the atrial electrogram from the patient's pacemaker.

Spontaneous subarachnoid haemorrhage and outcome--results from Tan Tock Seng Hospital, Singapore.

PubMed

Wong, S H; Yeo, T T; Seow, W T; Tan, K K; Ong, P L

1999-07-01

To ascertain the number of cases of spontaneous (aneurysmal) subarachnoid haemorrhage presenting to Tan Tock Seng Hospital, Singapore, over a one year period, the demographics of the patients involved, their treatment and their eventual outcome. A retrospective study from June 1995 to June 1996. There were 62 patients admitted over this period with an average of 5 patients per month. Their ages ranged from 9 to 85 years with a mean of 54 years. All 62 patients underwent 4-vessel cerebral angiograms. Forty-three patients (69%) underwent clipping of their aneurysms. Twelve patients (19%) had negative angiograms. Four patients (6%) underwent coiling of their aneurysms via interventional neuroradiology techniques. Patients with subarachnoid haemorrhage of Grades 1 to 3 on the WFNS (World Federation of Neurological Surgeons) grading had a favourable outcome (Glasgow Outcome Score of 4 and 5) in 85% of the cases. The overall mortality rate for the operated group (all grades) was 11%. However for the group with good WFNS grading, namely the Grade 1 to 2 groups, there were no deaths. Twenty-four percent of patients developed clinically symptomatic vasospasm. Eighteen percent of patients required ventriculo-peritoneal shunting for hydrocephalus secondary to the subarachnoid haemorrhage. The overall management mortality (operated and non-operated cases) was 14% for proven aneurysmal and angiographically-negative spontaneous subarachnoid haemorrhage. These results are comparable to that of other reputable centers reported in the literature.

Prerequisite for successful surgical outcome in urothelium lined seromuscular colocystoplasty.

PubMed

Jung, Hyun Jin; Lee, Hyeyoung; Im, Young Jae; Lee, Yong Seung; Hong, Chang Hee; Han, Sang Won

2012-04-01

Urothelium lined seromuscular colocystoplasty is an ideal method of augmentation cystoplasty that avoids various complications caused by the use of gastrointestinal segments. We reviewed the long-term outcomes using this technique at a single institution. We retrospectively analyzed 34 patients who underwent urothelium lined seromuscular colocystoplasty between January 1996 and December 2007. A total of 33 patients, excluding 1 who had previously undergone artificial urinary sphincter implantation, were included in the study. Changes in urodynamic parameters, duration of anticholinergic use, incontinence and surgical complications were analyzed. Mean±SD age at surgery was 10.0±5.7 years (range 3.0 to 26.0) and duration of followup was 6.0±2.3 years (2.7 to 13.4). A total of 17 patients (51.5%) underwent simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty. Mean bladder capacity increased by a factor of 2.96 and mean percentage of expected bladder capacity for age increased by a factor of 1.96 postoperatively. Of patients who underwent anti-incontinence surgery 4 of 10 whose abdominal leak point pressure was less than 40 cm H2O required additional surgery, whereas none whose abdominal leak point pressure was 40 to 60 cm H2O required reoperation. Two of 16 patients who did not undergo anti-incontinence surgery eventually required continence surgery. A total of 13 patients (39.4%) were able to discontinue anticholinergics at 47.3 months postoperatively. There were no bladder perforations, bowel obstructions or metabolic abnormalities. Urothelium lined seromuscular colocystoplasty can be primarily considered in patients without prior bladder mucosal injury. Constant high bladder outlet pressure to facilitate adhesion of bladder mucosa and seromuscular patch is critical for the best results. We recommend abdominal leak point pressure 60 cm H2O or less as an indication for simultaneous anti-incontinence surgery and urothelium lined seromuscular colocystoplasty. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Solar power R and D for Air Force space requirements

NASA Technical Reports Server (NTRS)

Wise, J. F.

1980-01-01

The requirements for improved solar power system technology for DOD satellites are reported. It is shown that the technology is required in several areas including solar cells, array blanket technology, energy storage and power system operation, and regulation and control. It is further shown that as the missions become more critical to defence, military aspects such as survivability, hardening, and eventually defence must be addressed.

Creating Simulated Microgravity Patient Models

NASA Technical Reports Server (NTRS)

Hurst, Victor; Doerr, Harold K.; Bacal, Kira

2004-01-01

The Medical Operational Support Team (MOST) has been tasked by the Space and Life Sciences Directorate (SLSD) at the NASA Johnson Space Center (JSC) to integrate medical simulation into 1) medical training for ground and flight crews and into 2) evaluations of medical procedures and equipment for the International Space Station (ISS). To do this, the MOST requires patient models that represent the physiological changes observed during spaceflight. Despite the presence of physiological data collected during spaceflight, there is no defined set of parameters that illustrate or mimic a 'space normal' patient. Methods: The MOST culled space-relevant medical literature and data from clinical studies performed in microgravity environments. The areas of focus for data collection were in the fields of cardiovascular, respiratory and renal physiology. Results: The MOST developed evidence-based patient models that mimic the physiology believed to be induced by human exposure to a microgravity environment. These models have been integrated into space-relevant scenarios using a human patient simulator and ISS medical resources. Discussion: Despite the lack of a set of physiological parameters representing 'space normal,' the MOST developed space-relevant patient models that mimic microgravity-induced changes in terrestrial physiology. These models are used in clinical scenarios that will medically train flight surgeons, biomedical flight controllers (biomedical engineers; BME) and, eventually, astronaut-crew medical officers (CMO).

Why the general dentist needs to know how to manage oral lichen planus.

PubMed

Price, Stephanie M; Murrah, Valerie A

2015-01-01

Oral lichen planus (OLP) is a frequently mismanaged chronic disease that requires care throughout a patient's life, and therefore a condition the general dentist must know how to manage. Patients with OLP often suffer considerable physical discomfort and an inability to perform proper oral hygiene, eventually resulting in poor periodontal health. In addition, these patients are confronted with the psychological stress of knowing that OLP is not curable. This is accompanied by a fear of other negative health developments, particularly oral cancer. The objective of this study was to identify major issues surrounding the management of OLP by the general dentist. A literature review of over 1100 articles was performed. An eclectic compilation of the issues revealed 12 major areas of concern. This article reviews those concerns and presents strategies for coping with the myriad signs, symptoms, and complications associated with this disease, as well as educational approaches and legal considerations. A rationale is provided to place the responsibility for the management of these patients under the person best positioned to coordinate care for this condition--the general dentist. A general dentist can contribute to the overall oral health of an OLP patient with timely diagnosis, effective treatment, thorough patient education, and the orchestration of efforts by a team of health care providers.

Endovascular repair of ruptured abdominal aortic aneurysms: experience in a community hospital.

PubMed

Davit, Flavia E; Cole, Theresa; Helling, Thomas; Tretter, James

2007-11-01

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66-82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multicenter study may eventually show this method to be helpful in patients who require repair of RAAA.

Hydrogeochemical analyses of groundwater from Ameca, Jalisco Mexico.

NASA Astrophysics Data System (ADS)

Tostado, M.; Rosas-Elguera, J.; Gomez Hermosillo, C.

2008-05-01

The accelerated demographic and industrial growth of settlements in mid cities and surrounding urbane areas, requires larger water volumes for its support, including public use. Usually, these requirements are not met by superficial waters consequently underground water is required to fulfill the general necessities. TheAmeca region in Jalisco, Mexico, is located around 80km west of Guadalajara. This region has been sustained by Agriculture and mining for several decades. This last activity has been mainly developed to the north of the city, precisely on the recharge zone. The infiltrated water, eventually form the aquifers. While it travels, and due to its intrinsic dilution capacity, the water may become polluted. Eventually, if he pollutants are toxic, the water from wells used in cities like Ameca, may result in serious health problems. In this study, the Ameca aquifer is evaluated through chemical analyses of the water from wells serving the city. Thus the natural pollution caused by mineral deposit zones and mines located on the recharge zone can be evaluated.

Missed Radiation Therapy and Cancer Recurrence

Cancer.gov

Patients who miss radiation therapy sessions during cancer treatment have an increased risk of their disease returning, even if they eventually complete their course of radiation treatment, according to a new study.

Long-term Expectations of Vagus Nerve Stimulation: A Look at Battery Replacement and Revision Surgery.

PubMed

Couch, Jonathan D; Gilman, Arthur M; Doyle, Werner K

2016-01-01

Vagus nerve stimulation (VNS) is an established surgical treatment for medically intractable epilepsy with more than 75 000 devices implanted worldwide. While there are many reports documenting efficacy, complications, and clinical use, there are very few reports concerning VNS battery replacement and revision surgeries. To review our experience with VNS battery replacement and revision surgery. We retrospectively reviewed 1144 consecutive VNS procedures performed by a single surgeon between 1998 and 2012. Six hundred forty-four of those procedures were the initial placement of the VNS device. These patients were then followed to determine when a battery change occurred and what type of revision or removal was necessary. In the study, 46% of patients required at least 1 or more type of battery replacement or revision surgery. The most common types of surgery were for generator battery depletion (27%), poor efficacy (9%), and lead malfunction (8%). Only 2% of patients were noted to have an infection. VNS battery replacement, revisions, and removals account for almost one-half of all VNS procedures. Our findings suggest important long-term expectations for VNS including expected complications, battery life, and other surgical issues. Review of the literature suggests that this is the first large review of VNS revisions by a single center. Our findings are important to better characterize long-term surgical expectations of VNS therapy. A significant portion of patients undergoing VNS therapy will eventually require revision.

Determining diabetic retinopathy screening interval based on time from no retinopathy to laser therapy.

PubMed

Hughes, Daniel; Nair, Sunil; Harvey, John N

2017-12-01

Objectives To determine the necessary screening interval for retinopathy in diabetic patients with no retinopathy based on time to laser therapy and to assess long-term visual outcome following screening. Methods In a population-based community screening programme in North Wales, 2917 patients were followed until death or for approximately 12 years. At screening, 2493 had no retinopathy; 424 had mostly minor degrees of non-proliferative retinopathy. Data on timing of first laser therapy and visual outcome following screening were obtained from local hospitals and ophthalmology units. Results Survival analysis showed that very few of the no retinopathy at screening group required laser therapy in the early years compared with the non-proliferative retinopathy group ( p < 0.001). After two years, <0.1% of the no retinopathy at screening group required laser therapy, and at three years 0.2% (cumulative), lower rates of treatment than have been suggested by analyses of sight-threatening retinopathy determined photographically. At follow-up (mean 7.8 ± 4.6 years), mild to moderate visual impairment in one or both eyes due to diabetic retinopathy was more common in those with retinopathy at screening (26% vs. 5%, p < 0.001), but blindness due to diabetes occurred in only 1 in 1000. Conclusions Optimum screening intervals should be determined from time to active treatment. Based on requirement for laser therapy, the screening interval for diabetic patients with no retinopathy can be extended to two to three years. Patients who attend for retinal screening and treatment who have no or non-proliferative retinopathy now have a very low risk of eventual blindness from diabetes.

Clinical evidence on the magnitude of change in growth pathway activity in relation to Tamoxifen resistance is required.

PubMed

Mansouri, Sepideh; Farahmand, Leila; Teymourzadeh, Azin; Majidzadeh-A, Keivan

2017-08-08

Despite prolonged disease-free survival and overall survival rates in estrogen receptor (ER)-positive patients undergoing adjuvant treatment, Tamoxifen therapy tends to fail due to eventual acquisition of resistance. Although numerous studies have emphasized the role of receptor tyrosine kinases (RTKs) in the development of Tamoxifen resistance, inadequate clinical evidence is available regarding the alteration of biomarker expression during acquired resistance, thus undermining the validity of the findings. Results of two meta-analyses investigating the effect of HER2 status on the prognosis of Tamoxifen-receiving patients have demonstrated that despite HER2-negative patients having longer disease-free survival; there is no difference in overhaul survival between the two groups. Furthermore, due to the intricate molecular interactions among estrogen receptors including ERα36, ERα66, and also RTKs, it is not surprising that RTK suppression does not restore Tamoxifen sensitivity. In considering such a complex network, we speculate that by the time HER2/EGFR is suppressed via targeted therapies, activation of ERα66 and ERα36 initiate molecular signaling pathways downstream of RTKs, thereby enhancing cell proliferation even in the presence of both Tamoxifen and RTK inhibitors. Although clinical findings regarding the molecular pathways downstream of RTKs have been thoroughly discussed in this review, further clinical studies are required in determining a consistency between preclinical and clinical findings. Discovering the best targets in preventing tumor progression requires thorough comprehension of estrogen-dependent and estrogen-independent pathways during Tamoxifen resistance development. Indeed, exploring additional clinically-proven targets would allow for better characterized treatments being available for breast cancer patients. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Unilateral Sympathectomy for Primary Palmar Hyperhidrosis.

PubMed

Ravari, Hassan; Rajabnejad, Ataollah

2015-12-01

Primary palmar hyperhidrosis that arises mostly during puberty and early adolescence has a tremendous impact on the quality of life in patients. This study aimed to investigate the effectiveness of unilateral video-assisted thoracic sympathectomy for dominant hand in these patients. From July 2010 to June 2013, 52 patients with primary palmar hyperhidrosis underwent unilateral video-assisted thoracoscopic sympathectomy for dominant hand. We analyzed the outcomes regarding the resolution of symptoms, occurrence of complications, recurrence rate, and compensatory hyperhidrosis, and need of operation for opposite side. All patients were followed up from 6 to 42 months. Palmar hyperhidrosis was completely alleviated and absolute dryness was achieved in all patients at the same hand after the operation. Palmar hyperhidrosis in the opposite hand was cured to a complete dryness in 24 (46.15%) patients. No change happened in the opposite hand in 22 (42.3%) patients, but an increase was seen in 6 (11.53%) patients. Only seven (13.46%) patients needed to undergo contralateral sympathectomy. Compensatory hyperhidrosis occurred in 13 patients (25%) after unilateral sympathectomy. Another five patients (totally 18, 34.6%) were involved with compensatory hyperhidrosis after contralateral sympathectomy. It was mainly on the trunk in all 18 patients. Unilateral dominant side thoracoscopic sympathectomy for patients with primary palmar hyperhidrosis is an effective, safe, and minimally invasive procedure. Only a small number of patients will eventually require a contralateral sympathectomy in nondominant hand. Georg Thieme Verlag KG Stuttgart · New York.

Dimensions of tinnitus-related complaints reported by patients and their significant others: protocol for a systematic review

PubMed Central

Haider, Haúla; Fackrell, Kathryn; Kennedy, Veronica; Hall, Deborah A

2016-01-01

Introduction Over 70 million people in Europe and >50 million people in the USA are reported to experience tinnitus (the sensation of noise in the absence of any corresponding sound source). Tinnitus is a multidimensional concept. Individual patients may report different profiles of tinnitus-related symptoms which may each require a tailored management approach and an appropriate measure of therapeutic benefit. This systematic review concerns the patient perspective and has the purpose to find what symptoms are reported by people who experience tinnitus and by their significant others. Methods and analysis This protocol lays out the methodology to define what dimensions of tinnitus-related symptoms patients and their significant others report as being a problem. Methods are defined according to the Preferred Reporting Items for Systematic reviews and Meta-analyses for Protocols (PRISMA-P) 2015 and data will be collated in a narrative synthesis. Findings will contribute to the eventual establishment of a Core Domain Set for clinical trials of tinnitus. Ethics and dissemination No ethical issues are foreseen. Findings will be reported at national and international ENT and audiology conferences and in a peer-reviewed journal. Trial registration number CRD42015020629. PMID:27855082

Lung transplantation for cystic fibrosis: results, indications, complications, and controversies.

PubMed

Lynch, Joseph P; Sayah, David M; Belperio, John A; Weigt, S Sam

2015-04-01

Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab.

PubMed

Song, G-W; Lee, S-G; Hwang, S; Kim, K-H; Ahn, C-S; Moon, D-B; Ha, T-Y; Jung, D-H; Park, G-C; Kim, W-J; Sin, M-H; Yoon, Y-I; Kang, W-H; Kim, S-H; Tak, E-Y

2016-01-01

ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized. © Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.

Problem based review: The patient taking methadone.

PubMed

Arora, Alok; Williams, Karen

2013-01-01

Methadone maintenance treatment (MMT) is an effective therapy for opioid-dependence; its use is based on a harm reduction philosophy and represents one of a range of treatment approaches for opioid-dependent individuals. The medical literature supports MMT as a well established and cost-effective treatment for opioid-dependence that allows a return-to-normal physiological, psychological and societal functioning. The effectiveness of MMT is enhanced by psycho-social interventions such as contingency management and addressing other co-existing health and social needs. MMT saves lives and reduces violent and non-violent crime, drug use and the transmission of HIV, hepatitis C and other communicable diseases. For some people, MMT may continue for life, while others may eventually be able to discontinue and remain abstinent. Methadone interacts with numerous drugs and prolongs the corrected QT interval (QTc) with risk of sudden cardiac death. It has a prolonged half-life and premature discharge of patients after methadone overdose may be fatal. Each patient must be assessed, treated and monitored on an individual basis. Successful outcomes through MMT require knowledge, experience, vigilance, and diligence on the part of the physician, the patient and all of those involved in treatment.

The probability of seizures during EEG monitoring in critically ill adults.

PubMed

Westover, M Brandon; Shafi, Mouhsin M; Bianchi, Matt T; Moura, Lidia M V R; O'Rourke, Deirdre; Rosenthal, Eric S; Chu, Catherine J; Donovan, Samantha; Hoch, Daniel B; Kilbride, Ronan D; Cole, Andrew J; Cash, Sydney S

2015-03-01

To characterize the risk for seizures over time in relation to EEG findings in hospitalized adults undergoing continuous EEG monitoring (cEEG). Retrospective analysis of cEEG data and medical records from 625 consecutive adult inpatients monitored at a tertiary medical center. Using survival analysis methods, we estimated the time-dependent probability that a seizure will occur within the next 72-h, if no seizure has occurred yet, as a function of EEG abnormalities detected so far. Seizures occurred in 27% (168/625). The first seizure occurred early (<30min of monitoring) in 58% (98/168). In 527 patients without early seizures, 159 (30%) had early epileptiform abnormalities, versus 368 (70%) without. Seizures were eventually detected in 25% of patients with early epileptiform discharges, versus 8% without early discharges. The 72-h risk of seizures declined below 5% if no epileptiform abnormalities were present in the first two hours, whereas 16h of monitoring were required when epileptiform discharges were present. 20% (74/388) of patients without early epileptiform abnormalities later developed them; 23% (17/74) of these ultimately had seizures. Only 4% (12/294) experienced a seizure without preceding epileptiform abnormalities. Seizure risk in acute neurological illness decays rapidly, at a rate dependent on abnormalities detected early during monitoring. This study demonstrates that substantial risk stratification is possible based on early EEG abnormalities. These findings have implications for patient-specific determination of the required duration of cEEG monitoring in hospitalized patients. Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Productivity loss of caregivers of schizophrenia patients: a cross-sectional survey in Japan.

PubMed

Sruamsiri, Rosarin; Mori, Yasuhiro; Mahlich, Jörg

2018-04-27

When a family member is diagnosed with schizophrenia, it causes stress to the caregiver that can eventually result in missed work days and lower work performance. This study aims at revealing productivity costs for caregivers of schizophrenia patients in Japan. A cross-sectional survey of caregivers was conducted and resulted in 171 respondents. The assessment of work productivity included calculating the costs of absenteeism, presenteeism and total productivity costs. This was accomplished using the "Work Productivity and Activity Impairment Questionnaire" (WPAI). A relative majority of caregivers in the sample provided care for their spouse (47%), 18% cared for their brother or sister and 16% provided care for their child. Per capita productivity costs totaled JPY 2.42 million, with JPY 2.36 million (97%) of that amount being due to presenteeism. The burden on caregivers is substantial enough to warrant structured support programs aimed at maintaining careers' physical and mental health, helping them provide more effective care to schizophrenia patients and eventually increase productivity at work.

The use of intermittent positive pressure ventilation to differentiate pneumonia from atelectasis during anesthesia in a red panda (Ailurus fulgens).

PubMed

Phair, Kristen; West, Gary; Biller, David

2010-12-01

Radiography is a valuable tool for assessment of pulmonary disease. Specifically, radiographs utilizing positive pressure ventilation can distinguish between anesthesia-induced atelectasis and pulmonary disease when survey radiographs are ambiguous. Positive pressure ventilation can be used to radiographically prove or disprove pulmonary disease. This is of particular clinical importance when working with exotic, zoo, or wildlife species because the majority of these patients require general anesthesia to perform physical examinations and diagnostics such as radiography safely and efficiently. This report is a case example of pulmonary disease in a red panda (Ailurus fulgens) and demonstrates how positive pressure ventilation verified both the presence of pulmonary disease and the eventual resolution of the disease. Anesthetized patients on gas anesthesia will rapidly become atelectic. Through the use of positive pressure ventilation, anesthesia-induced atelectasis and true pulmonary disease can readily be distinguished. This is a technique that should not be overlooked when performing thoracic radiography in zoo species.

Case report: delayed presentation of postural headache in an adolescent girl after microscopic lumbar discectomy.

PubMed

Kundu, Anjana; Sano, Yuko; Pagel, Paul S

2008-10-01

To discuss the diagnostic and therapeutic challenges presented by an adolescent girl with delayed postural headaches and photophobia that occurred three months after an apparently uncomplicated microscopic lumbar discectomy. A previously healthy girl was admitted to our hospital with a one-week history of an unremitting, frontal-retroorbital postural headache and photophobia. Three months before admission, the patient had undergone a L5-S1 left hemilaminotomy and foraminotomy with microdiscectomy for excision of a herniated intervertebral disc. Conservative treatment failed to provide symptomatic relief. Cranial magnetic resonance imaging showed enhancement of the pachymeninges, consistent with intracranial hypotension. A chronic cerebrospinal leak was identified by high-resolution computed tomography (CT) myelography. Epidural blood patches were performed, with and without CT guidance, that provided temporary relief of the patient's symptoms; however, direct suture plication of the dural tear was eventually required for definitive treatment. This case emphasizes that delayed presentation of dural injury may occur after lumbar surgery and describes the potential therapeutic implications for this unusual complication.

The pathogenesis of steroid-induced osteonecrosis of the femoral head: A systematic review of the literature.

PubMed

Wang, Ao; Ren, Ming; Wang, Jincheng

2018-05-30

Steroid (glucocorticoid)-induced osteonecrosis of the femoral head (SONFH) is a metabolic disease that occurs due to the use of glucocorticoid drugs, leading to impaired blood supply to the femoral head and death of bone cells and bone marrow composition, which in turn lead to structural change, collapse of the femoral head, and articular dysfunction. SONFH is a challenging disorder to treat in adults due to frequent collapse of the femoral head and dysfunction of the hip joint. Eventually, patients require joint arthroplasty surgery, which severely impairs the patients' quality of life. However, the exactly pathogenesis of SONFH is still not clear. Recently, as the development of precision medicine and lucubrating on stem cell and molecular biology, the exact pathogenesis of SONFH is being investigated and more new treatments are being explored. This review article discusses five major theories about the pathogenesis of SONFH. Copyright © 2017. Published by Elsevier B.V.

Inferior ST-Elevation Acute Myocardial Infarction or an Inferior-Lead Brugada-like Electrocardiogram Pattern Associated With the Use of Pregabalin and Quetiapine?

PubMed

Brunetti, Natale D; Ieva, Riccardo; Correale, Michele; Cuculo, Andrea; Santoro, Francesco; Guaricci, Andrea I; De Gennaro, Luisa; Gaglione, Antonio; Di Biase, Matteo

2016-01-01

The Brugada electrocardiogram pattern is characterized by coved-type ST-elevation (>2 mm) in the right precordial leads. We report the case of a 62-year-old man, with bipolar disorder, admitted to the emergency department because of dyspnea and chest discomfort. The patient was on treatment with pregabalin and quetiapine. Unexpectedly, electrocardiogram at admission showed diffuse ST-elevation, more evident in inferior leads, where a Brugada-like pattern was present. The patient underwent coronary angiography with a diagnosis of suspected acute coronary syndrome. Coronary angiography, however, showed mild coronary artery disease not requiring coronary angioplasty. Echocardiography did not reveal left ventricular dysfunction or pericardial effusion. Troponin levels remained normal over serial controls. Eventually, chest radiography showed lung opacities and consolidation suggestive for pneumonia. To the best of our knowledge, this is one of the first cases showing a transient Brugada-like electrocardiogram pattern in inferior leads, probably amplified by the administration of pregabalin and quetiapine.

Written advice can provide a safe and acceptable alternative to new patient assessment for selected referrals to haematologists.

PubMed

Ganly, Peter S; Keeman, Helen; Spearing, Ruth L; Smith, Mark P; Patton, Nigel; Merriman, Eileen G; Gibbons, Steve S

2008-01-07

To measure the safety and acceptability of providing written advice (WA) for selected patients referred to a haematology service, as an alternative to inpatient or outpatient assessment. Review of the initial management and subsequent course of patients newly referred to a tertiary referral hospital in Christchurch, New Zealand, between 16 October 2003 and 8 June 2006. Structured questionnaires were sent to all referring doctors and patients recently managed with WA. Numbers and diagnoses of patients managed with WA, early assessment or delayed assessment; re-referral and treatment details; characteristics of WA letters; and opinions of referring doctors and their patients on the WA process. 26% of new referrals (714/2785) were managed with prompt WA, while 16% (455/2785) received the alternative of delayed assessment. After a median follow-up of 23 months (range, 8-40 months), 13% of those managed with WA (91/714) were re-referred back to the same haematologists; 7% (52/714) were assessed in hospital and 2% (15/714) eventually required treatment. There were no deaths due to haematological causes. Over 90% of responding referring doctors said the WA process was rapid and effective, and 77% of recently managed patients were pleased to be treated by their own doctors. Using WA to manage a substantial minority of patients referred to haematologists can be rapid and safe. It is widely accepted by referring doctors.

Benign emptying of the postpneumonectomy space.

PubMed

Merritt, Robert E; Reznik, Scott I; DaSilva, Marcelo C; Sugarbaker, David J; Whyte, Richard I; Donahue, Dean M; Hoang, Chuong D; Smythe, W Roy; Shrager, Joseph B

2011-09-01

A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment. After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics. Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%. To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Designing and Implementation of a Heart Failure Telemonitoring System.

PubMed

Safdari, Reza; Jafarpour, Maryam; Mokhtaran, Mehrshad; Naderi, Nasim

2017-09-01

The aim of this study was to identify patients at-risk, enhancing self-care management of HF patients at home and reduce the disease exacerbations and readmissions. In this research according to standard heart failure guidelines and Semi-structured interviews with 10 heart failure Specialists, a draft heart failure rule set for alerts and patient instructions was developed. Eventually, the clinical champion of the project vetted the rule set. Also we designed a transactional system to enhance monitoring and follow up of CHF patients. With this system, CHF patients are required to measure their physiological measurements (vital signs and body weight) every day and to submit their symptoms using the app. additionally, based on their data, they will receive customized notifications and motivation messages to classify risk of disease exacerbation. The architecture of system comprised of six major components: 1) a patient data collection suite including a mobile app and website; 2) Data Receiver; 3) Database; 4) a Specialists expert Panel; 5) Rule engine classifier; 6) Notifier engine. This system has implemented in Iran for the first time and we are currently in the testing phase with 10 patients to evaluate the technical performance of our system. The developed expert system generates alerts and instructions based on the patient's data and the notify engine notifies responsible nurses and physicians and sometimes patients. Detailed analysis of those results will be reported in a future report. This study is based on the design of a telemonitoring system for heart failure self-care that intents to overcome the gap that occurs when patients discharge from the hospital and tries to accurate requirement of readmission. A rule set for classifying and resulting automated alerts and patient instructions for heart failure telemonitoring was developed. It also facilitates daily communication among patients and heart failure clinicians so any deterioration in health could be identified immediately.

Repaglinide in combination therapy.

PubMed

Moses, R

2002-12-01

Type 2 diabetes mellitus (T2DM) is a progressive disorder requiring increasingly aggressive treatment to achieve and maintain target blood glucose concentrations in the presence of deteriorating insulin secretion and increasing insulin resistance. Diet and lifestyle modification are often sufficient initially; however, most patients eventually require pharmacological intervention. With disease progression, monotherapy becomes less effective, so combination therapy is required, using drugs with complementary modes of action to maximise glycaemic control. The prandial glucose regulator repaglinide has been studied in combination with metformin (an inhibitor of hepatic glucose production), neutral protamine Hagedorn (NPH)-insulin (which has a long duration of effect, but at the risk of early hypoglycaemia and late hyperglycaemia in the dosing interval) and three thiazolidinediones (TZDs--troglitazone, rosiglitazone and pioglitazone, which stimulate nuclear receptors to increase insulin sensitivity and reduce insulin resistance) in patients whose diabetes was inadequately controlled by previous monotherapy or combination therapy. The combination of repaglinide and metformin resulted in reduced fasting plasma glucose concentrations (by 2.2 mmol/l) and HbA1c (by 1.4%). Combination therapy with repaglinide and bedtime NPH-insulin resulted in reductions in fasting plasma glucose (by 5.4 mmol/l) and HbA1c (by 0.7%). The combination of repaglinide and each TZD also resulted in consistent decreases in fasting plasma glucose concentrations and HbA1c. No severe hypoglycaemic episodes were reported in the three studies. In conclusion, repaglinide has additive, and often synergistic, effects on glycaemic control when given in combination regimens and should be a valuable option in the management of patients with T2DM.

Value of innovation for hematologic malignancies.

PubMed

Monia, Marchetti

2016-01-01

Several novel drugs are dramatically improving both lifespan and quality-of-life of patients with blood cancers. Prolonged disease duration and increased treatment costs for hematologic malignancies impose a relevant economic burden onto healthcare services, despite the low incidence of blood cancers. Therefore, an appropriate paradigm for valuing 'innovation' is urgently required in order to refine pricing and reimbursement decisions. Cost-per-QALY-gained is still the standard metric for assessing the 'incremental' value of new drugs; however, the high number of 'comparator' therapies and the huge variety of treatment sequences make plain two-treatment comparisons sub-optimal, while multiple-treatment and multiple-sequence comparisons require complex and less-transparent decision models. A repository of standard backbones for decision models might allow benchmarking and comparability among cost-effectiveness analyses; however, an international effort is required to build it up. Deontology recommends that hematologists act in optimizing healthcare resources while preserving patient-physician alliance, but clinical practice guidelines do not support doctors in balancing cost against clinical outcomes. Decision models of chronic blood cancers unexpectedly proved that cost might be an appropriate value for innovation if treatments avoided severe toxicity and further lines of treatments, despite the eventually long duration of treatment and the competing risk of death due to comorbidity and old age. The improved transparency of decision models allows sharing of relevant structural and analytic parameters (i.e., time horizon, comparator treatments, hierarchy of end-point, assumptions, source of data, sub-group analyses) by stakeholders, physicians and patients, making health economics a noble 'translator' of values for innovation.

Math Requirement Fulfillment and Educational Success of Community College Students: A Matter of When

ERIC Educational Resources Information Center

Wang, Xueli; Wang, Yan; Wickersham, Kelly; Sun, Ning; Chan, Hsun-yu

2017-01-01

Objective: In community colleges, achieving competence in math is critical to students' timely progression through coursework and eventual educational success; yet, it remains unclear when the optimal timing to complete required math courses is in order to maximize the chance of completing a credential on time. This study examines the timing of…

Clinical manufacturing of CAR T cells: foundation of a promising therapy

PubMed Central

Wang, Xiuyan; Rivière, Isabelle

2016-01-01

The treatment of cancer patients with autologous T cells expressing a chimeric antigen receptor (CAR) is one of the most promising adoptive cellular therapy approaches. Reproducible manufacturing of high-quality, clinical-grade CAR-T cell products is a prerequisite for the wide application of this technology. Product quality needs to be built-in within every step of the manufacturing process. We summarize herein the requirements and logistics to be considered, as well as the state of the art manufacturing platforms available. CAR-T cell therapy may be on the verge of becoming standard of care for a few clinical indications. Yet, many challenges pertaining to manufacturing standardization and product characterization remain to be overcome in order to achieve broad usage and eventual commercialization of this therapeutic modality. PMID:27347557

West Nile Meningoencephalitis Presenting as Isolated Bulbar Palsy With Hypercapnic Respiratory Failure: Case Report and Literature Review.

PubMed

Tso, Geoffrey; Kaldas, Kirsten; Springer, Joseph; Barot, Nikhil; Kamangar, Nader

2016-05-01

Since the outbreak of West Nile virus (WNV) in the United States in 1999, the WNV neuroinvasive disease has been increasingly reported with a wide spectrum of neuromuscular manifestations. We submit a case of a 46-year-old male with a history of alcohol abuse, diabetes, hypertension, and hepatitis C who presented with fever, nausea, shortness of breath, and dysphagia. The patient rapidly developed hypercapnic respiratory failure and was found to have WNV meningoencephalitis without obvious neuromuscular weakness. His hospital course was significant for repeated failures of extubation secondary to persistent bulbar weakness eventually requiring tracheotomy. This is a unique case of WNV meningoencephalitis with bulbar palsy without other neuromuscular manifestations resulting in recurrent hypercapnic respiratory failure. © The Author(s) 2015.

Patient satisfaction is a best practice.

PubMed

2009-10-01

There are several best practices ED physicians and nurses can adopt to minimize the likelihood of a lawsuit, but perhaps none is more important than ensuring high patient satisfaction scores. Research shows a definite correlation between increasing patient satisfaction and decreasing the medical malpractice frequency. Bad outcomes are more likely to lead to lawsuits if the patient doesn't like their doctor or nurse. Being attuned to patients and their perspective is one of the best ways to prevent complaints, which eventually can lead to lawsuits.

Weight Loss and Variation of Levothyroxine Requirements in Hypothyroid Obese Patients After Bariatric Surgery.

PubMed

Fierabracci, Paola; Martinelli, Silvia; Tamberi, Anna; Piaggi, Paolo; Basolo, Alessio; Pelosini, Caterina; Ricco, Ilaria; Magno, Silvia; Querci, Giorgia; Ceccarini, Giovanni; Scartabelli, Giovanna; Salvetti, Guido; Vitti, Paolo; Santini, Ferruccio

2016-04-01

Obesity and hypothyroidism are both common disorders within the general population. Obese hypothyroid subjects require higher doses of levothyroxine (LT4) compared with normal weight individuals. Previous studies on the effects of bariatric surgery on LT4 dose requirements in hypothyroid subjects have provided conflicting results. The aim of this study was to evaluate the LT4 requirements in a group of obese subjects with acquired hypothyroidism, before and after weight loss achieved by bariatric surgery. Ninety-three obese hypothyroid subjects (mean age = 48 ± 9 years; mean body mass index = 45.9 ± 5.6 kg/m(2)), were evaluated before and 28 ± 8 months after bariatric surgery. Changes in the LT4 dose, anthropometric measures, and hormone values were evaluated. In 20 patients, data of body composition, assessed by dual energy X-ray absorptiometry, were also analyzed. On average, after weight loss, a significant reduction of the total dose of LT4 was documented (from 130.6 ± 48.5 to 116.2 ± 38.6 μg/day; p < 0.001). The LT4 dose had to be reduced in 47 patients, was unchanged in 34, and had to be increased in 12 patients affected by autoimmune thyroiditis. Reduction of the LT4 dose was proportional to reduction of the lean body mass. The weight loss achieved with modern surgical bariatric procedures is associated with a reduction of LT4 requirements in most hypothyroid subjects, which appears to be related to a decrease of the lean body mass. Occasionally, a concurrent decline of residual thyroid function, as it occurs in autoimmune thyroiditis, can counteract this phenomenon and eventually produce an increase of LT4 needs. It is believed that during the weight loss phase that follows bariatric surgery, there is no need for preventive adjustments of the LT4 dose, but serum thyroid hormones and thyrotropin should be periodically monitored in order to detect possible variations of LT4 requirements and to allow proper corrections of the therapy.

Designing and Implementation of a Heart Failure Telemonitoring System

PubMed Central

Safdari, Reza; Jafarpour, Maryam; Mokhtaran, Mehrshad; Naderi, Nasim

2017-01-01

Introduction: The aim of this study was to identify patients at-risk, enhancing self-care management of HF patients at home and reduce the disease exacerbations and readmissions. Method: In this research according to standard heart failure guidelines and Semi-structured interviews with 10 heart failure Specialists, a draft heart failure rule set for alerts and patient instructions was developed. Eventually, the clinical champion of the project vetted the rule set. Also we designed a transactional system to enhance monitoring and follow up of CHF patients. With this system, CHF patients are required to measure their physiological measurements (vital signs and body weight) every day and to submit their symptoms using the app. additionally, based on their data, they will receive customized notifications and motivation messages to classify risk of disease exacerbation. The architecture of system comprised of six major components: 1) a patient data collection suite including a mobile app and website; 2) Data Receiver; 3) Database; 4) a Specialists expert Panel; 5) Rule engine classifier; 6) Notifier engine. Results: This system has implemented in Iran for the first time and we are currently in the testing phase with 10 patients to evaluate the technical performance of our system. The developed expert system generates alerts and instructions based on the patient’s data and the notify engine notifies responsible nurses and physicians and sometimes patients. Detailed analysis of those results will be reported in a future report. Conclusion: This study is based on the design of a telemonitoring system for heart failure self-care that intents to overcome the gap that occurs when patients discharge from the hospital and tries to accurate requirement of readmission. A rule set for classifying and resulting automated alerts and patient instructions for heart failure telemonitoring was developed. It also facilitates daily communication among patients and heart failure clinicians so any deterioration in health could be identified immediately. PMID:29114106

Operative interventions for failed heller myotomy: a single institution experience.

PubMed

Pallati, Pradeep K; Mittal, Sumeet K

2011-03-01

Recurrent dysphagia and/or gastroesophageal reflux (GER) are failures of treatment after Heller myotomy for achalasia. We present our single center experience with surgical interventions for these failures. We did a retrospective analysis of a prospectively collected database. Based on preoperative symptoms and endoscopy, esophagogram, and manometry results, patients were divided into three groups to guide management. Telephone follow-up was done using a structured foregut questionnaire. Between December 2003 and June 2009, 16 patients underwent operative interventions for disabling symptoms after previous Heller myotomy. Eight patients presented primarily with recurrent dysphagia and underwent transabdominal Heller myotomy with partial fundoplication. Seven patients reported good to excellent symptom relief at mean follow-up of 42 months. One patient reported no relief and eventually required esophageal bypass with retrosternal gastric pull-up. Four patients presented with uncontrolled GER. Two patients who underwent redo partial fundoplication reported poor symptomatic outcome and one patient has since undergone short limb Roux-en-y gastric bypass (SLRNYGB) with excellent symptom relief. The other two patients underwent SLRNYGB with excellent relief at 10 months. Four patients had end stage achalasia and underwent esophageal resection with reconstruction. All reported excellent symptom relief at mean follow-up of 36 months. Transabdominal redo Heller myotomy for dysphagia has good outcomes. Redo fundoplication for GER after previous myotomy has poor results and SLRNYGB is an effective option in these patients. Esophageal resection remains an effective, albeit morbid, option for end-stage achalasia.

Incidence of pericardial effusion after left atrial appendage closure: The impact of underlying heart rhythm. data from the EWOLUTION study.

PubMed

Schmidt, Boris; Betts, Timothy R; Sievert, Horst; Bergmann, Martin W; Kische, Stephan; Pokushalov, Evgeny; Schmitz, Thomas; Meincke, Felix; Mazzone, Patrizio; Stein, Kenneth M; Ince, Hüseyin; Boersma, Lucas V A

2018-05-03

Pericardial effusion/tamponade (PE/PT) is a rare but serious complication following left atrial appendage closure (LAAC). It may be speculated that LAA contraction during sinus rhythm (SR) exerts mechanical force on the device that eventually leads to PE. We sought to determine the incidence and predictors of PE following LAAC using Watchman with special emphasis on the underlying heart rhythm during implant. From 47 centers in 13 European countries 1020 patients underwent LAAC and data on baseline rhythm were available from 1010 patients (mean age 73 ± 9 years, 60% male, median CHA2DS2-VASc = 4). Data were collected via electronic case report forms. A Cox-proportional hazard model was calculated adjusting for multiple variables: age, gender, number of recaptures and device oversizing. During implant, 41% and 59% of patients were in SR and atrial fibrillation (AF), respectively. PE/PT rate was significantly lower in patients implanted during AF at day 30 post implant (n = 1; 0.2% versus n = 6; 1.5%; p = 0.02). No PE requiring intervention occurred in the AF group compared to 5 events (1.2%) in the SR group (p = 0.01). While univariate analysis identified SR and gender as predictors for PE/tamponade, multivariate analysis only showed a statistical trend for both variables. The overall incidence of PE/PT was very low after LAAC using Watchman. Although SR was not identified as an independent predictor of PE/PT, all events requiring intervention occurred in patients with SR. It may be advisable to perform an extended echocardiographic follow-up in that patient population. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

The 200th anniversary of the stethoscope: Can this low-tech device survive in the high-tech 21st century?

PubMed

Bank, Ivan; Vliegen, Hubert W; Bruschke, Albert V G

2016-12-14

In 1816, Laennec discovered that auscultation of the heart and lungs could effectively be performed by placing a hollow cylinder (initially made of a roll of paper) between the chest of the patient and the ear of the examiner. This was the first step in the development of the stethoscope, which was a breakthrough in the diagnosis and management of cardiac and pulmonary patients. Technical improvements of the stethoscope followed and in cardiac patients auscultation soon became a major diagnostic tool. In the second half of the 20th century, new powerful non-invasive diagnostic modalities were developed and the interest in auscultation declined. As a result, the auscultatory skills of students and physicians at all levels of training decreased to a disappointingly low level. We now must decide whether we should stimulate the use of and proficiency in auscultation or if we should accept the further decline and eventual abolishment of this component of the physical examination. Reviewing the literature and taking into consideration the setting in which the patients are presented, including the availability of advanced diagnostic facilities, we conclude that the time-honoured stethoscope, in spite of its limitations, still has potential as a patient-friendly, effective, and economical instrument in medical practice. However, new initiatives are required to train students, physicians and allied health professionals in cardiac auscultation to avoid misinterpretations that may harm the patients and generate extra costs. To be successful such programs will require wide support from the medical community. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Urgent Chemotherapy for Life-Threatening Complications Related to Solid Neoplasms.

PubMed

Zerbib, Yoann; Rabbat, Antoine; Fartoukh, Muriel; Bigé, Naïke; Andréjak, Claire; Mayaux, Julien; De Prost, Nicolas; Misset, Benoît; Lemiale, Virginie; Bruneel, Fabrice; Maizel, Julien; Ricome, Sylvie; Jacobs, Frédéric; Bornstain, Caroline; Dupont, Hervé; Baudin, François; Azoulay, Elie; Pène, Frédéric

2017-07-01

Solid neoplasms can be directly responsible for organ failures at the time of diagnosis or relapse. The management of such specific complications relies on urgent chemotherapy and eventual instrumental or surgical procedures, combined with advanced life support. We conducted a multicenter study to address the prognosis of this condition. A multicenter retrospective (2001-2015) chart review. Medical and respiratory ICUs. Adult patients who received urgent chemotherapy in the ICU for organ failure related to solid neoplasms were included. The modalities of chemotherapy, requirements of adjuvant instrumental or surgical procedures, and organ supports were collected. Endpoints were short- and long-term survival rates. None. One hundred thirty-six patients were included. Lung cancer was the most common malignancy distributed into small cell lung cancer (n = 57) and non-small cell lung cancer (n = 33). The main reason for ICU admission was acute respiratory failure in 111 patients (81.6%), of whom 89 required invasive mechanical ventilation. Compression and tissue infiltration by tumor cells were the leading mechanisms resulting in organ involvement in 78 (57.4%) and 47 (34.6%) patients. The overall in-ICU, in-hospital, 6-month, and 1-year mortality rates were 37%, 58%, 74%, and 88%, respectively. Small cell lung cancer was identified as an independent predictor of hospital survival. However, this gain in survival was not sustained since the 1-year survival rates of small cell lung cancer, non-small cell lung cancer, and non-lung cancer patients all dropped below 20%. Urgent chemotherapy along with aggressive management of organ failures in the ICU can be lifesaving in very selected cancer patients, most especially with small cell lung cancer, although the long-term survival is hardly sustainable.

Experience in Bedside Placement, Clinical Validity, and Cost-Efficacy of a Self-Propelled Nasojejunal Feeding Tube

PubMed Central

Puiggròs, Carolina; Molinos, Rosa; Ortiz, M. Dolors; Ribas, Montserrat; Romero, Carlos; Vázquez, Concepcion; Segurola, Hegoi; Burgos, Rosa

2015-01-01

Background: The procedures needed to insert nasojejunal tubes (NJTs) are often invasive or uncomfortable for the patient and require hospital resources. The objectives of this study were to describe our experience in inserting a self-propelling NJT with distal pigtail end and evaluate clinical validity and cost efficacy of this enteral nutrition (EN) approach compared with parenteral nutrition (PN). Materials and Methods: Prospective study from July 2009 to December 2010, including hospitalized noncritical patients who required short-term jejunal EN. The tubes were inserted at bedside, using intravenous erythromycin as a prokinetic drug. Positioning was considered correct when the distal end was beyond the ligament of Treitz. Migration failure was considered when the tube was not positioned into the jejunum within 48 hours postinsertion. Results: Fifty-six insertions were recorded in 47 patients, most frequently in severe acute pancreatitis (69.6%). The migration rates at 18 and 48 hours postinsertion were 73.2% and 82.1%, respectively. There was migration failure in 8.9% of cases, and 8.9% were classified null (the tube was no longer in the gastrointestinal tract at 18 hours). There were no reported or observed complications. The mean duration of the EN was 12 ± 10.8 days. Five different types of EN formula were used. The total study cost was 53.9% lower compared with using PN in all patients. Conclusions: Our study demonstrated that bedside insertion of a self-propelling NJT is a safe, cost-effective, and successful technique for postpyloric enteral feeding in at least 73% of the patients, and only 18% of patients could eventually need other placement techniques. It can avoid the need for more aggressive or expensive placement techniques or even PN if we cannot achieve enteral access. PMID:26214512

Cost considerations in selecting coronary artery revascularization therapy in the elderly.

PubMed

Maziarz, David M; Koutlas, Theodore C

2004-01-01

This article presents some of the cost factors involved in selecting coronary artery revascularization therapy in an elderly patient. With the percentage of gross national product allocated to healthcare continuing to rise in the US, resource allocation has become an issue. Percutaneous coronary intervention continues to be a viable option for many patients, with lower initial costs. However, long-term angina-free results often require further interventions or eventual surgery. Once coronary artery revascularization therapy is selected, it is worthwhile to evaluate the cost considerations inherent to various techniques. Off-pump coronary artery bypass graft surgery has seen a resurgence, with improved technology and lower hospital costs than on-pump bypass surgery. Numerous factors contributing to cost in coronary surgery have been studied and several are documented here, including the potential benefits of early extubation and the use of standardized optimal care pathways. A wide range of hospital-level cost variation has been noted, and standardization issues remain. With the advent of advanced computer-assisted robotic techniques, a push toward totally endoscopic bypass surgery has begun, with the eventual hope of reducing hospital stays to a minimum while maximizing outcomes, thus reducing intensive care unit and stepdown care times, which contribute a great deal toward overall cost. At the present time, these techniques add a significant premium to hospital charges, outweighing any potential length-of-stay benefits from a cost standpoint. As our elderly population continues to grow, use of healthcare resource dollars will continue to be heavily scrutinized. Although the clinical outcome remains the ultimate benchmark, cost containment and optimization of resources will take on a larger role in the future. Copyright 2004 Adis Data Information BV

My Story: Real Stories of People Living with Thalassemia

MedlinePlus

... My Story Recommend on Facebook Tweet Share Compartir Real Stories from People living with Thalassemia On this ... blood diseases. Eventually, I would really like to travel the world and treat patients in places where ...

Depression and Suicide Risk

MedlinePlus

... due to another medical disorder Relationship Between Depression & Suicide: 1. Depression is the psychiatric diagnosis most commonly associated with ... of patients with treated depression eventually die by suicide. xiv 4. Depression is present in at least 50 percent of ...

Long-term safety and outcome of fludarabine, cyclophosphamide and mitoxantrone (FCM) regimen in previously untreated patients with advanced follicular lymphoma: 12 years follow-up of a phase 2 trial.

PubMed

Magnano, Laura; Montoto, Silvia; González-Barca, Eva; Briones, Javier; Sancho, Juan Manuel; Muntañola, Ana; Salar, Antonio; Besalduch, Joan; Escoda, Lourdes; Moreno, Carol; Domingo-Domenech, Eva; Estany, Cristina; Oriol, Albert; Altés, Albert; Pedro, Carmen; Gardella, Santiago; Asensio, Antoni; Vivancos, Pilar; Fernández de Sevilla, Alberto; Ribera, Josep María; Colomer, Dolors; Campo, Elias; López-Guillermo, Armando

2017-04-01

Fludarabine combinations are very affective in follicular lymphoma (FL) with high rates of complete response and prolonged survival. However, late toxicities could be a concern. The aim of the present study was to analyze the long-term impact on survival, relapse and late toxicities of a trial of treatment with fludarabine, mitoxantrone and cyclophosphamide (FCM regimen) for untreated patients with advanced stage FL. One hundred and twenty patients enrolled in a phase 2 trial of treatment with FCM regimen between 2000 and 2003 were evaluated. After a median follow-up of 12 years, 52 patients eventually relapsed/progressed with 10 year progression-free survival (PFS) of 46 %. Ten patients showed histological transformation to aggressive lymphoma with a risk of transformation of 2 and 9 % at 5 and 10 years, respectively. Three patients developed therapy-related myelodysplastic syndrome/acute myeloid leukaemia (MDS/AML) and seven solid neoplasms with an overall risk of 3 and 8 % at 5 and 10 years, respectively. Twenty-six patients eventually died during the follow-up. Overall survival at 10 years was 83 %. In conclusion, FCM regimen allows excellent long-lasting response in previously untreated patients with FL. The incidence of late events including histological transformation and secondary neoplasia is low but not negligible.

Discrete Pathophysiology is Uncommon in Patients with Nonspecific Arm Pain.

PubMed

Kortlever, Joost T P; Janssen, Stein J; Molleman, Jeroen; Hageman, Michiel G J S; Ring, David

2016-06-01

Nonspecific symptoms are common in all areas of medicine. Patients and caregivers can be frustrated when an illness cannot be reduced to a discrete pathophysiological process that corresponds with the symptoms. We therefore asked the following questions: 1) Which demographic factors and psychological comorbidities are associated with change from an initial diagnosis of nonspecific arm pain to eventual identification of discrete pathophysiology that corresponds with symptoms? 2) What is the percentage of patients eventually diagnosed with discrete pathophysiology, what are those pathologies, and do they account for the symptoms? We evaluated 634 patients with an isolated diagnosis of nonspecific upper extremity pain to see if discrete pathophysiology was diagnosed on subsequent visits to the same hand surgeon, a different hand surgeon, or any physician within our health system for the same pain. There were too few patients with discrete pathophysiology at follow-up to address the primary study question. Definite discrete pathophysiology that corresponded with the symptoms was identified in subsequent evaluations by the index surgeon in one patient (0.16% of all patients) and cured with surgery (nodular fasciitis). Subsequent doctors identified possible discrete pathophysiology in one patient and speculative pathophysiology in four patients and the index surgeon identified possible discrete pathophysiology in four patients, but the five discrete diagnoses accounted for only a fraction of the symptoms. Nonspecific diagnoses are not harmful. Prospective randomized research is merited to determine if nonspecific, descriptive diagnoses are better for patients than specific diagnoses that imply pathophysiology in the absence of discrete verifiable pathophysiology.

Munchausen's syndrome: a medico-legal dilemma.

PubMed

Mydlo, J H; Macchia, R J; Kanter, J L

1997-07-01

In his or her life-long career, the physician will eventually encounter a patient with factitious disorder, or Munchausen's syndrome. We discuss two patients complaining of renal colic that were identified as having Munchausen's syndrome. We review the literature to identify certain aspects of the disease and to discuss the medical and legal implications for the treating physician and hospital.

Outcomes of changing immunosuppressive therapy after treatment failure in patients with noninfectious uveitis.

PubMed

Joshi, Lavnish; Talat, Lazha; Yaganti, Satish; Sandhu, Sartaj; Taylor, Simon R J; Wakefield, Denis; McCluskey, Peter; Lightman, Susan

2014-05-01

To evaluate the outcomes of changing immunosuppressive therapy for noninfectious uveitis after failure. Retrospective cohort study. Patients with noninfectious uveitis managed at 2 tertiary uveitis clinics in the United Kingdom and Australia. Participants with a history of using immunosuppressive therapy were identified in clinics, and notes were reviewed by doctors trained in uveitis therapy. Each treatment episode/course (starting or changing a therapy) was identified, and demographic details, clinical characteristics, drug used (second-line immunosuppressive agent [ISA] or biologicals), and drug doses were obtained. For each treatment episode, the reasons for changing therapy, corticosteroid-sparing effects, and control of inflammation were determined. A total of 147 patients were identified who underwent 309 different treatment episodes. Fifty-five percent of patients eventually required a change in treatment after their first treatment episode/course. Forty-five episodes involved switching from one ISA to another, with 50% to 100% of these patients achieving "success" (prednisolone ≤10 mg and sustained control) with the new ISA. A combination of ISAs were used in 53 episodes, with "success" being achieved in 50% to 71% of these patients. Biological agents were used in 45 episodes, the most common one being infliximab, which achieved success in 80% of patients. Our data suggest that control of inflammation can be achieved after switching or combining ISAs. Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Long-term Durability of Infrainguinal Endovascular and Open Revascularization for Disabling Claudication.

PubMed

Khan, Sikandar Z; Rivero, Mariel; Cherr, Gregory S; Harris, Linda M; Dryjski, Maciej L; Dosluoglu, Hasan H

2018-05-15

Infrainguinal revascularization for disabling claudication (DC) is frequently performed, but long-term results are still unknown. In this study, we compared clinical outcomes of infrainguinal endovascular (EV) and open interventions for DC after the failure of medical management. One hundred ninety-four patients with DC (Rutherford category 3) who had open (n = 53) or EV (n = 141) interventions were grouped as open-great saphenous vein (GSV) (n = 21), open-prosthetic (n = 32), EV-Trans-Atlantic Inter-Society Consensus II (TASC II) A and B (AB) (n = 48), and EV-TASC II C and D (CD) (n = 93). Patency, primary clinical success (PCS; sustained improvement in symptoms without reintervention), and secondary clinical success (SCS; sustained improvement in symptoms with reintervention) rates were compared. Mean follow-up was 57 ± 33 months. Five-year primary patency was 58% in open-GSV, 40% in open-prosthetic, 72% in EV-AB, and 38% in EV-CD (P < 0.001). Five-year secondary patency was 77% in open-GSV, 50% in open-prosthetic, 96% in EV-AB, and 61% in EV-CD (P < 0.001). Freedom from major adverse limb events was 73% in open-GSV, 77% in EV-AB, 70% in EV-CD, and 67% in open-prosthetic (P = 0.279). Five-year PCS was 46% in open-GSV, 40% in open-prosthetic, 57% in EV-AB, and 44% in EV-CD (P = 0.02). Five-year SCS was 78% in open-GSV, 78% in open-prosthetic, 85% in EV-AB, and 84% in EV-CD (P = 0.732). A total of 116 reinterventions were performed, 10 in 6 limbs (27%) in open-GSV, 18 in 12 limbs (36%) in open-prosthetic, 26 in 15 limbs (24%) in EV-AB, and 62 in 39 limbs (36%) in EV-CD. Reinterventions included 71 (61%) EV and 45 (39%) open procedures. Durability of infrainguinal interventions in claudicants depends mainly on anatomic complexity of disease. Good long-term clinical success can be achieved with both open and EV interventions, albeit with high reintervention rates, especially in patients with TASC II C and D disease. A considerable subset of EV patients will eventually require surgical revascularization to maintain clinical benefit. In this study, almost 20% of patients undergoing EV for TASC II C and D disease eventually required surgical bypass. Copyright © 2018 Elsevier Inc. All rights reserved.

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

Mirsadraee, Saeed; Tuite, David; Nicholson, Anthony, E-mail: Tony.Nicholson@leedsth.nhs.u

This case series examines the safety and efficacy of uterine artery embolization (UAE) in the treatment of obstructive nephropathy caused by large fibroids. Between 2004 and 2007, 10 patients referred with symptomatic uterine fibroids that were found to be causing either unilateral (7 patients) or bilateral (3 patients) hydronephrosis were treated by UAE. Presenting complaints included menorrhagia, dysmenorrhea, bulk symptoms, loin pain, postobstructive atrophy, and mild renal impairment. All had posterior intramural dominant fibroids >11 cm in maximum sagittal diameter and uterine volumes between 3776 and 15,625 ml. Outcome measures at between 12 and 36 months included procedural success, repeatmore » intervention, relief of symptoms, resolution of hydronephrosis, stable renal function and size, and avoidance of hysterectomy. In all cases the cause of renal obstruction was confirmed to be a giant fibroid compressing the ureter at the pelvic brim. In all cases UAE was technically successful, though two patients required a repeat procedure. In eight patients hydronephrosis resolved and the obstruction was relieved, though two still had some bulk symptoms not requiring further treatment. Renal function improved or was stable in all cases. Renal size was stable in all cases. Where menorrhagia was part of the symptom complex it was relieved in all cases. Two patients diagnosed as having postobstructive atrophy of one kidney underwent retrograde ureteric stenting on the nonatrophied side prior to UAE. This was unsuccessful in one of the cases due to the distortion caused by the fibroid. Despite improvement in hydronephrosis this patient underwent hysterectomy at 7 months after a renogram demonstrated persistent obstruction at the pelvic brim. In the second patient a double pigtail stent was inserted with difficulty and eventually removed at 8 months. This patient has had stable renal function and size for 3 years post-UAE. We conclude that UAE is safe and effective in treating patients with obstructive hydronephrosis caused by large fibroids.« less

Transfer of ipsilateral fibula on vascular pedicle for treatment of congenital pseudarthrosis of the tibia.

PubMed

Tan, Jane S; Roach, James W; Wang, Angela A

2011-01-01

Although the use of free vascularized fibula grafts has frequently been reported in the treatment of congenital pseudarthrosis of the tibia, the use of ipsilateral fibula graft on a vascular pedicle is uncommon. We reviewed the long-term results of this procedure in 11 patients. The records of 11 patients who underwent transfer of the ipsilateral fibula on a vascular pedicle between 2.1 and 10.8 years of age were retrospectively reviewed. Average follow-up was 11 years after the index procedure. Seven patients had reached skeletal maturity. Clinical records and radiographs were reviewed to determine patient demographics, surgical parameters, union rate, refracture rate, residual deformity, and functional outcome. Eight patients (73%) achieved union at an average of 20.1 months. Additional bone grafting procedures were required in 4 patients with distal nonunions. There were 3 refractures (38%). Four patients eventually underwent amputation, and 1 patient had a persistent nonunion at final follow-up. Residual deformity included tibial valgus and procurvatum deformities, limb length discrepancy, and ankle valgus. Use of the ipsilateral fibula did not seem to increase the risk of ankle valgus. Functional outcomes were good in all but one patient. Use of the ipsilateral fibula as a pedicle graft provides reasonable results in healing congenital pseudarthrosis of the tibia. Patients should be monitored for the sequelae of this condition, including nonunion, refracture, shortening, and angular deformity, and treated accordingly. Therapeutic Level IV.

Refractory open-angle glaucoma after neodymium-yttrium-aluminum-garnet laser lysis of vitreous floaters.

PubMed

Cowan, Lisa A; Khine, Kay T; Chopra, Vikas; Fazio, Doreen T; Francis, Brian A

2015-01-01

To illustrate 3 cases of chronic open-angle glaucoma secondary to the neodymium-yttrium-aluminum-garnet (Nd:YAG) laser vitreolysis procedure for symptomatic vitreous floaters. Observational case series. Location of the study was the Doheny Eye Institute. Three eyes of 2 patients who developed chronic open-angle glaucoma after Nd:YAG vitreolysis for symptomatic floaters presenting with very high intraocular pressure (IOP >40 mm Hg) were selected. The time from the laser treatment to the onset of elevated pressure ranges from 1 week to 8 months. There was no associated inflammation, steroid use, or other identifiable cause of chronic IOP elevation. All eyes were treated initially with glaucoma medication, followed by selective laser trabeculoplasty (SLT) and eventually glaucoma surgery (Trabectome) in 2 eyes for disease management. In all eyes, intraocular pressures were eventually stabilized within a normal pressure range from 18 to 38 months following Nd:YAG vitreolysis. At the latest follow-up post surgery, all eyes had intraocular pressures of 22 mm Hg or less with or without medications. Secondary open-angle glaucoma is a complication of Nd:YAG vitreolysis for symptomatic floaters that may present with an increase in intraocular pressure immediately, or many months after the surgery. Furthermore this complication may be permanent and require chronic medical therapy or glaucoma surgery. Copyright © 2015 Elsevier Inc. All rights reserved.

Quantitative Imaging in Cancer Clinical Trials

PubMed Central

Yankeelov, Thomas E.; Mankoff, David A.; Schwartz, Lawrence H.; Lieberman, Frank S.; Buatti, John M.; Mountz, James M.; Erickson, Bradley J.; Fennessy, Fiona M.M.; Huang, Wei; Kalpathy-Cramer, Jayashree; Wahl, Richard L.; Linden, Hannah M.; Kinahan, Paul; Zhao, Binsheng; Hylton, Nola M.; Gillies, Robert J.; Clarke, Laurence; Nordstrom, Robert; Rubin, Daniel L.

2015-01-01

As anti-cancer therapies designed to target specific molecular pathways have been developed, it has become critical to develop methods to assess the response induced by such agents. While traditional, anatomic CT and MRI exams are useful in many settings, there is increasing evidence that these methods cannot answer the fundamental biological and physiological questions essential for assessment and, eventually, prediction of treatment response in the clinical trial setting, especially in the critical period soon after treatment is initiated. To optimally apply advances in quantitative imaging methods to trials of targeted cancer therapy, new infrastructure improvements are needed that incorporate these emerging techniques into the settings where they are most likely to have impact. In this review, we first elucidate the needs for therapeutic response assessment in the era of molecularly targeted therapy and describe how quantitative imaging can most effectively provide scientifically and clinically relevant data. We then describe the tools and methods required to apply quantitative imaging and provide concrete examples of work making these advances practically available for routine application in clinical trials. We conclude by proposing strategies to surmount barriers to wider incorporation of these quantitative imaging methods into clinical trials and, eventually, clinical practice. Our goal is to encourage and guide the oncology community to deploy standardized quantitative imaging techniques in clinical trials to further personalize care for cancer patients, and to provide a more efficient path for the development of improved targeted therapies. PMID:26773162

Quality assurance and training procedures for computer-aided detection and diagnosis systems in clinical usea)

PubMed Central

Huo, Zhimin; Summers, Ronald M.; Paquerault, Sophie; Lo, Joseph; Hoffmeister, Jeffrey; Armato, Samuel G.; Freedman, Matthew T.; Lin, Jesse; Ben Lo, Shih-Chung; Petrick, Nicholas; Sahiner, Berkman; Fryd, David; Yoshida, Hiroyuki; Chan, Heang-Ping

2013-01-01

Computer-aided detection/diagnosis (CAD) is increasingly used for decision support by clinicians for detection and interpretation of diseases. However, there are no quality assurance (QA) requirements for CAD in clinical use at present. QA of CAD is important so that end users can be made aware of changes in CAD performance both due to intentional or unintentional causes. In addition, end-user training is critical to prevent improper use of CAD, which could potentially result in lower overall clinical performance. Research on QA of CAD and user training are limited to date. The purpose of this paper is to bring attention to these issues, inform the readers of the opinions of the members of the American Association of Physicists in Medicine (AAPM) CAD subcommittee, and thus stimulate further discussion in the CAD community on these topics. The recommendations in this paper are intended to be work items for AAPM task groups that will be formed to address QA and user training issues on CAD in the future. The work items may serve as a framework for the discussion and eventual design of detailed QA and training procedures for physicists and users of CAD. Some of the recommendations are considered by the subcommittee to be reasonably easy and practical and can be implemented immediately by the end users; others are considered to be “best practice” approaches, which may require significant effort, additional tools, and proper training to implement. The eventual standardization of the requirements of QA procedures for CAD will have to be determined through consensus from members of the CAD community, and user training may require support of professional societies. It is expected that high-quality CAD and proper use of CAD could allow these systems to achieve their true potential, thus benefiting both the patients and the clinicians, and may bring about more widespread clinical use of CAD for many other diseases and applications. It is hoped that the awareness of the need for appropriate CAD QA and user training will stimulate new ideas and approaches for implementing such procedures efficiently and effectively as well as funding opportunities to fulfill such critical efforts. PMID:23822459

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

Ito, Hisao; Yamada, Takayuki; Ishibashi, Tadashi

A 65-year-old man underwent a thromboexclusionoperation for management of chronic Stanford type B dissecting aneurysmin 1991. However, long-term follow-up CT scans after the operation revealed that the ascending aorta gradually enlarged and was eventually complicated by recurrent aortic dissection. The patient complained of frequent bloody sputum, whereas chest roentogenography showed no pulmonary abnormalities. Subsequent swallow esophagogram demonstrated that the upper esophagus was deviated to the right and the middle esophagus was greatly compressed by the aortic clamp. Esophageal endoscopy showed a bloody inner surface and marked swelling of the middle esophagus. The patient eventually died of massive hematemesis in 2001.more » We describe the imaging features of unanticipated complications such as recurrent dissecting aneurysm or impending esophageal rupture.Furthermore, we discuss the cause of hematemesis and document that the aortic clamp migrated and resulted in development of a recurrent aneurysmal dissection, which in turn resulted in esophageal rupture with aneurysmal disruption.« less

Integrated Human-Robotic Missions to the Moon and Mars: Mission Operations Design Implications

NASA Technical Reports Server (NTRS)

Mishkin, Andrew; Lee, Young; Korth, David; LeBlanc, Troy

2007-01-01

For most of the history of space exploration, human and robotic programs have been independent, and have responded to distinct requirements. The NASA Vision for Space Exploration calls for the return of humans to the Moon, and the eventual human exploration of Mars; the complexity of this range of missions will require an unprecedented use of automation and robotics in support of human crews. The challenges of human Mars missions, including roundtrip communications time delays of 6 to 40 minutes, interplanetary transit times of many months, and the need to manage lifecycle costs, will require the evolution of a new mission operations paradigm far less dependent on real-time monitoring and response by an Earthbound operations team. Robotic systems and automation will augment human capability, increase human safety by providing means to perform many tasks without requiring immediate human presence, and enable the transfer of traditional mission control tasks from the ground to crews. Developing and validating the new paradigm and its associated infrastructure may place requirements on operations design for nearer-term lunar missions. The authors, representing both the human and robotic mission operations communities, assess human lunar and Mars mission challenges, and consider how human-robot operations may be integrated to enable efficient joint operations, with the eventual emergence of a unified exploration operations culture.

Integrated Human-Robotic Missions to the Moon and Mars: Mission Operations Design Implications

NASA Technical Reports Server (NTRS)

Korth, David; LeBlanc, Troy; Mishkin, Andrew; Lee, Young

2006-01-01

For most of the history of space exploration, human and robotic programs have been independent, and have responded to distinct requirements. The NASA Vision for Space Exploration calls for the return of humans to the Moon, and the eventual human exploration of Mars; the complexity of this range of missions will require an unprecedented use of automation and robotics in support of human crews. The challenges of human Mars missions, including roundtrip communications time delays of 6 to 40 minutes, interplanetary transit times of many months, and the need to manage lifecycle costs, will require the evolution of a new mission operations paradigm far less dependent on real-time monitoring and response by an Earthbound operations team. Robotic systems and automation will augment human capability, increase human safety by providing means to perform many tasks without requiring immediate human presence, and enable the transfer of traditional mission control tasks from the ground to crews. Developing and validating the new paradigm and its associated infrastructure may place requirements on operations design for nearer-term lunar missions. The authors, representing both the human and robotic mission operations communities, assess human lunar and Mars mission challenges, and consider how human-robot operations may be integrated to enable efficient joint operations, with the eventual emergence of a unified exploration operations culture.

Exploring avoidant/restrictive food intake disorder in eating disordered patients: a descriptive study.

PubMed

Norris, Mark L; Robinson, Amy; Obeid, Nicole; Harrison, Megan; Spettigue, Wendy; Henderson, Katherine

2014-07-01

To assess and compare clinical characteristics of patients with avoidant/restrictive food intake disorder (ARFID) to those with anorexia nervosa (AN). A retrospective review of adolescent eating disorder (ED) patients assessed between 2000 and 2011 that qualified for a diagnosis of ARFID was completed. A matched AN sample was used to compare characteristics between groups. Two hundred and five patients met inclusion criteria and were reviewed in detail. Of these, 34 (5%) patients met criteria for ARFID. A matched sample of 36 patients with AN was used to draw comparisons. Patients with ARFID were younger than those with AN, more likely to present before age 12, and more likely to be male. Patients in both groups presented at low weights. Common eating-specific behaviors and symptoms in the ARFID group included food avoidance, loss of appetite, abdominal pain, and fear of vomiting. Rates of comorbid psychiatric diagnoses and medical morbidity were high in both groups. Almost 80% of AN patients and one-third of ARFID patients required hospital admission as a result of medical instability. Symptom profiles in 4/34 ARFID patients resulted in eventual reclassification to AN. This study supports the notion that a small percentage of adolescent patients presenting with restrictive eating disorders meet criteria for ARFID. Patients are younger than average, more likely to be male compared to adolescent AN samples, and have high rates of psychiatric and medical morbidity. The study also suggests that a proportion of patients evolve into AN as treatment progresses. © 2013 Wiley Periodicals, Inc.

Indications, retrieval rate, and complications of inferior vena cava filters: Single-center experience in Saudi Arabia.

PubMed

Shabib, Abdullah Bin; Alsayed, Fahad; Aldughaythir, Saad; Habeeb, Hanan; Al Tamimi, Sumayyah; Masuadi, Emad; Alzahrani, Mohsen; Alaklabi, Ali; Alotaibi, Azzam; Rajendram, Rajkumar; Almegren, Mosaad

2018-01-01

Inferior vena cava (IVC) filter is indicated in patients with acute venous thromboembolism (VTE) in whom therapeutic anticoagulation is contraindicated. While prophylactic insertion of an IVC filter may be considered for patients at high risk of VTE, there are significant differences between clinical guidelines on the role of IVC filters. These discrepancies have arisen predominantly because of the paucity of data on the efficacy and safety of IVC filters. We, therefore, evaluated the indications for filter insertion, the rate of filter retrieval and complications in patients who received IVC filters at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. A descriptive, retrospective review of electronic- and paper-based medical records was performed. Consecutive sampling was used to study all adult patients who received an IVC filter at KAMC between 2007 and 2016 and met the inclusion criteria. A total of 382 IVC filters were inserted. 113 patients (30%) had an acute VTE and a contraindication to anticoagulation while 53 patients (14%) received an IVC filter in the absence of VTE (i.e., prophylactic). Only 124 (32.5%) IVC filters were eventually retrieved. The most common reason for nonretrieval was the need for permanent filtration (155, 60%). Thrombotic complications developed in 72 (19%) patients; nine patients had fatal pulmonary embolism. The insertion of IVC filters in this cohort was associated with low retrieval rate and relatively high incidence of thrombotic complications. Follow-up of patients is required to detect IVC filter-related complications and to increase retrieval rate.

Approach to Non-Neutropenic Fever in Pediatric Oncology Patients-A Single Institution Study.

PubMed

Ali, Bilal Abou; Hirmas, Nader; Tamim, Hani; Merabi, Zeina; Hanna-Wakim, Rima; Muwakkit, Samar; Abboud, Miguel; Solh, Hassan El; Saab, Raya

2015-12-01

Pediatric oncology patients with fever, even when not neutropenic, are known to be at an increased risk of bloodstream infections. However, there are no standard guidelines for management of fever in non-neutropenic patients, resulting in variability in practice across institutions. We retrospectively analyzed the clinical characteristics, management, and outcome of all febrile non-neutropenic episodes in pediatric oncology patients at a single institution over the two-year period 2011-2012, to identify predictors of bloodstream infections. We assessed the efficacy of a uniform approach to outpatient management of a defined subset of patients at low risk of invasive infections. A total of 254 episodes in 83 patients were identified. All patients had implanted central venous catheters (port). Sixty-two episodes (24%) were triaged as high-risk and admitted for inpatient management; five (8%) had positive blood cultures. The remaining 192 episodes were triaged as low risk and managed with once daily outpatient intravenous ceftriaxone; three (1.6%) were associated with bacteremia, and 10% required eventual inpatient management. Of all the factors analyzed, only signs of sepsis (lethargy, chills, hypotension) were associated with positive bloodstream infection. Treatment of a defined subset of patients with outpatient intravenous ceftriaxone was safe and effective. Signs of sepsis were the only factor significantly associated with bloodstream infection. This study provides a baseline for future prospective studies assessing the safety of withholding antibiotics in this subset of patients. © 2015 Wiley Periodicals, Inc.

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PubMed

Iselin, C E; Webster, G D

1999-08-01

As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.

Impairments in part-whole representations of objects in two cases of integrative visual agnosia.

PubMed

Behrmann, Marlene; Williams, Pepper

2007-10-01

How complex multipart visual objects are represented perceptually remains a subject of ongoing investigation. One source of evidence that has been used to shed light on this issue comes from the study of individuals who fail to integrate disparate parts of visual objects. This study reports a series of experiments that examine the ability of two such patients with this form of agnosia (integrative agnosia; IA), S.M. and C.R., to discriminate and categorize exemplars of a rich set of novel objects, "Fribbles", whose visual similarity (number of shared parts) and category membership (shared overall shape) can be manipulated. Both patients performed increasingly poorly as the number of parts required for differentiating one Fribble from another increased. Both patients were also impaired at determining when two Fribbles belonged in the same category, a process that relies on abstracting spatial relations between parts. C.R., the less impaired of the two, but not S.M., eventually learned to categorize the Fribbles but required substantially more training than normal perceivers. S.M.'s failure is not attributable to a problem in learning to use a label for identification nor is it obviously attributable to a visual memory deficit. Rather, the findings indicate that, although the patients may be able to represent a small number of parts independently, in order to represent multipart images, the parts need to be integrated or chunked into a coherent whole. It is this integrative process that is impaired in IA and appears to play a critical role in the normal object recognition of complex images.

Renal Replacement Therapy in Severe Burns: A Multicenter Observational Study.

PubMed

Chung, Kevin K; Coates, Elsa C; Hickerson, William L; Arnold-Ross, Angela L; Caruso, Daniel M; Albrecht, Marlene; Arnoldo, Brett D; Howard, Christina; Johnson, Laura S; McLawhorn, Melissa M; Friedman, Bruce; Sprague, Amy M; Mosier, Michael J; Conrad, Peggie F; Smith, David J; Karlnoski, Rachel A; Aden, James K; Mann-Salinas, Elizabeth A; Wolf, Steven E

2018-06-20

Acute kidney injury (AKI) after severe burns is historically associated with a high mortality. Over the past two decades, various modes of renal replacement therapy (RRT) have been utilized in this population. The purpose of this multicenter study was to evaluate demographic, treatment and outcomes data among severe burn patients treated with RRT collectively at various burn centers around the United States. After institutional review board approval, a multicenter observational study was conducted. All adult patients 18 or older, admitted with severe burns who were placed on RRT for acute indications but not randomized into a concurrently enrolling interventional trial were included. Across 8 participating burn centers, 171 subjects were enrolled during a 4 year period. Complete data was available in 170 subjects with a mean age of 51±17, percent total body surface area (TBSA) burn of 38±26% and Injury Severity Score of 27±21. 80% of subjects were male and 34% were diagnosed with smoke inhalation injury. The preferred mode of therapy was continuous venovenous hemofiltration at a mean delivered dose of 37±19 (mL/kg/hr) and a treatment duration of 13±24 days. Overall, in hospital mortality was 50%. Among survivors, 21% required RRT upon discharge from the hospital while 9% continued to require RRT 6 months after discharge. This is the first multi-center cohort of burn patients who underwent RRT reported to date. Overall mortality is comparable to other critically ill populations who undergo RRT. Most patients who survive to discharge eventually recover renal function.

Outcome of Endodontically Treated Teeth Diagnosed With Cracked Tooth

DTIC Science & Technology

2015-06-01

However, variable symptoms complicate the diagnosis (9). In a study of 32 patients presenting with diffuse longstanding orofacial pain eventually...883-92. 22)Byrnjulsen A, Fristad I, Grevstad T, Hals-Kvinnsland I. Incompletely fractured teeth associated with diffuse longstanding orofacial pain ...cracked tooth is highly associated with discomfort. Patients often describe a momentary, sudden, sharp, lancinating pain that results in continuous tooth

A small-scale randomised controlled trial of home telemonitoring in patients with severe chronic obstructive pulmonary disease.

PubMed

Shany, Tal; Hession, Michael; Pryce, David; Roberts, Mary; Basilakis, Jim; Redmond, Stephen; Lovell, Nigel; Schreier, Guenter

2017-08-01

Introduction This was a pilot study to examine the effects of home telemonitoring (TM) of patients with severe chronic obstructive pulmonary disease (COPD). Methods A randomised controlled 12-month trial of 42 patients with severe COPD was conducted. Home TM of oximetry, temperature, pulse, electrocardiogram, blood pressure, spirometry, and weight with telephone support and home visits was tested against a control group receiving only identical telephone support and home visits. Results The results suggest that TM had a reduction in COPD-related admissions, emergency department presentations, and hospital bed days. TM also seemed to increase the interval between COPD-related exacerbations requiring a hospital visit and prolonged the time to the first admission. The interval between hospital visits was significantly different between the study arms, while the other findings did not reach significance and only suggest a trend. There was a reduction in hospital admission costs. TM was adopted well by most patients and eventually, also by the nursing staff, though it did not seem to change patients' psychological well-being. Discussion Ability to draw firm conclusions is limited due to the small sample size. However the trends of reducing hospital visits warrant a larger study of a similar design. When designing such a trial, one should consider the potential impact of the high quality of care already made available to this patient cohort.

Continuous spinal drain following endoscopic third ventriculostomy: a proposal to change the definition of failure.

PubMed

Ozisik, Pinar; Roth, Jonathan; Beni-Adani, Liana; Constantini, Shlomi

2011-11-01

This study evaluates the safety, efficacy, and indications for continuous lumbar drainage (CLD) in patients following endoscopic third ventriculostomy (ETV). We retrospectively reviewed the clinical data of 22 consecutive patients treated between 1996 and 2010 with CLD after ETV. The decision to insert a CLD was made in selected patients only. CLD was inserted in cases of high measured intracranial pressure (12 patients), clinical symptoms indicative of continuing hydrocephalus (2 patients), and "prophylactically" in 8 patients, based either on the clinical condition of patients before ETV or on technical difficulties during the ETV procedure, which seemed to increase the risk of ETV failure. CLD insertion took place either in the operating room immediately following the ETV procedure or under very specific conditions and with close patient monitoring in an ICU setting. Only four patients eventually required shunting, all within 1 month after ETV. Therefore, the overall ETV success rate was 81.8% (18/22 patients). Of the 14 patients suffering from measured or clinically observed continuing hydrocephalus, 12 (85%) ultimately recovered without the need for a permanent shunt. Without the CLD, some of these patients would probably have been declared "failures" and referred for a standard shunt. CLD provided a time window following ETV for the absorption system to recover and return to full functionality. Selective usage of CLD is a reasonable and safe method to gain time and possibly facilitates the recovery of absorption capacity following ETV. CLD should be considered before conceding a post-ETV patient as a failure.

Changing the status of drugs from prescription to over-the-counter availability.

PubMed

Brass, E P

2001-09-13

The availability of drugs on an over-the-counter basis, including those previously available only by prescription, provides patients with improved access to effective therapies. Removal of the requirement for prescriptions saves both the health care professional and the patient time. However, the overall effect on health care costs is complex. One such effect may be that costs shift from third-party payers to patients. In addition, short-term cost savings may be offset over the long term by problems due to inappropriate use or suboptimal therapy. Optimal therapy with an over-the-counter drug requires that the consumer diagnose the underlying condition correctly and use the drug in a manner that minimizes risk. Assessment of the ability of patients to use drugs in this manner is a critical component of the regulatory review of over-the-counter drugs. The available data arouse the concern that without the supervision of a health care professional, some patients may not be able to use over-the-counter drugs appropriately for certain diagnoses or chronic conditions or in high-risk situations. On the other hand, the widespread use of over-the-counter aspirin on a long-term basis for cardiovascular-risk reduction illustrates the potential value of increased drug availability for long-term therapy. Advances in technology may facilitate the growth of over-the-counter drug therapy. For example, the wide availability and acceptance of reliable methods for measuring serum cholesterol in nonmedical settings may eventually contribute to the safety and effectiveness of over-the-counter treatments for hyperlipidemia. Thus, the future promises increases in the number of drugs available over the counter and in the variety of indications for their use.

Collaterals management during pancreatoduodenectomy in patients with celiac axis stenosis: A systematic review of the literature.

PubMed

Giovanardi, Francesco; Lai, Quirino; Garofalo, Manuela; Arroyo Murillo, Gabriela A; Choppin de Janvry, Eleonore; Hassan, Redan; Larghi Laureiro, Zoe; Consolo, Adriano; Melandro, Fabio; Berloco, Pasquale B

2018-05-15

Celiac axis stenosis (CAS) represents an uncommon and typically innocuous condition. However, when a pancreatic resection is required, a high risk for upper abdominal organs ischemia is observed. In presence of collaterals, such a risk is minimized if their preservation is realized. The aim of the present study is to systematically review the literature with the intent to address the routine management of collateral arteries in the case of CAS patients requiring pancreatoduodenectomy. A systematic search was done in accordance with the PRISMA guidelines, using "celiac axis stenosis" AND "pancreatoduodenectomy" as MeSH terms. Seventy-four articles were initially screened: eventually, 30 articles were identified (n = 87). The main cause of CAS was median arcuate ligament (MAL) (n = 31; 35.6%), followed by atherosclerosis (n = 20; 23.0%). CAS was occasionally discovered during the Whipple procedure in 15 (17.2%) cases. Typically, MAL was divided during surgery (n = 24/31; 77.4%). In the great majority of cases (n = 83; 95.4%), vascular abnormalities involved the pancreatoduodenal arteries (i.e., dilatation, arcade, channels, aneurysms). Collateral arteries were typically preserved, being divided or reconstructed in only 14 (16.1%) cases, respectively. Severe ischemic complications were reported in six (6.9%) patients, 20.0% of whom were reported in patients with preoperatively unknown CAS (p-value 0.06). A correct pre-operative evaluation of anatomical conditions as well as a correct surgical planning represent the paramount targets in CAS patients with arterial collaterals. Vascular flow must be always safeguarded preserving/reconstructing the collaterals or resolving the CAS, with the final intent to avoid dreadful intra- and post-operative complications. Copyright © 2018 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Treatment of yellow scorpion (Leiurus quinquestriatus) sting: a case report.

PubMed

Shalita, Eric A; Wells, Ryan D

2007-01-01

To report the treatment given to a 26-year-old Air Force medic who was stung twice by a yellow scorpion (Leiurus quinquestriatus) while stationed in Iraq and to describe the problems and issues related to the use of the scorpion antivenin. The patient presented 2 hours after envenomation to the local military treatment facility, where she was minimally symptomatic initially. Shortness of breath and anxiety developed, and the patient was sedated, intubated, and evacuated to a large Air Force medical facility for more advanced care. Vasopressor support was required during flight. At the medical facility, antivenin was administered, and the patient's cardiac condition was stabilized with norepinephrine drip, mild hydration, and vasopressor support. A second dose of antivenin diluted in sodium chloride and further pressor support were required. ST-segment depression eventually resolved, and the patient was gradually taken off norepinephrine and extubated. She recovered fully within 2 weeks and returned to active duty. Because the antivenin used is not licensed by the Food and Drug Administration, informed consent was needed; however, it could not be obtained because the patient was unconscious, intubated, and in a life-or-death situation. Antivenin selection is based on the species of scorpion and symptom severity; therefore, the scorpion should be, with great care, killed for identification. In the military setting, inventory control, storage, and accountability are vital issues surrounding antivenin use, and these are discussed in this article. Immediate action and effective communication, along with timely antivenin administration and well-equipped intensive care facilities, were integral in saving the life of this victim of a yellow scorpion envenomation. All level 3 facilities in Southwest Asia must be familiar with ordering, administering, and documenting this antivenin because it is difficult to obtain and infrequently available.

Software Architecture Evolution

ERIC Educational Resources Information Center

Barnes, Jeffrey M.

2013-01-01

Many software systems eventually undergo changes to their basic architectural structure. Such changes may be prompted by new feature requests, new quality attribute requirements, changing technology, or other reasons. Whatever the causes, architecture evolution is commonplace in real-world software projects. Today's software architects, however,…

Measuring Transcutaneous Oxygenation to Validate the Duration Required to Achieve Electrode Equilibration.

PubMed

Chiang, Nathaniel; Jain, Jitendra K; Sleigh, Jamie; Vasudevan, Thodur

2018-06-01

The transcutaneous oxygenation measurement (TCOM) system is useful in assessing tissue viability. There are no clear recommendations regarding the duration required for the electrode to equilibrate and reliably evaluate tissue oxygenation values. The objective of this study was to validate the duration required to achieve electrode equilibration in a clinical setting. Minute-by-minute recordings using TCOM (TCOM3; Radiometer Medical ApS, Brønshøj, Copenhagen) were obtained for 82 limbs in 50 participants. Twenty-five limbs were in patients with peripheral vascular disease; 30 were in patients with no known peripheral vascular disease; and 27 were in healthy volunteers. Transcutaneous partial pressure of oxygen and carbon dioxide (TcPO2 and TcPCO2) were recorded over a 15-minute period. Participants' TcPO2 decreased and TcPCO2 increased over time. Both changed in a nonlinear fashion, eventually settling at an "equilibrium" where the measurements became stable. The difference in proportional change of TcPO2 between minutes 14 and 15 was 0.8%, and for TcPCO2was 2.9%. Changes in TCOM measurements over time were similar among the 3 groups. This is the first study to target minute-by-minute variation in TcPO2 and TcPCO2 measurements. Recording for a minimum of 15 minutes allows a reliable period for the TCOM electrode to equilibrate to record absolute values and determine wound healing potential.

An upper limb robot model of children limb for cerebral palsy neurorehabilitation.

PubMed

Pathak, Yagna; Johnson, Michelle

2012-01-01

Robot therapy has emerged in the last few decades as a tool to help patients with neurological injuries relearn motor tasks and improve their quality of life. The main goal of this study was to develop a simple model of the human arm for children affected with cerebral palsy (CP). The Simulink based model presented here shows a comparison for children with and without disabilities (ages 6-15) with normal and reduced range of motion in the upper limb. The model incorporates kinematic and dynamic considerations required for activities of daily living. The simulation was conducted using Matlab/Simulink and will eventually be integrated with a robotic counterpart to develop a physical robot that will provide assistance in activities of daily life (ADLs) to children with CP while also aiming to improve motor recovery.

Rhabdomyolysis in a Sickle Cell Trait Positive Active Duty Male Soldier.

PubMed

Saxena, Pulkit; Chavarria, Christopher; Thurlow, John

2016-01-01

Exertional rhabdomyolysis is a complication of sickle cell trait (SCT) likely first reported in the military population over 40 years ago. Although commonly a benign condition, numerous studies and case reports have identified SCT positive patients to be at increased risk for rhabdomyolysis, compartment syndrome and sudden cardiac death. We report a recent case of an SCT positive African American active duty male Soldier who suffered exertional rhabdomyolysis following an Army Physical Fitness Test. His course was complicated by acute renal failure requiring hemodialysis, and he eventually recovered renal function. The diagnosis was significantly delayed despite a typical clinical presentation and available SCT screening results. The case highlights the importance of the recognition of SCT as a risk factor for severe rhabdomyolysis, and suggests more must be done for an effective SCT screening program for the active duty military population.

A Wearable Body Controlling Device for Application of Functional Electrical Stimulation

PubMed Central

Jeffery, Nicholas D.

2018-01-01

In this research, we describe a new balancing device used to stabilize the rear quarters of a patient dog with spinal cord injuries. Our approach uses inertial measurement sensing and direct leg actuation to lay a foundation for eventual muscle control by means of direct functional electrical stimulation (FES). During this phase of development, we designed and built a mechanical test-bed to develop the control and stimulation algorithms before we use the device on our animal subjects. We designed the bionic test-bed to mimic the typical walking gait of a dog and use it to develop and test the functionality of the balancing device for stabilization of patient dogs with hindquarter paralysis. We present analysis for various muscle stimulation and balancing strategies, and our device can be used by veterinarians to tailor the stimulation strength and temporal distribution for any individual patient dog. We develop stabilizing muscle stimulation strategies using the robotic test-bed to enhance walking stability. We present experimental results using the bionic test-bed to demonstrate that the balancing device can provide an effective sensing strategy and deliver the required motion control commands for stabilizing an actual dog with a spinal cord injury. PMID:29670039

Rationale and Description of Right Ventricle-Protective Ventilation in ARDS.

PubMed

Paternot, Alexis; Repessé, Xavier; Vieillard-Baron, Antoine

2016-10-01

Pulmonary vascular dysfunction is associated with ARDS and leads to increased right-ventricular afterload and eventually right-ventricular failure, also called acute cor pulmonale. Interest in acute cor pulmonale and its negative impact on outcome in patients with ARDS has grown in recent years. Right-ventricular function in these patients should be closely monitored, and this is helped by the widespread use of echocardiography in intensive care units. Because mechanical ventilation may worsen right-ventricular failure, the interaction between the lungs and the right ventricle appears to be a key factor in the ventilation strategy. In this review, a rationale for a right ventricle-protective ventilation approach is provided, and such a strategy is described, including the reduction of lung stress (ie, the limitation of plateau pressure and driving pressure), the reduction of PaCO2 , and the improvement of oxygenation. Prone positioning seems to be a crucial part of this strategy by protecting both the lungs and the right ventricle, resulting in increased survival of patients with ARDS. Further studies are required to validate the positive impact on prognosis of right ventricle-protective mechanical ventilation. Copyright © 2016 by Daedalus Enterprises.

Medical Error Disclosure and Patient Safety: Legal Aspects

PubMed Central

Guillod, Olivier

2013-01-01

Reducing the number of preventable adverse events has become a public health issue. The paper discusses in which ways the law can contribute to that goal, especially by encouraging a culture of safety among healthcare professionals. It assesses the need or the usefulness to pass so-called disclosure laws and apology laws, to adopt mandatory but strictly confidential Critical Incidents Reporting Systems in hospitals, to change the fault-based system of medical liability or to amend the rules on criminal liability. The paper eventually calls for adding the law to the present agenda of patient safety. Significance for public health The extent of preventable adverse events and the correlative need to improve patient safety are recognized today as a public health issue. In order to lower the toll associated with preventable adverse events, the former culture of professionalism (based on the premise that a good physician doesn’t make mistakes) must be replaced by a culture of safety, which requires a multi-pronged approach that includes all the main stakeholders within the healthcare system. A number of legal reforms could help in prompting such a change. This contribution stresses the need to include legal aspects when trying to find appropriate responses to public health issues. PMID:25170502

Distraction to treat knee osteoarthritis.

PubMed

Flouzat-Lachaniette, Charles-Henri; Roubineau, François; Heyberger, Clémence; Bouthors, Charlie

2017-03-01

The objective of this article is to review data on joint distraction used to treat knee osteoarthritis. Joint distraction is a surgical procedure in which the two bony ends of the joint are gradually pulled apart then kept separated for 2 months in an external fixation frame. Weight bearing is continued to ensure variations in hydrostatic pressure within the joint. In published studies, joint distraction provided substantial clinical and structural improvements in patients with knee osteoarthritis, delaying joint replacement surgery for at least 2 years. Animal studies showed that joint distraction was associated with decrease in the secondary inflammatory response, cartilage breakdown, and subchondral bone remodeling. In vitro, the intermittent application of hydrostatic pressure stimulated the production of extracellular matrix, particularly in joints with osteoarthritis. Nevertheless, several considerations invite caution when considering the more widespread use of joint distraction. Published studies have short follow-ups and small sample sizes. In addition, the high frequency of pin tract infection is of concern, since most patients eventually require knee replacement surgery. These two considerations indicate a need for longer-term prospective studies of patient cohorts. Copyright © 2016 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.

A Wearable Body Controlling Device for Application of Functional Electrical Stimulation.

PubMed

Taghavi, Nazita; Luecke, Greg R; Jeffery, Nicholas D

2018-04-18

In this research, we describe a new balancing device used to stabilize the rear quarters of a patient dog with spinal cord injuries. Our approach uses inertial measurement sensing and direct leg actuation to lay a foundation for eventual muscle control by means of direct functional electrical stimulation (FES). During this phase of development, we designed and built a mechanical test-bed to develop the control and stimulation algorithms before we use the device on our animal subjects. We designed the bionic test-bed to mimic the typical walking gait of a dog and use it to develop and test the functionality of the balancing device for stabilization of patient dogs with hindquarter paralysis. We present analysis for various muscle stimulation and balancing strategies, and our device can be used by veterinarians to tailor the stimulation strength and temporal distribution for any individual patient dog. We develop stabilizing muscle stimulation strategies using the robotic test-bed to enhance walking stability. We present experimental results using the bionic test-bed to demonstrate that the balancing device can provide an effective sensing strategy and deliver the required motion control commands for stabilizing an actual dog with a spinal cord injury.

Clinical utility of insulin and insulin analogs

PubMed Central

Sanlioglu, Ahter D.; Altunbas, Hasan Ali; Balci, Mustafa Kemal; Griffith, Thomas S.; Sanlioglu, Salih

2013-01-01

Diabetes is a pandemic disease characterized by autoimmune, genetic and metabolic abnormalities. While insulin deficiency manifested as hyperglycemia is a common sequel of both Type-1 and Type-2 diabetes (T1DM and T2DM), it does not result from a single genetic defect—rather insulin deficiency results from the functional loss of pancreatic β cells due to multifactorial mechanisms. Since pancreatic β cells of patients with T1DM are destroyed by autoimmune reaction, these patients require daily insulin injections. Insulin resistance followed by β cell dysfunction and β cell loss is the characteristics of T2DM. Therefore, most patients with T2DM will require insulin treatment due to eventual loss of insulin secretion. Despite the evidence of early insulin treatment lowering macrovascular (coronary artery disease, peripheral arterial disease and stroke) and microvascular (diabetic nephropathy, neuropathy and retinopathy) complications of T2DM, controversy exists among physicians on how to initiate and intensify insulin therapy. The slow acting nature of regular human insulin makes its use ineffective in counteracting postprandial hyperglycemia. Instead, recombinant insulin analogs have been generated with a variable degree of specificity and action. Due to the metabolic variability among individuals, optimum blood glucose management is a formidable task to accomplish despite the presence of novel insulin analogs. In this article, we present a recent update on insulin analog structure and function with an overview of the evidence on the various insulin regimens clinically used to treat diabetes. PMID:23584214

Field amputation: response planning and legal considerations inspired by three separate amputations.

PubMed

Raines, Alexander; Lees, Jason; Fry, William; Parks, Aaron; Tuggle, David

2014-01-01

Surgical procedures in the field are occasionally required as life-saving measures. Few centers have a planned infrastructure for field physician support. Focused efforts are needed to create teams that can meet such needs. Additionally, certain legal issues surrounding these efforts should be considered. Three cases of field dismemberment inspired this call for preparation. In one case, an earthquake caused the collapse of a bridge, entrapping a child within a car. A through-knee amputation was required to free the patient with local anesthetic only. The second case was the result of a truck bomb causing the collapse of a building whereby a victim was trapped by a pillar. After retrieval of supplies from a local hospital, a through-knee amputation was performed. The third case involved a young man whose arm became entangled in an oil derrick. This patient was sedated and intubated in an erect position and the arm was amputated. Fortunately, each of these victims survived. However, the care these patients received was unplanned and had the potential for failure. The authors feel that disaster teams, including a surgeon, should be identified in advance as responders to a disaster on short notice. Legal issues including statespecific Good Samaritan laws and financial support systems must also be considered. As hospitals and trauma systems prepare for disaster situations, they should consider the eventuality of field dismemberment. This involves identifying a team, including a surgeon, and devising an infrastructure allowing rapid response capabilities, including surgical procedures in the field.

Prediction and prevention of suicide in patients with unipolar depression and anxiety

PubMed Central

Gonda, Xenia; Fountoulakis, Konstantinos N; Kaprinis, George; Rihmer, Zoltan

2007-01-01

Epidemiological data suggest that between 59 and 87% of suicide victims suffered from major depression while up to 15% of these patients will eventually commit suicide. Male gender, previous suicide attempt(s), comorbid mental disorders, adverse life-situations, acute psycho-social stressors etc. also constitute robust risk factors. Anxiety and minor depression present with a low to moderate increase in suicide risk but anxiety-depression comorbidity increases this risk dramatically Contrary to the traditional psychoanalytic approach which considers suicide as a retrospective murder or an aggression turned in-wards, more recent studies suggest that the motivations to commit suicide may vary and are often too obscure. Neurobiological data suggest that low brain serotonin activity might play a key role along with the tryptophan hydroxylase gene. Social factors include social support networks, religion etc. It is proven that most suicide victims had asked for professional help just before committing suicide, however they were either not diagnosed (particularly males) or the treatment they received was inappropriate or inadequate. The conclusion is that promoting suicide prevention requires the improving of training and skills of both psychiatrists and many non-psychiatrists and especially GPs in recognizing and treating depression and anxiety. A shift of focus of attention is required in primary care to detect potentially suicidal patients presenting with psychological problems. The proper use of antidepressants, after a careful diagnostic evaluation, is important and recent studies suggest that successful acute and long-term antidepressant pharmacotherapy reduces suicide morbidity and mortality. PMID:17803824

Long-term outcomes of fertility-sparing treatment of atypical polypoid adenomyoma with medroxyprogesterone acetate.

PubMed

Nomura, Hidetaka; Sugiyama, Yuko; Tanigawa, Terumi; Matoda, Maki; Kanao, Hiroyuki; Kondo, Eiji; Takeshima, Nobuhiro

2016-01-01

Our objective was to analyze the long-term oncologic outcomes of fertility-preserving hormonal treatment with medroxyprogesterone acetate (MPA) in patients with APA. In a retrospective chart review, we identified patients with APA who were treated with MPA for fertility preservation at our hospital between 2001 and 2011. Eighteen patients with histologically diagnosed APA were identified. Clinical data including treatment, obstetrical, and oncologic outcomes were recorded. The mean observation period was 77.6 months (median 73.5, range 22-142), and the mean age was 33.6 years. Four patients also developed well-differentiated endometrial carcinoma. After the treatment, 14 patients (77.8 %) achieved either a complete response or partial response. Eight patients experienced recurrence, while four experienced persistent disease. Ten patients (55.6 %) eventually underwent hysterectomy. The median time to hysterectomy was 40.3 months (range 24-68). Nine patients progressed to endometrial cancer, and one experienced persistent APA. Among younger patients (<35 years of age), four out of five patients who were married could have children. Seven patients (38.9 %) showed no evidence of the disease during the observation period (median 60 months, range 22-117 months). No one died because of the disease during the observation period. MPA yields a high response rate in APA, and if only younger patients are considered, a favorable pregnancy rate can be obtained. However, because recurrence rate is high, long-term follow-up under supervision of a trained gynecologic oncologist is required. To confirm MPA's utility, multi-center collaboration would be warranted.

Broken heart syndrome triggered by an obstructive goiter not associated with thyrotoxicosis.

PubMed

Hatzakorzian, Roupen; Bui, Helen; Schricker, Thomas; Backman, Steven B

2013-08-01

Takotsubo cardiomyopathy (TC) is described as transient ventricular dysfunction following emotional or physical trauma. A few reports have described patients with TC in association with various circumstances of thyrotoxicosis. We report an unusual case of TC in a patient with a large retrosternal goiter and normal thyroid function. We speculate that TC was triggered by compromise of tracheal flow induced by the goiter. A 68-yr-old woman without primary heart disease presented with cardiorespiratory collapse requiring ventilatory and cardiovascular support, including placement of an intra-aortic balloon pump. She was diagnosed with a severe form of TC based on characteristic echocardiography findings and clinical course. Within less than a week, her myocardial function completely normalized. The patient was later found to have a large retrosternal goiter compressing her trachea, though her thyroid function was normal. A total thyroidectomy was eventually performed, and she made a full recovery. Subsequently, the patient was found to have a positive JAK2 mutation for a myeloproliferative disorder. Takotsubo cardiomyopathy may be regarded as the final common pathway of cardiac dysfunction triggered by various stress conditions, in this case, a large retrosternal goiter not associated with thyrotoxicosis and likely exacerbated by severe leukocytosis related to a myeloproliferative disorder.

Case review analysis of operating room decisions to cancel surgery.

PubMed

Chang, Ju-Hsin; Chen, Ke-Wei; Chen, Kuen-Bao; Poon, Kin-Shing; Liu, Shih-Kai

2014-07-23

Cancellation of surgery close to scheduled time causes a waste of healthcare resources. The current study analyzes surgery cancellations occurring after the patient has been prepared for the operating room, in order to see whether improvements in the surgery planning process may reduce the number of cancellations. In a retrospective chart review of operating room surgery cancellations during the period from 2006 to 2011, cancellations were divided into the following categories: inadequate NPO; medical; surgical; system; airway; incomplete evaluation. The relative use of these reasons in relation to patient age and surgical department was then evaluated. Forty-one percent of cancellations were for other than medical reasons. Among these, 17.7% were due to incomplete evaluation, and 8.2% were due to family issues. Sixty seven percent of cancelled cases eventually received surgery. The relative use of individual reasons for cancellation varied with patient age and surgical department. The difference between cancellations before and after anesthesia was dependent on the causes of cancellation, but not age, sex, ASA status, or follow-up procedures required. Almost half of the cancellations were not due to medical reasons, and these cancellations could be reduced by better administrative and surgical planning and better communication with the patient and/or his family.

Thyroid Storm Caused by a Chinese Herb Contaminated with Thyroid Hormones

PubMed Central

St-Onge, Maude; Vandenberghe, Hilde; Thompson, Margaret

2015-01-01

Patient: Male, 70 Final Diagnosis: Thyroid storm Symptoms: Atrial fibrillation • confusion • hyperthermia • tachycardia Medication: — Clinical Procedure: Intubation • cardioversion Specialty: Critical Care Medicine Objective: Adverse events of drug therapy Background: We report a case of thyroid storm caused by consuming a Chinese herb contaminated with thyroid hormones. Case Report: A 70-year-old man presented to an emergency department after 2 days of nausea, vomiting, and weakness. Three days previously, he had started taking Cordyceps powder and “Flower Man Sang Hung” as recommended by his Chinese physician. Following admission, the patient deteriorated and was eventually diagnosed with thyroid storm complicated by rapid atrial fibrillation requiring cardioversion, intubation, and intensive care admission. The analysis of the Chinese herb “Flower Man Sang Hung” was positive for levothyroxine. The patient was extubated 11 days after admission and discharged to a rehabilitation centre after 17 days of hospitalization. The Chinese medicine physician was informed of the events. Conclusions: Herbal products can be the source of illness, medication interactions, and contamination. Awareness should be raised among Chinese medicine physicians, allopathic physicians, and their patients. Clinicians should also have a low threshold of suspicion to seek laboratory analysis of suspect substances when the cause of the clinical presentation is unclear. PMID:25644333

Dimensions of tinnitus-related complaints reported by patients and their significant others: protocol for a systematic review.

PubMed

Haider, Haúla; Fackrell, Kathryn; Kennedy, Veronica; Hall, Deborah A

2016-10-08

Over 70 million people in Europe and >50 million people in the USA are reported to experience tinnitus (the sensation of noise in the absence of any corresponding sound source). Tinnitus is a multidimensional concept. Individual patients may report different profiles of tinnitus-related symptoms which may each require a tailored management approach and an appropriate measure of therapeutic benefit. This systematic review concerns the patient perspective and has the purpose to find what symptoms are reported by people who experience tinnitus and by their significant others. This protocol lays out the methodology to define what dimensions of tinnitus-related symptoms patients and their significant others report as being a problem. Methods are defined according to the Preferred Reporting Items for Systematic reviews and Meta-analyses for Protocols (PRISMA-P) 2015 and data will be collated in a narrative synthesis. Findings will contribute to the eventual establishment of a Core Domain Set for clinical trials of tinnitus. No ethical issues are foreseen. Findings will be reported at national and international ENT and audiology conferences and in a peer-reviewed journal. CRD42015020629. 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/.

Primary cement spacers: a cost-effective, durable limb salvage option for knee tumors.

PubMed

Puri, Ajay; Gulia, Ashish; Pruthi, Manish; Koushik, S

2012-08-01

Of a total of 818 limb sparing resections in the lower limb requiring reconstruction between December 2002 and April 2010 at our centre, primary cement spacers were used in 15 cases. In three cases they were used as joint sparing intercalary reconstructions and in 12 cases knee arthrodesis was done. Implants used to provide stability to the construct included stacked intramedullary Kuntscher nails in four, an interlocking nail in one, plates in two and a combination of nail with plate in eight. Mean length of bone resected was 18 cm. Mean follow-up was 26 months (10-87 months). There were no local recurrences and none of the spacers needed revision for mechanical failure. The Musculoskeletal Tumor Society score for patients ranged from 20 to 29 with a mean of 24 (80%). Patients with intercalary resection had better functional scores than those with arthrodesis. The construct was successfully revised to a vascularised fibula arthrodesis or prosthesis with good eventual function in three cases. Cement spacers are a suitable cost-effective, durable reconstruction modality in selected patients with good functional outcomes. They are an option to amputation in patients with financial constraints and those that present with large volume or infected fungating tumors. Copyright © 2011 Elsevier B.V. All rights reserved.

Portopulmonary hypertension: state of the art.

PubMed

Porres-Aguilar, Mateo; Zuckerman, Marc J; Figueroa-Casas, Juan B; Krowka, Michael J

2008-01-01

Portopulmonary hypertension is an uncommon but treatable pulmonary vascular consequence of portal hypertension, which can lead to significant morbidity and mortality. Portopulmonary hypertension results from excessive pulmonary vasoconstriction and vascular remodeling that eventually leads to right-heart failure and death if left untreated. Although pulmonary vascular disease in these patients may be asymptomatic or associated with subtle and nonspecific symptoms (dyspnea, fatigue and lower extremity swelling), it should be looked for especially if patients are potential candidates for liver transplantation. Patients with clinical suspicion of portopulmonary hypertension should undergo screening testing, specifically echocardiography. Right heart catheterization remains the gold standard for the diagnosis. The existence of moderate to severe disease poses higher risks and challenges for liver transplantation. The disease has a substantial impact on survival and requires focused pharmacological therapy. New and evolving medical therapies, such as prostanoids (intravenous, inhaled or oral), endothelin receptors antagonists, phosphodiesterases inhibitors, combination therapy and other experimental drugs might change the natural course of the disease. Case reports and cases series have been published regarding the efficacy and safety of pharmacological therapy, but randomized, controlled multicenter trials are urgently needed. Liver transplantation is not the treatment of choice for portopulmonary hypertension, but after optimal hemodynamic and clinical improvement with medical therapy as a bridge, liver transplant can be considered an option in selected patients.

Non-stimulated adrenal venous sampling using Dyna computed tomography in patients with primary aldosteronism

PubMed Central

Chang, Chin-Chen; Lee, Bo-Ching; Liu, Kao-Lang; Chang, Yeun-Chung; Wu, Vin-Cent; Huang, Kuo-How

2016-01-01

In this retrospective study, we aimed to examine the effect of applying Dyna computed tomography (CT) on the success rate of adrenal venous sampling (AVS) without adrenocorticotropic hormone stimulation. A total of 100 consecutive patients with primary aldosteronism who underwent AVS between May 2012 and July 2015 were enrolled. In all the cases, Dyna CT was used in AVS to validate catheter position in the right adrenal vein. A selectivity index (cortisoladrenal vein /cortisolinferior vena cava) of ≥2.0 of both adrenal veins were required for successful AVS. Dyna CT indicated misplaced catheters in 16 patients; of these patients, 75% (12/16) eventually had successful right AVS after catheter repositioning. The success rate of initial sampling at the right adrenal vein was 76% (76/100), which increased to 88% (88/100) after Dyna CT was applied (p < 0.001). The most common inadvertently catheterised vessels detected using Dyna CT were the accessory hepatic veins (56.3%, 9/16), followed by the renal capsular veins (37.5%, 6/16). The overall success rate of non-stimulated AVS using Dyna CT was 87% (87/100). Thus, the application of Dyna CT further increased the success rate of non-stimulated AVS. PMID:27876824

The modern staged repair of classic bladder exstrophy: a detailed postoperative management strategy for primary bladder closure.

PubMed

Stec, Andrew A; Baradaran, Nima; Schaeffer, Anthony; Gearhart, John P; Matthews, Ranjiv I

2012-10-01

Successful primary bladder closure of classic bladder exstrophy sets the stage for development of adequate bladder capacity and eventual voided continence. The postoperative pathway following primary bladder closure at the authors' institution is quantitatively and qualitatively detailed. Sixty-five consecutive newborns (47 male) undergoing primary closure of classic bladder exstrophy were identified and data were extracted relating to immediate postoperative care. Overall success rate was utilized to validate the pathway. Mean age at time of primary closure was 4.6 days and mean hospital stay was 35.8 days. Osteotomy was performed in 19 patients (mean age 8.8 days), and was not required in 39 infants (mean age 2.9 days). All patients were immobilized for 4 weeks. Tunneled epidural analgesia was employed in 61/65 patients. All patients had ureteral catheters and a suprapubic tube, along with a comprehensive antibiotic regimen. Postoperative total parenteral nutrition was commonly administered, and enteral feedings started around day 4.6. Our success rate of primary closure was 95.4%. A detailed and regimented plan for bladder drainage, immobilization, pain control, nutrition, antimicrobial prophylaxis, and adequate healing time is a cornerstone for the postoperative management of the primary closure of bladder exstrophy. Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

The laparoscopic mini-gastric bypass: the Italian experience: outcomes from 974 consecutive cases in a multicenter review.

PubMed

Musella, M; Susa, A; Greco, F; De Luca, M; Manno, E; Di Stefano, C; Milone, M; Bonfanti, R; Segato, G; Antonino, A; Piazza, L

2014-01-01

Due to the failure of the "old Mason loop," the mini-gastric bypass (MGB) has been viewed with skepticism. During the past 12 years, a growing number of authors from around the world have continued to report excellent short- and long-term results with MGB. One university center, three regional hospitals, and two private hospitals participated in this study. From July 2006 to December 2012, 475 men (48.8 %) and 499 women (51.2 %) underwent 974 laparoscopic MGBs. The mean age of these patients was 39.4, and their preoperative body mass index was 48 ± 4.58 kg/m(2). Type 2 diabetes mellitus (T2DM) affected 224 (22.9 %) of the 974 patients, whereas 291 of the 974 patients (29.8 %) presented with hypertension. The preoperative gastrointestinal status was explored in all the patients through esophagogastroduodenoscopia. The major end points of the study were definitions of both MGB safety and efficacy in the long term as well as the endoscopic changes in symptomatic patients eventually produced by surgery. The rate of conversion to open surgery was 1.2 % (12/974), and the mortality rate was 0.2 % (2/974). The perioperative morbidity rate was 5.5 % (54/974), with 20 (2 %) of the 974 patients requiring an early surgical revision. The mean hospital length of stay was 4.0 ± 1.7 days. At this writing, 818 patients are being followed up. Late complications have affected 74 (9 %) of the 818 patients. The majority of these complications (66/74, 89.1 %) have occurred within 1 year after surgery. Bile reflux gastritis was symptomatic, with endoscopic findings reported for 8 (0.9 %) and acid peptic ulcers for 14 (1.7 %) of the 818 patients. A late revision surgery was required for 7 (0.8 %) of the 818 patients. No patient required revision surgery due to biliary gastritis. At 60 months, the percentage of excess weight loss was 77 ± 5.1 %, the T2DM remission was 84.4 %, and the resolution of hypertension was 87.5 %. Despite initial skepticism, this study, together with many other large-scale, long-term similar studies from around the world (e.g., Taiwan, United States, France, Spain, India, Lebanon) demonstrated the MGB to be a short, simple, low-risk, effective, and durable bariatric procedure.

A NEW APPROACH FOR BIODIESEL PRODUCTION FROM ALGAE

EPA Science Inventory

The supply of energy for the United States and world is currently dependent on extraction of fossil fuels. Eventually, a novel or sustainable source of energy will be required for industrial societies. In particular, transportation fuels are currently dependent on dwindling su...

Value Added

ERIC Educational Resources Information Center

Welch, Matt

2004-01-01

This article profiles retiring values teacher Gene Doxey and describes his foundational contributions to the students of California's Ramona Unified School District. Every one of the Ramona Unified School District's 7,200 students is eventually funneled through Doxey's Contemporary Issues class, a required rite of passage between elementary school…

Case reports - When bronchial obstruction in the young adult is not asthma and inhalers do not help.

PubMed

Sigvard, Anne; Bødtger, Uffe

2016-08-01

Localised bronchial obstruction is a rare differential diagnosis to asthma. We describe two younger patients treated unsuccessfully for asthma and eventually diagnosed with localised bronchoconstriction. Bronchoscopy revealed bronchoconstriction: Tracheobronchomalacia in case 1 and fixed obstruction in case 2. A systematic approach to the asthma patient with absent response to therapy facilitates rational use of therapeutic and diagnostic resources.

[Some ethical considerations, especially identity, during xenotransplantation].

PubMed

Cüer, P

2000-05-01

Provided that a pandemic due to retroviruses or prions eventually transmitted by animals is under control, in accordance with the fundamental ethical rule to serve the best interest of the patient, any organ xenotransplantation raises an important ethical dilemma: how to deliver proper and adapted information to the patient on the preservation of his identity. Xenotransplantation of any part of the brain seems to us unethical.

Reconstruction of thoracic burn sequelae by scar release and flap resurfacing.

PubMed

Angrigiani, Claudio; Artero, Guillermo; Castro, Gaston; Khouri, Roger K

2015-12-01

In the USA, 450,000 thermal burns receive medical treatment annually. Burn scars are commonly excised and covered with skin grafts. Long-term, these treatments commonly leave patients with discomfort, reduced total lung capacity and forced vital capacity, and restriction of thoracic expansion and shoulder joint mobility. In this article, we present our experience with using scar release and immediate flap reconstruction to treat thoracic restriction due to burn sequelae. From 1998 to 2014, we enrolled 16 patients with anterior thoracic burn sequelae that had previously been treated conservatively or with skin grafts that eventually recidivated. Preoperatively, we measured thoracic circumference in expiration and inspiration, %FVC, %FEV1, and shoulder mobility. All patients underwent anterior thoracic scar release and immediate flap resurfacing. At 2 weeks to 3 months postoperatively (mean, 2.6 months), mean thoracic circumference upon inspiration increased from 83.6 cm±5.7 to 86.5 cm±5.8 (p<0.0000000001). Mean %FVC improved from 76.0%±2.64% to 88.2%±4.69% (p<0.0000001). Mean %FEV1 improved from 79.2%±3.85 to 87.8%±2.98 (p<0.000001). All 14 patients who had restricted shoulder mobility preoperatively no longer had restricted shoulder mobility postoperatively. The mean patient-reported satisfaction was 4.6/5 (range, 3-5). At a mean follow up of 2.5 years, none of the contractures recidivated. Complications included 2 cases of tissue necrosis of the distal end of the flap. In one case, the flap was restored; in the other case, the patient eventually had to receive a new flap. Additional complications included two local infections that were successfully treated with oral and local antibiotics and two hematomas that were drained and eventually healed without tissue loss. Scar releases and flaps provide a safe and effective method for the correction of restricted thoracic expansion, respiratory restriction, decreased range of shoulder motion, and discomfort from thoracic burn sequelae. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.

Analysis of volumetric response of pituitary adenomas receiving adjuvant CyberKnife stereotactic radiosurgery with the application of an exponential fitting model.

PubMed

Yu, Yi-Lin; Yang, Yun-Ju; Lin, Chin; Hsieh, Chih-Chuan; Li, Chiao-Zhu; Feng, Shao-Wei; Tang, Chi-Tun; Chung, Tzu-Tsao; Ma, Hsin-I; Chen, Yuan-Hao; Ju, Da-Tong; Hueng, Dueng-Yuan

2017-01-01

Tumor control rates of pituitary adenomas (PAs) receiving adjuvant CyberKnife stereotactic radiosurgery (CK SRS) are high. However, there is currently no uniform way to estimate the time course of the disease. The aim of this study was to analyze the volumetric responses of PAs after CK SRS and investigate the application of an exponential decay model in calculating an accurate time course and estimation of the eventual outcome.A retrospective review of 34 patients with PAs who received adjuvant CK SRS between 2006 and 2013 was performed. Tumor volume was calculated using the planimetric method. The percent change in tumor volume and tumor volume rate of change were compared at median 4-, 10-, 20-, and 36-month intervals. Tumor responses were classified as: progression for >15% volume increase, regression for ≤15% decrease, and stabilization for ±15% of the baseline volume at the time of last follow-up. For each patient, the volumetric change versus time was fitted with an exponential model.The overall tumor control rate was 94.1% in the 36-month (range 18-87 months) follow-up period (mean volume change of -43.3%). Volume regression (mean decrease of -50.5%) was demonstrated in 27 (79%) patients, tumor stabilization (mean change of -3.7%) in 5 (15%) patients, and tumor progression (mean increase of 28.1%) in 2 (6%) patients (P = 0.001). Tumors that eventually regressed or stabilized had a temporary volume increase of 1.07% and 41.5% at 4 months after CK SRS, respectively (P = 0.017). The tumor volume estimated using the exponential fitting equation demonstrated high positive correlation with the actual volume calculated by magnetic resonance imaging (MRI) as tested by Pearson correlation coefficient (0.9).Transient progression of PAs post-CK SRS was seen in 62.5% of the patients receiving CK SRS, and it was not predictive of eventual volume regression or progression. A three-point exponential model is of potential predictive value according to relative distribution. An exponential decay model can be used to calculate the time course of tumors that are ultimately controlled.

The Space Station Prototype Program - The development of a regenerative life support system for extended-duration missions.

NASA Technical Reports Server (NTRS)

Willis, N. C., Jr.; Neel, J. M.

1972-01-01

Design concepts and test philosophies which may contribute to the development of a low-cost maintainable environmental control/life support system are examined. It is shown that the concept of producing flight prototype equipment during a developmental program can reduce the eventual cost of a flight system by incorporating realistic flight-type design requirements without imposing exacting design features and stringent controls. A flight prototype design is one that can be converted readily into an actual flight design without any conceptual change. Modularity of subsystems provides the system and the program a degree of flexibility relative to the eventual vehicle configuration and technological improvements.

Rare upper gastrointestinal hemorrhage of cetuximab: A case report.

PubMed

Duan, Shi-Jie; Gao, Zi-Ming; Wang, Peng-Liang; Gong, Bao-Cheng; Huang, Han-Wei; Luo, Lei; Wang, Xin; Xing, Ya-Nan; Xu, Hui-Mian; Liu, Fu-Nan

2017-12-01

cetuximab, an epidermal growth factor receptor inhibitor, is a targeted therapeutic regimen of colorectal cancers. Several common adverse effects have been found, such as cutaneous or gastrointestinal toxicity. However, according to the articles had been published, upper gastrointestinal bleeding (UGIB) is considered to be rare and its mechanism remains unclear. In this report, we presented a 42-year-old male patient with advanced recto-sigmoid cancer. After palliative operation, the patient suffered from complete upper gastrointestinal (GI) obstruction, which was induced by extensive abdominal metastasis of the tumor. Considering his poor condition, we chose the targeted drug, cetuximab, as his further treatment. But after the application of cetuximab, the UGIB immediately happened twice in this patient. UGIB, as a rare complication of cetuximab, occured to the patient. We stopped the bleeding with thrombin, hemocoagulase and somatostatin and suspended the subsequent treatment plan of cetuximab. At the same time, anti-shock treatment was given immediately. He was died of respiratory and circulatory failure caused by UGIB and advanced tumor eventually. UGIB should be considered as a rare but severe complication of cetuximab. When cetuximab is applied for patients with advanced colon tumors, more cautions should be required if the patients are accompanied by upper gastrointestinal obstruction. In addition, for those patients who suffered from UGIB recently, cetuximab should be prohibited if the Rockall score ranged > 5 points. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

The effect of silicone implants on the diagnosis, prognosis, and treatment of breast cancer.

PubMed

Handel, Neal

2007-12-01

Because of the prevalence of breast cancer, many augmented women eventually will develop the disease. This article reviews what is known about the effect of implants on the detection, prognosis, and treatment of carcinoma of the breast. Observations were made on 4082 breast cancer patients (3953 nonaugmented and 129 augmented) treated over a 23-year time span. Findings in the two groups were compared and differences analyzed statistically. Mammograms of all women with palpable lesions were reviewed to assess mammographic sensitivity in patients with and without implants. Cosmetic outcomes in augmented patients treated with breast conservation therapy were reviewed. Augmented patients presented more frequently with palpable lesions, invasive tumors, axillary nodal metastases, and false-negative mammograms. However, there was no significant difference in stage of disease, tumor size, recurrence rates, or survival between the two groups. Augmented patients treated with breast conservation therapy often experienced poor cosmetic results and frequently required reoperation. Despite the diminished sensitivity of mammography in women with implants, augmented and nonaugmented patients are diagnosed at a similar stage of disease and have a comparable prognosis. Implants may impair mammography but appear to facilitate tumor detection on physical examination. Magnetic resonance imaging and breast ultrasound may be useful adjuncts, but conventional mammography remains the most reliable tool for diagnosing early breast cancer in augmented patients. Breast implants do not interfere with mastectomy or breast reconstruction but may compromise the outcome of breast conservation therapy.

Endoscopic duodenal perforation: surgical strategies in a regional centre

PubMed Central

2014-01-01

Background Duodenal perforation is an uncommon complication of endoscopic retrograde cholangio-pancreatography (ERCP) and a rare complication of upper gastrointestinal endoscopy. Most are minor perforations that settle with conservative management. A few perforations however result in life-threatening retroperitoneal necrosis and require surgical intervention. There is a relative paucity of references specifically describing the surgical interventions required for this eventuality. Methods Five cases of iatrogenic duodenal perforation were ascertained between 2002 and 2007 at Cairns Base Hospital. Clinical features were analyzed and compared, with reference to a review of ERCP at that institution for the years 2005/2006. Results One patient recovered with conservative management. Of the other four, one died after initial laparotomy. The other three survived, undergoing multiple procedures and long inpatient stays. Conclusions Iatrogenic duodenal perforation with retroperitoneal necrosis is an uncommon complication of endoscopy, but when it does occur it is potentially life-threatening. Early recognition may lead to a better outcome through earlier intervention, although a protracted course with multiple procedures should be anticipated. A number of surgical techniques may need to be employed according to the individual circumstances of the case. PMID:24461069

Veno-venous extracorporeal membrane oxygenation using a double-lumen bi-caval cannula for severe respiratory failure post total artificial heart implantation.

PubMed

Miessau, J; Yang, Q; Unai, S; Entwistle, J W C; Cavarocchi, N C; Hirose, H

2015-07-01

We report a unique utilization of a double-lumen, bi-caval Avalon cannula for veno-venous (VV) extracorporeal membrane oxygenation (ECMO) during placement of a total artificial heart (TAH, SynCardia, Tucson, AZ). A 22-year-old female with post-partum cardiomyopathy was rescued on veno-arterial (VA) ECMO because of cardiogenic shock. The inability to wean ECMO necessitated implantation of the TAH as a bridge to transplant. In addition, the patient continued to have respiratory failure and concomitant VV ECMO was planned with the implant. During TAH implantation, the Avalon cannula was placed percutaneously from the right internal jugular vein into the inferior vena cava (IVC) under direct vision while the right atrium was open. During VV ECMO support, adequate flows on both ECMO and TAH were maintained without adverse events. VV ECMO was discontinued, without reopening the chest, once the patient's respiratory failure improved. However, the patient subsequently developed a profound respiratory acidosis and required VV ECMO for CO2 removal. The Avalon cannula was placed in the femoral vein to avoid accessing the internal jugular vein and risking damage to the TAH. The patient's oxygenation eventually improved and the cannula was removed at the bedside. The patient was supported for 22 days on VV ECMO and successfully weaned from the ventilator prior to her orthotropic heart transplantation. © The Author(s) 2014.

[Anesthetic complications in sequential bipulmonary transplantation in patients with cystic fibrosis. Apropos of 6 cases].

PubMed

López, L M; Vicente, R; Ramos, F; Palacios, L; Calvo, A; Hernández, S; Borro, J M; Morales, P; Montero, R

1996-03-01

Cystic fibrosis (CF) is a disease characterized mainly by altered exocrine gland function that eventually produces irreversible dysfunction of the pancreas and lungs. The respiratory insufficiency that develops in CF patients in the advanced stages of disease can only be corrected at this time by lung or heart-lung transplantation. We describe our experience with 6 terminal phase CF patients who underwent sequential double lung transplantation (SDLT). Anesthesia was intravenous, with exhaustive hemodynamic and respiratory monitoring. During surgery the most frequently encountered hemodynamic complications were low minute volume, arterial hypotension and irregular heart rate. The main respiratory complications were hypoxemia, hypercapnia and pulmonary edema of the implanted lung, which developed in all cases to varying degrees related to the organ's state of preservation and duration of ischemia. Other complications were the need for extracorporeal circulation in 1 case, oliguria and blood loss requiring multiple transfusions. The most critical moments were at the time of clamping the pulmonary artery, the period after revascularization of the donated lung, and at the start of patient ventilation through the first implanted lung so that the second could be implanted. Although our series is small, it is of interest given the limited Spanish experience with lung transplantation in CF patients, and the good early results obtained, which are similar to those reported for other diseases.

Prostate specific antigen velocity as a measure of the natural history of prostate cancer: defining a 'rapid riser' subset.

PubMed

Nam, R K; Klotz, L H; Jewett, M A; Danjoux, C; Trachtenberg, J

1998-01-01

To study the rate of change in prostate specific antigen (PSA velocity) in patients with prostate cancer initially managed by 'watchful waiting'. Serial PSA levels were determined in 141 patients with prostate cancer confirmed by biopsy, who were initially managed expectantly and enrolled between May 1990 and December 1995. Sixty-seven patients eventually underwent surgery (mean age 59 years) because they chose it (the decision for surgery was not based on PSA velocity). A cohort of 74 patients remained on 'watchful waiting' (mean age 69 years). Linear regression and logarithmic transformations were used to segregate those patients who showed a rapid rise, defined as a > 50% rise in PSA per year (or a doubling time of < 2 years) and designated 'rapid risers'. An initial analysis based on a minimum of two PSA values showed that 31% were rapid risers. Only 15% of patients with more than three serial PSA determinations over > or = 6 months showed a rapid rise in PSA level. There was no advantage of log-linear analysis over linear regression models. Three serial PSA determinations over > or = 6 months in patients with clinically localized prostate cancer identifies a subset (15%) of patients with a rapidly rising PSA level. Shorter PSA surveillance with fewer PSA values may falsely identify patients with rapid rises in PSA level. However, further follow-up is required to determine if a rapid rise in PSA level identifies a subset of patients with an aggressive biological phenotype who are either still curable or who have already progressed to incurability through metastatic disease.

Experiences in Eliciting Security Requirements

DTIC Science & Technology

2006-12-01

FODA ) FODA is a domain analysis and engineer- ing method that focuses on developing reusable assets [9]. By examining related software systems and...describe a trade-off analysis that we used to select a suitable requirements elici- tation method and present results detailed from a case study of one...disaster planning, and how to improve Medicare. Eventually, technology-oriented problems may emerge from these soft problems, but much more analysis is

Nonsyndromic tooth agenesis patterns and associated developmental dental anomalies: a literature review with radiographic illustrations.

PubMed

Agarwal, P; Vinuth, D P; Dube, G; Dube, P

2013-01-01

Tooth agenesis is one of the most intriguing phenomena, because it is frequently associated with other oral anomalies, structural variations and malformations of other teeth, late eruption, transposition and crowding. The diagnosis can be quite challenging as radiographic examination is critical for the diagnosis but not always possible and the late developing teeth may be sometimes scored developmentally missing. Accurate diagnosis therefore requires radiographic, clinical, and dental cast examinations. It is an important clinical and public health problem. Patients with missing permanent teeth may suffer from a reduced chewing ability, inarticulate pronunciation, and an unfavorable aesthetic appearance. Clinically, early diagnosis of a dental anomaly can alert the clinician to the possible development of other associated dental anomalies in the same patient or family, and avoid the possible sequelae. Understanding of tooth agenesis patterns and their impact on diagnosis, prevention, and eventually therapeutics are becoming integral parts of comprehensive dental care. Dental examination with radiographic screening of hypodontia in early childhood should be emphasized as part of public oral health policy to allow early diagnosis and timely intervention.

Multi-template tensor-based morphometry: Application to analysis of Alzheimer's disease

PubMed Central

Koikkalainen, Juha; Lötjönen, Jyrki; Thurfjell, Lennart; Rueckert, Daniel; Waldemar, Gunhild; Soininen, Hilkka

2012-01-01

In this paper methods for using multiple templates in tensor-based morphometry (TBM) are presented and comparedtothe conventional single-template approach. TBM analysis requires non-rigid registrations which are often subject to registration errors. When using multiple templates and, therefore, multiple registrations, it can be assumed that the registration errors are averaged and eventually compensated. Four different methods are proposed for multi-template TBM. The methods were evaluated using magnetic resonance (MR) images of healthy controls, patients with stable or progressive mild cognitive impairment (MCI), and patients with Alzheimer's disease (AD) from the ADNI database (N=772). The performance of TBM features in classifying images was evaluated both quantitatively and qualitatively. Classification results show that the multi-template methods are statistically significantly better than the single-template method. The overall classification accuracy was 86.0% for the classification of control and AD subjects, and 72.1%for the classification of stable and progressive MCI subjects. The statistical group-level difference maps produced using multi-template TBM were smoother, formed larger continuous regions, and had larger t-values than the maps obtained with single-template TBM. PMID:21419228

Is social attention impaired in schizophrenia? Gaze, but not pointing gestures, is associated with spatial attention deficits.

PubMed

Dalmaso, Mario; Galfano, Giovanni; Tarqui, Luana; Forti, Bruno; Castelli, Luigi

2013-09-01

The nature of possible impairments in orienting attention to social signals in schizophrenia is controversial. The present research was aimed at addressing this issue further by comparing gaze and arrow cues. Unlike previous studies, we also included pointing gestures as social cues, with the goal of addressing whether any eventual impairment in the attentional response was specific to gaze signals or reflected a more general deficit in dealing with social stimuli. Patients with schizophrenia or schizoaffective disorder and matched controls performed a spatial-cuing paradigm in which task-irrelevant centrally displayed gaze, pointing finger, and arrow cues oriented rightward or leftward, preceded a lateralized target requiring a simple detection response. Healthy controls responded faster to spatially congruent targets than to spatially incongruent targets, irrespective of cue type. In contrast, schizophrenic patients responded faster to spatially congruent targets than to spatially incongruent targets only for arrow and pointing finger cues. No cuing effect emerged for gaze cues. The results support the notion that gaze cuing is impaired in schizophrenia, and suggest that this deficit may not extend to all social cues.

Long-term outcomes of Gamma Knife radiosurgery in patients with vestibular schwannomas.

PubMed

Murphy, Erin S; Barnett, Gene H; Vogelbaum, Michael A; Neyman, Gennady; Stevens, Glen H J; Cohen, Bruce H; Elson, Paul; Vassil, Andrew D; Suh, John H

2011-02-01

The authors sought to determine the long-term tumor control and side effects of Gamma Knife radiosurgery (GKRS) in patients with vestibular schwannomas (VS). One hundred seventeen patients with VS underwent GKRS between January 1997 and February 2003. At the time of analysis, at least 5 years had passed since GKRS in all patients. The mean patient age was 60.9 years. The mean maximal tumor diameter was 1.77 ± 0.71 cm. The mean tumor volume was 1.95 ± 2.42 ml. Eighty-two percent of lesions received 1300 cGy and 14% received 1200 cGy. The median dose homogeneity ratio was 1.97 and the median dose conformality ratio was 1.78. Follow-up included MR imaging or CT scanning approximately every 6-12 months. Rates of progression to surgery were calculated using the Kaplan-Meier method. Of the 117 patients in whom data were analyzed, 103 had follow-up MR or CT images and 14 patients were lost to follow-up. Fifty-three percent of patients had stable tumors and 37.9% had a radiographically documented response. Imaging-documented tumor progression was present in 8 patients (7.8%), but in 3 of these the lesion eventually stabilized. Only 5 patients required a neurosurgical intervention. The estimated 1-, 3-, and 5-year rates of progression to surgery were 1, 4.6, and 8.9%, respectively. One patient (1%) developed trigeminal neuropathy, 4 patients (5%) developed permanent facial neuropathy, 3 patients (4%) reported vertigo, and 7 patients (18%) had new gait imbalance following GKRS. Gamma Knife radiosurgery results in excellent local control rates with minimal toxicity for patients with VS. The authors recommend standardized follow-up to gain a better understanding of the long-term effects of GKRS.

Leptospirosis in New Orleans.

PubMed

Toliver, Herman L; Krane, N Kevin

2014-02-01

Leptospirosis is an unusual but reemerging zoonotic infectious disease in the United States where the diagnosis may not be suspected when patients initially present. The case report of a patient from New Orleans who presented with jaundice, hypotension and acute kidney injury is presented. In this patient, a broad differential diagnosis was considered on presentation and serologic testing for leptospirosis eventually confirmed the diagnosis. A review of the clinical manifestations, diagnostic studies and treatment are discussed so that leptospirosis will be considered more carefully in the initial evaluation and management of similar patients.

New Methods for Understanding Systems Consolidation

ERIC Educational Resources Information Center

Tayler, Kaycie K.; Wiltgen, Brian J.

2013-01-01

According to the standard model of systems consolidation (SMC), neocortical circuits are reactivated during the retrieval of declarative memories. This process initially requires the hippocampus. However, with the passage of time, neocortical circuits become strengthened and can eventually retrieve memory without input from the hippocampus.…

A synthesis and comparative evaluation of drainage water management

USDA-ARS?s Scientific Manuscript database

Viable large-scale crop production in the United States requires artificial drainage in humid and poorly drained agricultural regions. Excess water removal is generally achieved by installing tile drains that export water to open ditches that eventually flow into streams. Drainage water management...

The Optical Nation.

ERIC Educational Resources Information Center

Rubin, Philip A.

If the Corporation for Public Broadcasting (CPB) is eventually to serve all citizens with public radio and television, technological and regulatory innovation will be required. Service to rural America and service to specific groups within urban areas cannot be accomplished within the limits of existing technology and existing spectrum allocation…

Can intractable discogenic back pain be managed by low-level laser therapy without recourse to operative intervention?

PubMed Central

Ip, David; Fu, Nga-Yue

2015-01-01

Objective The aim of the study reported here was to investigate the possible clinical role of low-level laser therapy (LLLT) in discogenic back pain patients who failed to respond to a conventional physical therapy program to avoid recourse to operative intervention. Methods The paper reports on the long-term mean 5-year prospective follow-up of a patient cohort of 50 unselected patients visiting our tertiary referral pain center for discogenic back pain who had had a single-level lesion documented by magnetic resonance imaging followed by subsequent discography to confirm the affected disc being the pain generator. All of the patients who entered the study had failed response to a combination of nonsteroidal anti-inflammatory agents and had had not less than 3 months of conventional physical therapy. LLLT, at a wavelength of 810 nm wavelength emitted from a GaAIAs semiconductor laser device with 5.4 J per point and a power density of 20 mW/cm2, was employed. The treatment regimen consisted of three sessions of treatment per week for 12 consecutive weeks. Results All but one patient had significant improvement in their Oswestry Disability Index score, from a mean of 50% score to a mean of 10% score, at the end of treatment at 12 weeks. In addition, surprisingly, the improvement was found maintained at follow-up assessments 1 year and 5 years later. The one patient among the 50 patients who failed to respond eventually required surgery, while the others did not require surgery. Conclusion We conclude that LLLT is a viable option in the conservative treatment of discogenic back pain, with a positive clinical result of more than 90% efficacy, not only in the short-term but also in the long-term, with lasting benefits. PMID:26064065

Analysis of Predictors of Resection and Survival in Locally Advanced Stage III Pancreatic Cancer: Does the Nature of Chemotherapy Regimen Influence Outcomes?

PubMed

Bednar, Filip; Zenati, Mazen S; Steve, Jennifer; Winters, Sharon; Ocuin, Lee M; Bahary, Nathan; Hogg, Melissa E; Zeh, Herbert J; Zureikat, Amer H

2017-05-01

Locally advanced unresectable pancreatic cancer (LAPC) historically portends a poor prognosis. FOLFIRINOX and gemcitabine/nab-paclitaxel have proven effective in the metastatic setting. We sought to evaluate the outcomes of these regimens compared with older regimens in LAPC. A retrospective, single institutional review of all consecutive LAPC treated with "new" (FOLFIRINOX and/or gemcitabine/nab-paclitaxel) and "old" (gemcitabine or 5-FU) chemotherapy from 2010 to 2014 was performed. Univariate and multivariate predictors of resection and survival were determined. A total of 92 patients (new chemotherapy = 61, old chemotherapy = 31) were analyzed, of which 19 (21%) underwent eventual resection (median overall survival [OS] = 32 vs. 14.3 months for unresected patients, P = 0.0002). For the overall cohort, resection (hazard ratio [HR] 0.261, P = 0.014), radiation therapy (HR 0.458, P = 0.004), number of lines of chemotherapy (HR 0.486, P = 0.012), and new chemotherapy (HR 0.593 vs. old regimens, P = 0.065) were independent predictors of OS on multivariate analyses (MVA). On MVA, predictors of eventual resection were head and neck tumors (OR 0.307, P = 0.033) or SMA involvement (OR 0.285, P = 0.023). In nonresected patients (73), MVA showed treatment with new chemotherapy (HR 0.452, P = 0.006), radiation (HR 0.459, P = 0.006), and number of lines of CT (HR 0.705, P = 0.013) to be predictors of survival. In LAPC, use of FOLFIRNOX and/or gemcitabine/nab-paclitaxel is associated with improved survival compared with older chemotherapy regimens, regardless of eventual resection. Tumor location and relationship to certain vasculature are important determinants of resection in this cohort.

Lead toxicity masquerading as sickle cell crisis.

PubMed

Nelson, M S; Chisolm, J J

1986-06-01

We recently saw a 12-year-old black boy with known sickle cell disease who had been seen many times for abdominal pain thought to be secondary to a vasoocclusive crisis. The patient eventually was admitted, after a seizure and the onset of obtundation. The etiology of his acute encephalopathy remained unclear until bone films of his knees fortuitously revealed "lead lines." The patient was treated and did well subsequently. This case emphasizes the importance of considering other diagnoses when a sickle cell patient presents with a crisis.

"Pedogeriatrics": a pediatric nephrologist's outlook on common challenges facing pediatric and geriatric nephrologists.

PubMed

Grünberg, Jose

2010-03-01

Dramatic demographic changes longevity and medical progress helped create a new population made up of the survivors of previously fatal diseases. These trends pose new major social and economic challenges that should be accounted for in health policy making. This paper discusses the similarities between the specialties of pediatrics and geriatrics, especially in the realm of patient care. Children and the elderly share a limited autonomy and dependence on the human environment (i.e., willing and able caregiving persons) due to age or disease. The long-term care of dependent patients (DP) requires caregiving persons who share with dependent persons the risk of losing autonomy, facing burnout, family disruption, and interference with work and educational activities. Families with DPs may face potential losses of income because both patients and caregivers are partially or completely unable to work, the former for medical reasons and the latter due to the new demands on their time and energy. Additionally, new expenses have to be met because while direct medical expenses might be covered by insurance or the State, other expenses have to be financed by the family, such as co-payments for medicines, new water or electricity home installations, and transport and eventual hotel costs if they have to stay overnight near a hospital outside of their town. The main objectives of long-term care should be to maximize patients' independence and prevent their physical and psychological deterioration while minimizing the social, economic and personal costs to caregivers. To achieve these goals, one needs a holistic approach, a multidisciplinary professional team (doctors, nurses, social workers, nutritionists and psychologists) and auxiliary staff (secretaries, electricians, administrators, messengers, cleaning staff, doormen, nursing aids and coordinators of medical appointments and medical procedures). Optimal management of DPs on chronic treatments such as chronic dialysis requires adequate communication skills, respectful attitudes toward patients and caregivers and effective use of communication and information technologies. Auxiliary personnel require specific training to contribute effectively to the DP attention processes. This paper postulates that pediatric and geriatric teams and their patients would benefit from closer training and sharing of experiences and systems.

Comprehensive Approaches to Managing Delirium in Patients with Advanced Cancer

PubMed Central

Kang, Jung Hun; Shin, Seong Hoon; Bruera, Eduardo

2013-01-01

Delirium is a frequently under-recognized complication in patients with advanced cancer. Uncontrolled delirium eventually leads to significant distress to patients and their families. However, delirium episodes can be reversed in half of these patients by eliminating precipitating factors and using appropriate interventions. The purpose of this narrative review is to discuss the most recent updates in the literature on the management of delirium in patients with advanced cancer. This article addresses the epidemiology, cause, pathophysiology, clinical characteristics, and assessment of delirium as well as various treatment options, including nonpharmacologic intervention and palliative sedation. PMID:22959227

Active surveillance for localized prostate cancer: an analysis of patient contacts and utilization of healthcare resources.

PubMed

Thomsen, Frederik B; Berg, Kasper D; Røder, M Andreas; Iversen, Peter; Brasso, Klaus

2015-02-01

Evidence supports active surveillance (AS) as a means to reduce overtreatment of low-risk prostate cancer (PCa). The consequences of close and long-standing follow-up with regard to outpatient visits, tests and repeated biopsies are widely unknown. This study investigated the trajectory and costs of AS in patients with localized PCa. In total, 317 PCa patients were followed in a prospective, single-arm AS cohort. The primary outcomes were number of patient contacts, prostate-specific antigen (PSA) tests, biopsies, hospital admissions due to biopsy complications and patients eventually undergoing curative treatment. The secondary outcome was cost. The 5 year cumulative incidence of discontinued AS in a competing-risk model was 40%. During the first 5 years of AS patients underwent a median of two biopsy sets, and patients were seen in an outpatient clinic including PSA testing three to four times annually. In total, 38 of the 406 biopsy sessions led to hospital admission and 87 of the 317 patients required treatment for bladder outlet obstruction (BOO). With a median of 3.7 years' follow-up, the total cost of AS was euro (€) 1,240,286. Assuming all patients had otherwise undergone primary radical prostatectomy, the cost difference favoured AS with a net benefit of €662,661 (35% reduction). AS entails a close clinical follow-up with a considerable risk of rebiopsy complication, treatment of BOO and subsequent delayed definitive therapy. This risk should be weighed against a potential economic benefit and reduction in the risk of overtreatment compared to immediate radical treatment.

Overactivating CAR T cells interferes with their ability to fight cancer in mice | Center for Cancer Research

Cancer.gov

CAR T-cell therapy, in which a patient’s T cells are reprogrammed in the lab to boost their ability to recognize and destroy cancer cells when they are returned to the body, has led to dramatic responses for many patients with certain blood cancers. Not all patients respond to the treatment, however, and many who do eventually relapse. Read more…

Analysis of medical litigation among patients with medical disputes in cosmetic surgery in Taiwan.

PubMed

Lyu, Shu-Yu; Liao, Chuh-Kai; Chang, Kao-Ping; Tsai, Shang-Ta; Lee, Ming-Been; Tsai, Feng-Chou

2011-10-01

This study aimed to investigate the key factors in medical disputes (arguments) among female patients after cosmetic surgery in Taiwan and to explore the correlates of medical litigation. A total of 6,888 patients (3,210 patients from two hospitals and 3,678 patients from two clinics) received cosmetic surgery from January 2001 to December 2009. The inclusion criteria specified female patients with a medical dispute. Chi-square testing and multiple logistic regression analysis were used to analyze the data. Of the 43 patients who had a medical dispute (hospitals, 0.53%; clinics, 0.73%), 9 plaintiffs eventually filed suit against their plastic surgeons. Such an outcome exhibited a decreasing annual trend. The hospitals and clinics did not differ significantly in terms of patient profiles. The Chi-square test showed that most patients with a medical dispute (p < 0.05) were older than 30 years, were divorced or married, had received operations under general anesthesia, had no economic stress, had a history of medical litigation, and eventually did not sue the surgeons. The test results also showed that the surgeon's seniority and experience significantly influenced the possibility of medical dispute and nonlitigation. Multiple logistical regression analysis further showed that the patients who did decide to enter into litigation had two main related factors: marital stress (odds ratio [OR], 10.67; 95% confidence interval [CI], 1.20-94.73) and an education level below junior college (OR, 9.33; 95% CI, 1.01-86.36). The study findings suggest that the key characteristics of patients and surgeons should be taken into consideration not only in the search for ways to enhance pre- and postoperative communication but also as useful information for expert testimony in the inquisitorial law system.

Overlapping features of polymyositis and inclusion body myositis in HIV-infected patients

PubMed Central

Lloyd, Thomas E.; Pinal-Fernandez, Iago; Michelle, E. Harlan; Christopher-Stine, Lisa; Pak, Katherine; Sacktor, Ned

2017-01-01

Objective: To characterize patients with myositis with HIV infection. Methods: All HIV-positive patients with myositis seen at the Johns Hopkins Myositis Center from 2003 to 2013 were included in this case series. Muscle biopsy features, weakness pattern, serum creatine kinase (CK) level, and anti–nucleotidase 1A (NT5C1A) status of HIV-positive patients with myositis were assessed. Results: Eleven of 1,562 (0.7%) patients with myositis were HIV-positive. Myositis was the presenting feature of HIV infection in 3 patients. Eight of 11 patients had weakness onset at age 45 years or less. The mean time from the onset of weakness to the diagnosis of myositis was 3.6 years (SD 3.2 years). The mean of the highest measured CK levels was 2,796 IU/L (SD 1,592 IU/L). On muscle biopsy, 9 of 10 (90%) had endomysial inflammation, 7 of 10 (70%) had rimmed vacuoles, and none had perifascicular atrophy. Seven of 11 (64%) patients were anti-NT5C1A-positive. Upon presentation, all had proximal and distal weakness. Five of 6 (83%) patients followed 1 year or longer on immunosuppressive therapy had improved proximal muscle strength. However, each eventually developed weakness primarily affecting wrist flexors, finger flexors, knee extensors, or ankle dorsiflexors. Conclusions: HIV-positive patients with myositis may present with some characteristic polymyositis features including young age at onset, very high CK levels, or proximal weakness that improves with treatment. However, all HIV-positive patients with myositis eventually develop features most consistent with inclusion body myositis, including finger and wrist flexor weakness, rimmed vacuoles on biopsy, or anti-NT5C1A autoantibodies. PMID:28283597

77 FR 37786 - Airworthiness Directives; Bombardier, Inc. Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-25

... cracking of certain fuel access panels of the outer wing. This AD requires an external inspection, and if necessary an internal inspection, to determine if certain fuel access panels are installed, and replacement... if necessary, would defer the internal inspection; and eventual replacement of affected fuel access...

77 FR 18135 - Airworthiness Directives; Bombardier, Inc., Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-27

... access panels of the outer wing. This proposed AD would require an external inspection, and if necessary an internal inspection, to determine if certain fuel access panels are installed, and replacement if... necessary, would defer the internal inspection; and eventual replacement of affected fuel access panels with...

Ecological Effects of Weather Modification: A Problem Analysis.

ERIC Educational Resources Information Center

Cooper, Charles F.; Jolly, William C.

This publication reviews the potential hazards to the environment of weather modification techniques as they eventually become capable of producing large scale weather pattern modifications. Such weather modifications could result in ecological changes which would generally require several years to be fully evident, including the alteration of…

Ahead of the Times in Murfreesboro.

ERIC Educational Resources Information Center

Jones, John Hodge

1994-01-01

Murfreesboro (Tennessee) City Schools extended the school day and year with no additional cost to taxpayers. Implementation was arduous and faced great resistance. Eventual solution made better use of the school system's capital assets and human resources, rearranged Chapter 1 money, required additional business support and parents' willingness to…

Teacher Attrition, Retention and Mobility: Where Does Australian Stand?

ERIC Educational Resources Information Center

Kearney, Sean

2014-01-01

The teaching workforce is in a constant state of change, susceptible to fluctuating federal and state governments, policy directions within the various bureaucracies that control the curriculum, teachers' accreditation and certification requirements and universities that regulate entry into initial teacher education programs, and eventually the…

Metformin associated lactic acidosis (MALA): clinical profiling and management.

PubMed

Moioli, Alessandra; Maresca, Barbara; Manzione, Andrea; Napoletano, Antonello Maria; Coclite, Daniela; Pirozzi, Nicola; Punzo, Giorgio; Menè, Paolo

2016-12-01

Metformin (MF) accumulation during acute kidney injury is associated with high anion gap lactic acidosis type B (MF-associated lactic acidosis, MALA), a serious medical condition leading to high mortality. Despite dose adjustment for renal failure, diabetic patients with chronic kidney disease (CKD) stage III-IV are at risk for rapid decline in renal function by whatever reason, so that MF toxicity might arise if the drug is not timely withdrawn. Sixteen consecutive patients were admitted to our Hospital's Emergency Department with clinical findings consistent with MALA. Fifteen had prior history of CKD, 60 % of them with GFR between 30 and 60 ml/min. Of these, 5 required mechanical ventilation and cardiovascular support; 3 promptly recovered renal function after rehydration, whereas 10 (62 %) required continuous veno-venous renal replacement treatment. SOFA and SAPS II scores were significantly related to the degree of lactic acidosis. In addition, lactate levels were relevant to therapeutic choices, since they were higher in dialyzed patients than in those on conservative treatment (11.92 mmol/l vs 5.7 mmol/l, p = 0.03). The overall death rate has been 31 %, with poorer prognosis for worse acidemia, as serum pH was significantly lower in non-survivors (pH 6.96 vs 7.16, p > 0.04). Our own data and a review of the literature suggest that aged, hemodynamically frail patients, with several comorbidities and CKD, are at greater risk of MALA, despite MF dosage adjustment. Moreover, renal replacement therapy rather than simple acidosis correction by administration of alkali seems the treatment of choice, based on eventual renal recovery and overall outcome.

[Non operative treatment for perforated peptic ulcer: results of a prospective study].

PubMed

Songne, B; Jean, F; Foulatier, O; Khalil, H; Scotté, M

2004-12-01

The conservative management of perforated peptic ulcer has not gained widespread acceptance despite introduction of proton-pomp inhibitors because surgical procedures can achieve immediate closure by eventually using a laparoscopic approach. The aim of this prospective study was to evaluate the results of Taylor's method and to identify predictive factors of failure of medical treatment in patients presenting with perforated peptic ulcer. Between 1990 and 2000, 82 consecutive patients, with diagnosis of perforated peptic ulcer were prospectively included in this study. They were initially treated with non-operative procedure (nasogastric suction and intravenous administration of H2-blockers or proton-pomp inhibitors). No clinical improvement after 24 hours required a surgical treatment. Predictive factors of failure of non-operative treatment were tested in univariate or multivariate analysis. Clinical improvement was obtained with non-operative treatment in 54% of the patients (44/82). The overall mortality rate was 1%. In univariate analysis, significant predictive factors of failure of non-operative treatment were: size of pneumoperitoneum, heart beat >94 bpm, abdominal meteorism, pain at digital rectal exam, and age >59 years. In multivariate analysis, the significant factors were the size of pneumoperitoneum, heart beat, and abdominal meteorism. The association of these criteria: size of pneumoperitoneum >size of the first lumbar vertebra, heart beat >94 bpm, pain at digital rectal exam and age > 59 years , led to surgical treatment in all cases. These results suggest that more than 50% of patients with perforated peptic ulcer respond to conservative treatment without surgery and that the association of few criteria (size of pneumoperitoneum, heart beat, pain at digital rectal exam and age) require emergency surgery.

Glucose control and use of continuous glucose monitoring in the intensive care unit: a critical review.

PubMed

De Block, Christophe; Manuel-y-Keenoy, Begoña; Rogiers, Peter; Jorens, Philippe; Van Gaal, Luc

2008-08-01

Stress hyperglycemia recently became a major therapeutic target in the Intensive Care Unit (ICU) since it occurs in most critically ill patients and is associated with adverse outcome, including increased mortality. Intensive insulin therapy to achieve normoglycemia may reduce mortality, morbidity and the length of ICU and in-hospital stay. However, obtaining normoglycemia requires extensive efforts from the medical staff, including frequent glucose monitoring and adjustment of insulin dose. Current insulin titration is based upon discrete glucose measurements, which may miss fast changes in glycemia and which does not give a full picture of overall glycemic control. Recent evidence suggests that continuous monitoring of glucose levels may help to signal glycemic excursions and eventually to optimize insulin titration in the ICU. In this review we will summarise monitoring and treatment strategies to achieve normoglycemia in the ICU, with special emphasis on the possible advantages of continuous glucose monitoring.

Enhancing the many-to-many relations across IHE document sharing communities.

PubMed

Ribeiro, Luís S; Costa, Carlos; Oliveira, José Luís

2012-01-01

The Integrating Healthcare Enterprise (IHE) initiative is an ongoing project aiming to enable true inter-site interoperability in the health IT field. IHE is a work in progress and many challenges need to be overcome before the healthcare Institutions may share patient clinical records transparently and effortless. Configuring, deploying and testing an IHE document sharing community requires a significant effort to plan and maintain the supporting IT infrastructure. With the new paradigm of cloud computing is now possible to launch software devices on demand and paying accordantly to the usage. This paper presents a framework designed with purpose of expediting the creation of IHE document sharing communities. It provides semi-ready templates of sharing communities that will be customized according the community needs. The framework is a meeting point of the healthcare institutions, creating a favourable environment that might converge in new inter-institutional professional relationships and eventually the creation of new Affinity Domains.

Combined Orbital Fractures: Surgical Strategy of Sequential Repair

PubMed Central

Hur, Su Won; Kim, Sung Eun; Chung, Kyu Jin; Lee, Jun Ho; Kim, Tae Gon

2015-01-01

Background Reconstruction of combined orbital floor and medial wall fractures with a comminuted inferomedial strut (IMS) is challenging and requires careful practice. We present our surgical strategy and postoperative outcomes. Methods We divided 74 patients who underwent the reconstruction of the orbital floor and medial wall concomitantly into a comminuted IMS group (41 patients) and non-comminuted IMS group (33 patients). In the comminuted IMS group, we first reconstructed the floor stably and then the medial wall by using separate implant pieces. In the non-comminuted IMS group, we reconstructed the floor and the medial wall with a single large implant. Results In the follow-up of 6 to 65 months, most patients with diplopia improved in the first-week except one, who eventually improved at 1 year. All patients with an EOM limitation improved during the first month of follow-up. Enophthalmos (displacement, 2 mm) was observed in two patients. The orbit volume measured on the CT scans was statistically significantly restored in both groups. No complications related to the surgery were observed. Conclusions We recommend the reconstruction of orbit walls in the comminuted IMS group by using the following surgical strategy: usage of multiple pieces of rigid implants instead of one large implant, sequential repair first of the floor and then of the medial wall, and a focus on the reconstruction of key areas. Our strategy of step-by-step reconstruction has the benefits of easy repair, less surgical trauma, and minimal stress to the surgeon. PMID:26217562

Applicability of SREM to the Verification of Management Information System Software Requirements. Volume I.

DTIC Science & Technology

1981-04-30

However, SREM was not designed to harmonize these kinds of problems. Rather, it is a tool to investigate the logic of the processing specified in the... design . Supoorting programs were also conducted to perform basic research into such areas as software reliability, static and dynamic validation techniques...development. 0 Maintain requirements development independent of the target machine and the eventual software design . 0. Allow for easy response to

The Use of Wetting Agents/Fume Suppressants for Minimizing the Atmospheric Emissions from Hard Chromium Electroplating Baths

DTIC Science & Technology

2004-03-01

oxidized rapidly producing trivalent chromium and insoluble organic compounds that eventually decomposed to carbon dioxide. This behavior required...frequent or continuous WA/FS additions, making them a more temporary than permanent solution. The trivalent chromium was also a bath contaminant requiring...need for hard chromium electroplating, but is not expected to ever be able to eliminate it. • Trivalent Chromium Electroplating: Chromium can be

Implementation of the DoD Diversity and Inclusion Strategic Plan: A Framework for Change through Accountability

DTIC Science & Technology

2013-01-01

including the Civil Rights Act of 1964, federal regulations , and court decisions. The military component of DoD is granted some exceptions from EEOC rules...laws, regulations , and directives; communicating effectively to internal as well as external stakeholders; and coordinating efforts to ensure...Commission ( EEOC ) requirements and evaluate existing internal requirements. Using the results of this evaluation and with an eye toward the eventual

Clear cell sarcoma: the Roswell Park experience.

PubMed

Finley, J W; Hanypsiak, B; McGrath, B; Kraybill, W; Gibbs, J F

2001-05-01

Clear cell sarcoma of the tendons and aponeuroses (CCSTA) is an aggressive, rare soft-tissue tumor with approximately 300 reported cases. Although it appears to be histogenetically related to melanoma, its clinical behavior resembles soft tissue sarcoma with a propensity for lymph node metastases. We report our experience at a tertiary cancer center. Eight cases of CCSTA evaluated at Roswell Park Cancer Institute between 1970 and 1998 were reviewed retrospectively. Patient data analyzed included patient age, gender, anatomic location, size of tumor, development of local, regional and distant recurrence, and patient status at last follow up. Six of eight patients were alive at 2 years, while three of seven patients were alive at 5 years. Of the patients alive with no evidence of recurrence, two had tumors of less than 2 cm, and the remaining patient had incomplete information regarding tumor size. Five patients recurred within 2 years of definitive surgical management. Four had tumors > 5 cm. All five patients progressed to metastatic disease at a median follow up of 20 months (range 1-108 months) following definitive surgical management and all eventually died of their disease at a median of 3 months (range 0-24 months) from presentation with metastatic disease. Four of five patients with lesions > 5 cm received adjuvant chemotherapy with intent to cure, but all eventually died of disease at 4, 22, 34, and 41 months from initial presentation. CCSTA is an aggressive tumor of the soft tissues. Early recognition and management are associated with an excellent long-term prognosis. Tumors greater than 5 cm warrant aggressive surgical management and treatment, and are at high risk of the development of distant disease. Aggressive multiagent chemotherapy appeared to have no impact on outcome. Other adjuvant therapeutic options including immunotherapy should be investigated. Copyright 2001 Wiley-Liss, Inc.

Magnetic resonance imaging in evaluating workers' compensation patients.

PubMed

Babbel, Daniel; Rayan, Ghazi

2012-04-01

We studied the utility of magnetic resonance imaging (MRI) studies for workers' compensation patients with hand conditions in which the referring doctor obtained the images. We compared the MRI findings with the eventual clinical findings. We also investigated the approximate cost of these MRI studies. We retrospectively reviewed the charts of all workers' compensation patients seen in a hand and upper extremity practice over the course of 3 years. We selected patients who had MRI studies of the affected upper extremities before referral to the senior author (G.R.). We reviewed the charts for information regarding demographics, referral diagnoses, MRI diagnoses made by the radiologist, the area of the upper extremity studied, and eventual clinical diagnoses by the senior author. We made a determination as to whether a hand surgeon could have adequately diagnosed and treated the patients' conditions without the imaging studies. We also investigated the cost associated with these MRIs. We included 62 patients with a total of 67 MRI scans in this study. The MRI studies did not contribute to clinically diagnosing the patients' conditions in any of the cases we reviewed. The hand surgeon's clinical diagnosis disagreed with the radiologist's MRI diagnosis in 63% of patients. The MRI was unnecessary to arrive at the clinical diagnosis and did not influence the treatment offered for any of the 62 patients. The total cost for the 67 non-contrast MRI studies was approximately $53,000. Costly imaging studies are frequently done to determine the validity of a patient's reported problems; unfortunately, these tests are frequently unnecessary and waste resources. Magnetic resonance imaging scans may not be the standard for accurate diagnosis and can misdirect care. Therapeutic III. Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Magnetic Resonance Imaging Assessment of Squamous Cell Carcinoma of the Anal Canal Before and After Chemoradiation: Can MRI Predict for Eventual Clinical Outcome?

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

Goh, Vicky, E-mail: vicky.goh@stricklandscanner.org.u; Gollub, Frank K.; Liaw, Jonathan

2010-11-01

Purpose: To describe the MRI appearances of squamous cell carcinoma of the anal canal before and after chemoradiation and to assess whether MRI features predict for clinical outcome. Methods and Materials: Thirty-five patients (15 male, 20 female; mean age 60.8 years) with histologically proven squamous cell cancer of the anal canal underwent MRI before and 6-8 weeks after definitive chemoradiation. Images were reviewed retrospectively by two radiologists in consensus blinded to clinical outcome: tumor size, signal intensity, extent, and TNM stage were recorded. Following treatment, patients were defined as responders by T and N downstaging and Response Evaluation Criteria inmore » Solid Tumors (RECIST). Final clinical outcome was determined by imaging and case note review: patients were divided into (1) disease-free and (2) with relapse and compared using appropriate univariate methods to identify imaging predictors; statistical significance was at 5%. Results: The majority of tumors were {<=}T2 (23/35; 65.7%) and N0 (21/35; 60%), mean size 3.75cm, and hyperintense (++ to +++, 24/35 patients; 68%). Following chemoradiation, there was a size reduction in all cases (mean 73.3%) and a reduction in signal intensity in 26/35 patients (74.2%). The majority of patients were classified as responders (26/35 (74.2%) patients by T and N downstaging; and 30/35 (85.7%) patients by RECIST). At a median follow-up of 33.5 months, 25 patients (71.4%) remained disease-free; 10 patients (28.6%) had locoregional or metastatic disease. Univariate analysis showed that no individual MRI features were predictive of eventual outcome. Conclusion: Early assessment of response by MRI at 6-8 weeks is unhelpful in predicting future clinical outcome.« less

A qualitative analysis of the nutritional requirements of palliative care patients.

PubMed

Muir, C I; Linklater, G T

2011-10-01

The National Health Servive (NHS) Quality Improvement Scotland developed nutritional Clinical Standards to address the problem of malnutrition in hospitals. NHS palliative care units are obliged to incorporate these standards into nutritional aspects of care. The nutritional needs of this patient population are under-researched. The present study aimed to explore patients' views of nutrition, to begin to understand their concerns and to determine whether such standards meet the needs of patients in the palliative care setting. A qualitative study was conducted in 2009 in an NHS Palliative Care Unit. Six inpatients were involved in one-to-one interviews, which were audiotaped and transcribed verbatim. The transcripts were subject to qualitative data analysis in accordance with a previous framework. A recurring theme that emerged was that of change and uncertainty. Four main areas subject to change were: disease state, symptoms, oral dietary intake and weight. Each change could exert control over, or be controlled by, the patient. When patients were eventually unable to exert control, they accepted the change, either willingly or enforced, thereby unintentionally setting their own targets. The present study enables a deeper understanding of the concerns that palliative care patients have regarding their oral dietary intake and weight. Their 'malnutrition' not only refers to physical malnutrition alone, but also incorporates psychological and social 'malnutrition'. When applying standards or protocols regarding nutritional care, these wider issues must be taken into account to meet patients' nutritional needs. © 2011 The Authors. Journal of Human Nutrition and Dietetics © 2011 The British Dietetic Association Ltd.

Methylseleninic acid sensitizes Notch3-activated OVCA429 ovarian cancer cells to carboplatin

USDA-ARS?s Scientific Manuscript database

Ovarian cancer, the deadliest of gynecologic cancers, is usually diagnosed at advanced stage due to invalidated screening test and non-specific symptoms presented. Although carboplatin has been popular for treating ovarian cancer for decades, patients eventually develop resistance to this platinum-c...

Electronic Transcripts: Past, Present, and Future

ERIC Educational Resources Information Center

Harris, Sarah; Hannah, Andrew; Stones, Dave; Morley, Robert

2011-01-01

Electronic transcripts are no longer a concept awaiting definition. They are here to stay. Although paper transcripts remain the standard--at least in terms of volume--an ever-increasing number and eventual majority of students and alumni will expect if not require electronic transcripts. College registrars and admissions officers' obligation to…

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

Funk, David John

The inadvertent creation of transuranic waste carrying hazardous waste codes D001 and D002 requires the treatment of the material to eliminate the hazardous characteristics and allow its eventual shipment and disposal at the Waste Isolation Pilot Plant (WIPP). This report briefly summarizes the surrogate testing that was done in support of our understanding of this waste form.

Building Maintenance Syllabus.

ERIC Educational Resources Information Center

Fischer, Joseph; Messier, Joseph

Building maintenance is a basic two-year trade education course requiring 2 1/2 hours of study on each of 160 teaching days per year. Student abilities should range from those capable of the simplest custodial work to those who may eventually be superintendents of building complexes. The syllabus is organized in sections by traditional skills…

77 FR 75402 - Airworthiness Directives; The Boeing Company Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-20

... ``BAT'' position, isolating the battery and standby buses, disabling the battery charger, and eventually causing the main battery to be depleted. This proposed AD would require doing wiring changes and installing a new air/ground relay to the battery charger system. We are proposing this AD to prevent...

78 FR 72564 - Airworthiness Directives; The Boeing Company Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-03

... switch to the ``BAT'' position, isolating the battery and standby buses, disabling the battery charger, and eventually causing the main battery to be depleted. This AD requires doing wiring changes and installing a new air/ground relay to the battery charger system. We are issuing this AD to prevent discharge...

A comprehensive framework for evaluating the environmental health and safety implications of engineered nanomaterials

EPA Science Inventory

Engineered nanomaterials (ENM) are a growing aspect of the global economy, and their safe and sustainable development, use and eventual disposal requires the capability to forecast and avoid potential problems. This review is concerned with the releases of ENM into the environmen...

System specification for the reusable reentry satellite

NASA Technical Reports Server (NTRS)

1991-01-01

The RRS design shall provide a relatively inexpensive method of access to micro and fractional gravity space environments for an extended period of time, with eventual intact recovery on the surface of the Earth. This specification establishes the performance, design, development, and test requirements for the Reusable Reentry Satellite (RRS) system.

Teacher Preparation for Emergent Bilingual Students: Implications of Evidence for Policy

ERIC Educational Resources Information Center

López, Francesca; Santibañez, Lucrecia

2018-01-01

Failure to adequately prepare teachers of emergent bilingual (EB) students could have devastating consequences for student achievement, EB reclassification, and eventually, high school and college completion. To enhance the policy discourse, we explore how teacher certification requirements relate to both EB student achievement and teacher…

Bilingual Education: An Analytical Assessment.

ERIC Educational Resources Information Center

Mendoza, Agapito

Bilingual education has had great impact on education in the United States. Bilingual education programs have existed since 1845. Between 1854-1877, eight states enacted laws stipulating that local school boards had the power to require English-German bilingual programs. Many bilingual education programs were created, thrived, and eventually died;…

40 CFR 82.24 - Recordkeeping and reporting requirements for class II controlled substances.

Code of Federal Regulations, 2010 CFR

2010-07-01

... kilograms) of production of each class II controlled substance used in processes resulting in their...) The quantity (in kilograms) of production of each class II controlled substance used in processes... processes resulting in their transformation or eventual destruction; (vi) A list of the quantities and names...

Tricuspid valve endocarditis

PubMed Central

Hussain, Syed T.; Witten, James; Shrestha, Nabin K.; Blackstone, Eugene H.

2017-01-01

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (IE), encompassing only 5–10% of cases of IE. Ninety percent of RSIE involves the tricuspid valve (TV). Given the relatively small numbers of TVIE cases operated on at most institutions, the purpose of this review is to highlight and discuss the current understanding of IE involving the TV. RSIE and TVIE are strongly associated with intravenous drug use (IVDU), although pacemaker leads, defibrillator leads and vascular access for dialysis are also major risk factors. Staphylococcus aureus is the predominant causative organism in TVIE. Most patients with TVIE are successfully treated with antibiotics, however, 5–16% of RSIE cases eventually require surgical intervention. Indications and timing for surgery are less clear than for left-sided IE; surgery is primarily considered for failed medical therapy, large vegetations and septic pulmonary embolism, and less often for TV regurgitation and heart failure. Most patients with an infected prosthetic TV will require surgery. Concomitant left-sided IE has its own surgical indications. Earlier surgical intervention may potentially prevent further destruction of leaflet tissue and increase the likelihood of TV repair. Fortunately, TV debridement and repair can be accomplished in most cases, even those with extensive valve destruction, using a variety of techniques. Valve repair is advocated over replacement, particularly in IVDUs patients who are young, non-compliant and have a higher risk of recurrent infection and reoperation with valve replacement. Excising the valve without replacing, it is not advocated; it has been reported previously, but these patients are likely to be symptomatic, particularly in cases with septic pulmonary embolism and increased pulmonary vascular resistance. Patients with concomitant left-sided involvement have worse prognosis than those with RSIE alone, due predominantly to greater likelihood of invasion and abscess formation in left-sided IE. Patients with isolated TVIE have an operative mortality between 0–15% and excellent survival. PMID:28706868

Mobile applications to enhance self-management of gout.

PubMed

Nguyen, Amy D; Baysari, Melissa T; Kannangara, Diluk R W; Tariq, Amina; Lau, Annie Y S; Westbrook, Johanna I; Day, Richard O

2016-10-01

Gout is an arthritic condition that is characterised by extremely painful, debilitating acute attacks and eventual joint and organ damage if not controlled. Despite the availability of very effective therapies that, if adhered to, will prevent acute attacks and long-term damage, the disorder is increasingly prevalent. There is an urgent need to improve self-management of gout. Mobile health (mHealth) applications ('apps'), designed to facilitate management of chronic conditions, present novel opportunities for supporting patient self-management of gout. The aim of this review was to assess features of available gout management apps designed to assist consumers in managing their gout and their consistency with guidelines for gout management. English-language, smart-device apps designed to assist self-management of gout were identified using search term "gout" and downloaded from Apple and Google Play app stores. To be included in the review, apps had to allow users to monitor their gout disease (e.g. serum uric acid (sUA) tracking, record acute attacks) and/or educate patients about gout. Investigators derived patient-focused recommendations for gout management from contemporary guidelines. Features of reviewed apps were independently assessed by two reviewers for their facilitation of these recommendations. The search identified 57 apps possibly relevant to gout management, of which six met the inclusion criteria. One app incorporated all recommendations for patient-focused gout management from guidelines including monitoring sUA, recording attacks and lifestyle advice. However, the majority of these elements were not functional within the app, and instead required users to manually complete printouts. Currently, only one app exists that includes all recommendations to facilitate patient self-management of gout, however some features can only be actioned manually. Given the lack of progress in achieving better patient outcomes and the promise of mHealth interventions to deliver significant gains, new or updated gout management apps are required to promote successful self-management of this chronic disease. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Crohn Disease: Epidemiology, Diagnosis, and Management.

PubMed

Feuerstein, Joseph D; Cheifetz, Adam S

2017-07-01

Crohn disease is a chronic idiopathic inflammatory bowel disease condition characterized by skip lesions and transmural inflammation that can affect the entire gastrointestinal tract from the mouth to the anus. For this review article, we performed a review of articles in PubMed through February 1, 2017, by using the following Medical Subject Heading terms: crohns disease, crohn's disease, crohn disease, inflammatory bowel disease, and inflammatory bowel diseases. Presenting symptoms are often variable and may include diarrhea, abdominal pain, weight loss, nausea, vomiting, and in certain cases fevers or chills. There are 3 main disease phenotypes: inflammatory, structuring, and penetrating. In addition to the underlying disease phenotype, up to a third of patients will develop perianal involvement of their disease. In addition, in some cases, extraintestinal manifestations may develop. The diagnosis is typically made with endoscopic and/or radiologic findings. Disease management is usually with pharmacologic therapy, which is determined on the basis of disease severity and underlying disease phenotype. Although the goal of management is to control the inflammation and induce a clinical remission with pharmacologic therapy, most patients will eventually require surgery for their disease. Unfortunately, surgery is not curative and patients still require ongoing therapy even after surgery for disease recurrence. Importantly, given the risks of complications from both Crohn disease and the medications used to treat the disease process, primary care physicians play an important role in optimizing the preventative care management to reduce the risk of complications. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Multiple collagenase injections are safe for treatment of Dupuytren's contractures.

PubMed

Gajendran, Varun K; Hentz, Vincent; Kenney, Deborah; Curtin, Catherine M

2014-07-01

The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases. Copyright 2014, SLACK Incorporated.

Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.

PubMed

Ali, Husain Shabbir; Hassan, Ibrahim Fawzy; George, Saibu

2016-04-14

Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO). A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support. ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.

AA amyloidosis: Mount Sinai experience, 1997-2012.

PubMed

Bunker, Daniel; Gorevic, Peter

2012-01-01

AA amyloidosis is a systemic disease characterized by the extracellular deposition of amyloid fibrils derived from the acute-phase reactant serum amyloid A protein. It is typically a consequence of chronic inflammatory conditions like rheumatoid arthritis or Crohn's disease, although more patients are being identified who have more unusual causes or no known inflammatory stimulus. We performed a retrospective chart review of all patients with AA amyloidosis seen at Mount Sinai during the period of 1997-2012. Particular attention was paid to the patients' underlying diseases, extent of organ involvement, levels of inflammatory markers and proinflammatory cytokines, presence of pyrin gene mutations, and outcomes. Forty-three patients were seen at Mount Sinai with AA amyloidosis during this period. The most common underlying diseases were rheumatoid arthritis (21%) and Crohn's disease (16%), though 21% of patients were considered to have idiopathic AA amyloid after an extensive search found no underlying inflammatory disease. Almost all patients (95%) had renal involvement based on biopsy or clinical criteria, with 19 patients (44%) eventually requiring dialysis and 5 (12%) undergoing renal transplantation. Inflammatory markers were elevated in most patients; however, interleukin-6 was the only consistently elevated cytokine. Three patients (of 9 tested) were found to be positive for the E148Q pyrin gene mutation. Our study confirms the increasing number of patients being seen with idiopathic AA amyloidosis. More research is needed to determine if these patients have an underlying genetic susceptibility encoded in pyrin or other genes. Our study also confirms the dominance of renal disease in this population. The elevated levels of interleukin-6, in comparison with other cytokines, could represent a therapeutic target. © 2012 Mount Sinai School of Medicine.

Effect of a blackout in pediatric patients with home medical devices during the 2011 eastern Japan earthquake.

PubMed

Nakayama, Tojo; Tanaka, Soichiro; Uematsu, Mitsugu; Kikuchi, Atsuo; Hino-Fukuyo, Naomi; Morimoto, Tetsuji; Sakamoto, Osamu; Tsuchiya, Shigeru; Kure, Shigeo

2014-02-01

during the eastern Japan earthquake in 2011 and the following prolonged blackout, pediatric patients with home medical devices sought electricity at the pediatric department. We retrospectively studied the effect of this earthquake and the following blackout. we hand-reviewed pediatric admission records in Tohoku University Hospital for new inpatients attributed to the earthquake from March 11, 2011 to April 12, 2011. A survey by questionnaire regarding the situation during the earthquake was performed for parents of technology-assisted patients. during the study period, 24 pediatric patients were admitted to the pediatric department. Eighteen technology-assisted pediatric patients, including those with home respirators, accounted for 75% of new pediatric admissions. Patients who were admitted for electricity shortage stayed in the hospital for a mean of 11.0days (3-25days). The questionnaire survey showed that 55% of technology-assisted patients were admitted to medical centers for evacuation. The majority of patients (89%) with ventilators were eventually admitted to medical centers during the earthquake. Most of the parents of technology-assisted patients experienced a prolonged petrol shortage and difficulty in communications with medical centers. the current study suggests that technology-assisted pediatric patients with neurological disorders as the primary disease can overwhelm the capacity of hospital inpatient facilities in certain situations. Disaster preparedness should consider assuring power requirements in healthcare facilities and preparing backup power generators lasting for at least 24h for these patients. Preparing alternative measures for emergent electricity and communications could remedy serious conditions during a disaster. Copyright © 2013 The Japanese Society of Child Neurology. Published by Elsevier B.V. All rights reserved.

Knowledge-based requirements analysis for automating software development

NASA Technical Reports Server (NTRS)

Markosian, Lawrence Z.

1988-01-01

We present a new software development paradigm that automates the derivation of implementations from requirements. In this paradigm, informally-stated requirements are expressed in a domain-specific requirements specification language. This language is machine-understable and requirements expressed in it are captured in a knowledge base. Once the requirements are captured, more detailed specifications and eventually implementations are derived by the system using transformational synthesis. A key characteristic of the process is that the required human intervention is in the form of providing problem- and domain-specific engineering knowledge, not in writing detailed implementations. We describe a prototype system that applies the paradigm in the realm of communication engineering: the prototype automatically generates implementations of buffers following analysis of the requirements on each buffer.

Evaluation of patients' education on foot self-care status in diabetic patients.

PubMed

Kafaie, Parichehr; Noorbala, Mohamad Taghi; Soheilikhah, Sedigheh; Rashidi, Maryam

2012-12-01

Skin problems caused by neuropathy and antipathy are common manifestations of diabetes. The most serious about such problem is the diabetic foot, which may lead to eventual ulceration and amputation, and will decrease a patient's quality of life dramatically. The aim of this study is to assess the level of foot self-care and foot conditions in diabetic patients, and to demonstrate the role of self-care education in diabetic foot care. A total of 80 diabetic patients were included in the study, all of whom had referred to "Yazd Diabetic Research Center." The levels of their foot self-care were recorded in pre-test questionnaires, and then all of the patients were visited and educated by a Dermatologist for their foot self-care on a monthly basis, after which their post-test results were recorded through a second administration of the same questionnaire. Eventually, data from the pre and post-test questionnaires were analyzed to identify the possible effects of education. A total of 80 diabetic patients (34 males, 46 females) with a mean average age of 53.53 ± 10.19 and mean average duration of diabetes 12.42 ± 6.73 years were assessed. A significant increase in foot self-care through education was observed (baseline 27.06 ± 8.77, vs. post education 43.12 ± 8.77; P = 0.0001). After education, foot and nail lesions improved completely in 84% and 62.8%. Moreover, 77.8% of patients had suitable shoes and 79.6% had suitable socks. Our findings showed that foot self-care education could improve knowledge and performance of patients about various foot problems, and was significantly important in preventing ulcers.

Psychiatric patient disposition agreement between the emergency physician and the psychiatry consultant.

PubMed

Chakravarthy, Bharath; Menchine, Michael; Thompson, Daniel E; Rajeev, Sindhya; Santos, Barbara-Jean

2013-01-01

Mental illness is prevalent, disabling, and costly. Emergency department (ED) visits for mental health-related reasons are on the increase. Determine the level of agreement between emergency physicians and psychiatrists regarding psychiatric patient disposition. We conducted a prospective, observational study at a private university hospital ED from October 2008-April 2009 using a convenience sample of patients of all ages with psychiatric complaints who received formal psychiatric consultation during their ED visit. The emergency physician completed a data sheet prior to psychiatric consultation, assessing the likelihood of admission for psychiatric evaluation. We evaluated the positive predictive value (PPV) and negative predictive value (NPV) of the emergency physician admission decision for all patients before psychiatric consultation, compared with the patients' actual disposition as determined by the consulting psychiatrist. The study captured 230 subjects, 53% of whom were suicidal patients. 74% of patients were eventually admitted. The emergency physician decision to admit for inpatient psychiatric evaluation had a PPV of 87.3% (CI 81.4-91.9%) and an NPV of 66.7% (CI 52.9-78.6%) compared to the psychiatrist decision for the total sample, and a PPV of 90% (CI 82.4-95.1%) and an NPV of 69.6% (CI 47.1-86.8%) for suicidal patients. Additionally, the κ score, a measure of agreement between emergency physician disposition decision and psychiatrist disposition decision, was 0.530 (Cl 0.404-0.656). 95% of patients with an ED assessment of "definitely admit" were eventually admitted by the psychiatrist. Emergency physician disposition has a high PPV (87.3%) and a moderate NPV (66.7%) compared to psychiatrist disposition.

Patient and family physician preferences for care and communication in the eventuality of anthrax terrorism.

PubMed

Kahan, Ernesto; Fogelman, Yacov; Kitai, Eliezer; Vinker, Shlomo

2003-08-01

The threat of bioterrorism consequent to the September 11, 2001 attack in the USA generated suggestions for improved medical response mainly through hospital preparedness. The aim of the present study was to investigate the impact of this period of tension on patients' first choice for care and for receiving relevant information, and on primary care doctors' feelings of responsibility in the eventuality of an anthrax attack. During October 11-31, 2001, 500 patients from 30 clinics throughout Israel were asked to complete a questionnaire on their awareness of the anthrax threat, measures taken to prepare for it, and preferred sources of care and information. Their 30 physicians, and an additional 20, completed a questionnaire on knowledge about anthrax and anthrax-related patient behaviours and clinic visits. The outstanding finding was the low rate (30%) of patients who chose the hospital emergency department as their first choice for care or information if they were worried about an anthrax attack or the media communicated that an attack was in progress. The other two-thirds preferred their family doctor or the health authorities. Most of the physicians (89%) felt it was their responsibility to treat anthrax-infected patients and that they should therefore be supplied with appropriate guidelines. This study suggests that in Israel, a country with a high degree of awareness of civil defence aspects, both patients and primary care doctors believe that family physicians should have a major role in the case of bioterrorist attacks. This must be seriously considered during formulation of relevant health services programmes.

Arsenic trioxide at conventional dosage does not aggravate hemorrhage in the first-line treatment of adult acute promyelocytic leukemia.

PubMed

Cui, Wen; Wang, Jin; Nie, Rui-Min; Zhao, Ling-Ling; Gao, Meng-Qing; Zhu, Hong-Ming; Chen, Li; Hu, Jiong; Li, Jun-Min; Shen, Zhi-Xiang; Wang, Zhen-Yi; Chen, Sai-Juan; Chen, Zhu; Wang, Kan-Kan; Xi, Xiao-Dong; Mi, Jian-Qing

2018-04-01

The arsenic trioxide (ATO) plus all-trans retinoic acid (ATRA) therapy has demonstrated a tremendous success in the first-line treatment of acute promyelocytic leukemia (APL). Actually, early death (ED) is currently thought as a major challenge in APL. ATO has been reported to inhibit platelet function in vitro, and whether it increases the ED rate by exacerbating the hemorrhagic symptoms remains to be investigated. Effects of ATO on platelet aggregation and adhesion were evaluated in vitro and in thirty-two complete remission (CR) and four newly diagnosed APL patients. Furthermore, concentrations of plasma total arsenic were monitored in APL patients via ICP-MS. The inhibition of platelet function, either aggregation or adhesion, did occur in vitro when the concentration of ATO reached 2 μmol/L. However, in CR APL patients receiving ATO with normal platelet count, the platelets responded normally when being activated and so did those in the newly diagnosed patients with thrombocytopenia. Our data further showed that the conventional dosage of ATO reached a plasma concentration substantially below the required concentration to inhibit platelets. In the first-line treatment of APL, the use of ATO is safe and effective and does not compromise the hemostatic potential that may eventually increase ED rate. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

The Treatment of Obesity in Cardiac Rehabilitation

PubMed Central

Ades, Philip A.; Savage, Patrick D.; Harvey-Berino, Jean

2010-01-01

Obesity is an independent risk factor for the development of coronary heart disease (CHD). At entry into cardiac rehabilitation (CR) over 80% of patients are overweight and over 50% have the metabolic syndrome. Yet, CR programs do not generally include weight loss programs as a programmatic component and weight loss outcomes in CR have been abysmal. A recently published study outlines a template for weight reduction based upon a combination of behavioral weight loss counseling and an approach to exercise that maximized exercise-related caloric expenditure. This approach to exercise optimally includes walking as the primary exercise modality and eventually requires almost daily longer distance exercise to maximize caloric expenditure. Additionally, lifestyle exercise such as stair climbing and avoidance of energy-saving devices should be incorporated into the daily routine. Risk factor benefits of weight loss and exercise training in overweight patients with coronary heart disease are broad and compelling. Improvements in insulin resistance, lipid profiles, blood pressure, clotting abnormalities, endothelial-dependent vasodilatory capacity, and measures of inflammation such as C-reactive protein have all been demonstrated. CR/secondary prevention programs can no longer ignore the challenge of obesity management in patients with CHD. Individual programs need to develop clinically effective and culturally sensitive approaches to weight control. Finally, multicenter randomized clinical trials of weight loss in CHD patients with assessment of long-term clinical outcomes need to be performed. PMID:20436355

Evaluation of the cost-effectiveness of evolocumab in the FOURIER study: a Canadian analysis.

PubMed

Lee, Todd C; Kaouache, Mohammed; Grover, Steven A

2018-04-03

Evolocumab, a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor, has been shown to reduce low-density lipoprotein levels by up to 60%. Despite the absence of a reduction in overall or cardiovascular mortality in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, some believe that, with longer treatment, such a benefit might eventually be realized. Our aim was to estimate the potential mortality benefit over a patient's lifetime and the cost per year of life saved (YOLS) for an average Canadian with established coronary artery disease. We also sought to estimate the price threshold at which evolocumab might be considered cost-effective for secondary prevention in Canada. We calibrated the Cardio-metabolic Model, a well-validated tool for predicting cardiovascular events and life expectancy, to the reduction in nonfatal events seen in the FOURIER trial. Assuming that long-term treatment will eventually result in mortality benefits, we estimated YOLSs and cost per YOLS with evolocumab treatment plus a statin compared to a statin alone. We then estimated the annual drug costs that would provide a 50% chance of being cost-effective at willingness-to-pay values of $50 000 and $100 000. In secondary prevention in patients similar to those in the FOURIER study, evolocumab treatment would save an average of 0.34 (95% confidence interval [CI] 0.27-0.41) life-years at a cost of $101 899 (95% CI $97 325-$106 473), yielding a cost per YOLS of $299 482. We estimate that to have a 50% probability of achieving a cost per YOLS below $50 000 and $100 000 would require annual drug costs below $1200 and $2300, respectively. At current pricing, the use of evolocumab for secondary prevention is unlikely to be cost-effective in Canada. Copyright 2018, Joule Inc. or its licensors.

Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm.

PubMed

Schievink, Wouter I; Palestrant, David; Maya, M Marcel; Rappard, George

2009-03-01

Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray-white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.

Hospital readmission after a pancreaticoduodenectomy: an emerging quality metric?

PubMed Central

Kastenberg, Zachary J; Morton, John M; Visser, Brendan C; Norton, Jeffrey A; Poultsides, George A

2013-01-01

Background Hospital readmission has attracted attention from policymakers as a measure of quality and a target for cost reduction. The aim of the study was to evaluate the frequency and patterns of rehospitalization after a pancreaticoduodenectomy (PD). Methods The records of all patients undergoing a PD at an academic medical centre for malignant or benign diagnoses between January 2006 and September 2011 were retrospectively reviewed. The incidence, aetiology and predictors of subsequent readmission(s) were analysed. Results Of 257 consecutive patients who underwent a PD, 50 (19.7%) were readmitted within 30 days from discharge. Both the presence of any post-operative complication (P = 0.049) and discharge to a nursing/rehabilitation facility or to home with health care services (P = 0.018) were associated with readmission. The most common reasons for readmission were diet intolerance (36.0%), pancreatic fistula/abscess (26.0%) and superficial wound infection (8.0%). Nine (18.0%) readmissions had lengths of stay of 2 days or less and in four of those (8.0%) diagnostic evaluation was eventually negative. Conclusion Approximately one-fifth of patients require hospital readmission within 30 days of discharge after a PD. A small fraction of these readmissions are short (2 days or less) and may be preventable or manageable in the outpatient setting. PMID:23297725

Medical versus surgical abortion methods for pregnancy in China: a cost-minimization analysis.

PubMed

Xia, Wei; She, Shouzhang; Lam, Tai Hing

2011-01-01

Both medical and surgical abortions are popular in developing countries. However, the monetary costs of these two methods have not been compared. 430 women seeking abortions were recruited in 2008. Either a medical or surgical method was used for the abortion. We adopted the perspective of a third-party payer. Cost-minimization analysis was used based on all charges for the overall procedures in an out-patient clinic in Guangzhou, China. 219 subjects (51%) chose a medical method (mifepristone and misoprostol), whereas 211 subjects (49%) chose a surgical method. The efficacy in the surgical group was significantly higher than in the medical group (100 vs. 90%, p < 0.001). Surgical abortion incurred much more costs than medical abortion on average after initial treatment. When the subsequent costs were accumulated within the 2-week follow-up, the mean total cost in the medical group increased significantly due to failure of abortion and persistent bleeding. Patients undergoing medical abortion eventually incurred equivalent expenses compared to patients undergoing surgical abortion (p = 0.42). There was no difference in the mean final costs between the two abortion methods. Complications of persistent bleeding and failure to abort (requiring surgical intervention) in the medical treatment group increased the final mean total cost substantially. Copyright © 2011 S. Karger AG, Basel.

Chronic anorexia nervosa: enteral nutrition via percutaneous endoscopic gastrostomy and liaison psychiatry.

PubMed

Malfi, G; Agnello, E; Da Pont, M C; Palmo, A; Zullo, G; Monero, A; Macario, P F; Sterpone, S; Munno, D

2006-12-01

Anorexia nervosa is a complex mental disorder characterized by altered eating behaviour often resulting in life-threatening weight loss (<85% of expected body weight) associated with amenorrhea and a disturbance of body image. Although classified as mental health disorders, they may lead to serious medical consequences and have the highest rate of premature death of any mental health diagnosis. We report our experience with the use of enteral feeding via percutaneous endoscopic gastrostomy in a 39-year-old woman with chronic restricter anorexia nervosa treated in liaison psychiatry and psychotherapy. On admission to psychiatry unit, the patient presented seriously deteriorated general condition and a body mass index (BMI) of 10 (BMI = weight kg/height m(2)). She refused oral feeding, but eventually accepted nasogastric feeding. In preparation for her continuing long-term (>1 month) enteral feeding at home, a percutaneous endoscopic gastrostomy was performed and a home nutrition support regimen that met her energy-protein intake requirements was prescribed. During the follow-up period, an overall improvement in nutritional status, general condition, mood and cognitive functioning was observed. Patient compliance with refeeding is notoriously problematic; however, enteral feeding interventions may be feasible in the long-term treatment of selected anorexia nervosa patients when closely followed-up by a multidisciplinary medical team.

Retinal pigmentary changes in chronic uveitis mimicking retinitis pigmentosa.

PubMed

Sevgi, D Damla; Davoudi, Samaneh; Comander, Jason; Sobrin, Lucia

2017-09-01

To present retinal pigmentary changes mimicking retinitis pigmentosa (RP) as a finding of advanced uveitis. We retrospectively reviewed charts of patients without a family history of inherited retinal degenerations who presented with retinal pigment changes and signs of past or present intraocular inflammation. Comprehensive eye examination including best-corrected visual acuity, slit-lamp examination and dilated fundus examination was performed on all patients in addition to color fundus photography, optical coherence tomography, fluorescein angiography (FA), and full-field electroretinogram testing. We identified five patients with ages ranging from 33 to 66 years, who presented with RP-like retinal pigmentary changes which were eventually attributed to longstanding uveitis. The changes were bilateral in three cases and unilateral in two cases. Four of five cases presented with active inflammation, and the remaining case showed evidence of active intraocular inflammation during follow-up. This study highlights the overlapping features of advanced uveitis and RP including the extensive pigmentary changes. Careful review of possible past uveitis history, detailed examination of signs of past or present inflammation and ancillary testing, with FA often being most helpful, are required for the correct diagnosis. This is important, because intervention can prevent further damage if the cause of the pigmentary changes is destructive inflammation.

Evaluation and Management of Patients with Isolated Neutropenia

PubMed Central

Newburger, Peter E.; Dale, David C.

2013-01-01

Neutropenia, defined as an absolute neutrophil count below 1.5 × 109/L, encompasses a wide range of diagnoses, from normal variants to life-threatening acquired and congenital disorders. This review addresses the diagnosis and management of isolated neutropenia, not multiple cytopenias due to splenomegaly, bone marrow replacement, or myelosuppression by chemotherapy or radiation. Laboratory evaluation generally includes repeat complete blood counts with differentials and bone marrow examination with cytogenetics. Neutrophil antibody testing may be useful, but only in the context of clinical and bone marrow findings. The discovery of genes responsible for congenital neutropenias now permits genetic diagnosis in many cases. Management of severe chronic neutropenia includes common-sense precautions to avoid infection; aggressive treatment of bacterial or fungal infections; and administration of granulocyte colony-stimulating factor (G-CSF). Patients with severe congenital neutropenia, particularly those who respond poorly to G-CSF, have a risk of eventually developing myelodysplastic syndromes (MDS) or acute myeloid leukemia (AML) and require monitoring for this complication, which can also occur without G-CSF therapy. Patients with cyclic, idiopathic and autoimmune neutropenia have virtually no risk of evolving to MDS or AML. Hematopoietic stem cell transplantation is a curative therapy for congenital neutropenia with MDS/AML or with cytogenetic abnormalities indicating impending conversion. PMID:23953336

Docetaxel as adjuvant and neoadjuvant treatment for patients with breast cancer.

PubMed

Heys, Steven D; Sarkar, Tarun; Hutcheon, Andrew W

2004-10-01

Developments in the role of adjuvant and neoadjuvant chemotherapy for the treatment of patients with breast cancer have focused on the taxes, in particular, docetaxel. This paper discusses the rationale for the introduction of docetaxel into the management of patients following surgery and also its role in those patients with locally-advanced disease, focussing on key clinical trials. The addition of docetaxel to standard adjuvant chemotherapeutic regimens does seem to result in an increased survival in some patients with early-stage disease. In the neoadjuvant setting, the addition of docetaxel to standard regimens does increase pathological response rates, which is a surrogate marker of eventual outcome.

Treatment of type II endoleak using Onyx with long-term imaging follow-up.

PubMed

Khaja, Minhaj S; Park, Auh Whan; Swee, Warren; Evans, Avery J; Fritz Angle, J; Turba, Ulku C; Sabri, Saher S; Matsumoto, Alan H

2014-06-01

The purpose of our study is to report our experience with the use of an ethylene vinyl alcohol copolymer (Onyx) in an off-label fashion for the treatment of type II endoleak after endovascular repair of the thoracic (TEVAR) and abdominal (EVAR) aorta. A retrospective review of patients with type I and/or II endoleak treated with Onyx was performed. Data regarding the technical, clinical, and imaging outcomes were collected. Technical success was defined as decreased or eliminated endoleak on the first imaging follow-up. Clinical success was defined as unchanged or decreased aneurysm sac size on subsequent follow-up. Eighteen patients (15 male, 3 female) with a mean age of 79 years (range 69-92) met inclusion criteria (16 abdominal aortic aneurysm, 2 thoracic aortic aneurysm). Sixteen patients had type II endoleak, and 2 had complex type II endoleak with a type I component. The interval between endograft placement and treatment was a mean of 30 months. Direct sac treatment approach was used in 13 patients; transarterial approach was used in 3 patients. Seven patients required the use of coils, N-butyl cyanoacrylate glue, or Amplatzer vascular plugs. The average volume of Onyx used per treatment was 5.6 mL (range 2.5-13). Duration of imaging follow-up was 0.75-72.5 months (mean 32.8). Sixteen of 18 (88.9 %) patients had initial technical and clinical success. Two of 18 patients (11.1 %) were initial technical failures, and 1 remained a failure despite a second treatment and attempted surgical ligation. Eight of 18 (44.4 %) of patients eventually required a second intervention, 5 (27.8 %) of them due to delayed clinical failure. Complications included 1 psoas hematoma, 1 transient L2 nerve paresis, and 1 intraperitoneal Onyx leak; all of these were without clinical sequelae. Onyx with or without coil/glue/Amplatzer plug embolization is safe and useful in the treatment of type II endoleak after TEVAR and EVAR. However, long-term clinical and imaging follow-up is needed for early detection and management of recurrence of the primary endoleak or the development of new, secondary endoleaks or enlargement of the aneurysm sac.

Endovascular treatment of complicated aortic aneurysms in patients with underlying arteriopathies.

PubMed

Baril, Donald T; Carroccio, Alfio; Palchik, Eugene; Ellozy, Sharif H; Jacobs, Tikva S; Teodorescu, Victoria; Marin, Michael L

2006-07-01

Patients with arteriopathies including giant cell arteritis, Marfan syndrome, and Takayasu's disease are at risk for aneurysmal degeneration of the aorta. Aortic repair has been recommended for these patients to prevent rupture. The purpose of this study was to examine outcomes following endovascular stent graft (EVSG) repair of aortic aneurysms in this patient population. Over an 8-year period, 11 patients (six men, five women) with arteriopathies underwent endovascular aortic repair. The mean age was 50 (range 15-81). Diseases included Marfan syndrome (n = 6), Takayasu's disease (n = 3), and giant cell arteritis (n = 2). Success of EVSG repair was evaluated per the reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. Follow-up was a mean of 28.9 months (range 3-68). Six patients underwent EVSG repair of the thoracic aorta, four underwent EVSG repair of the abdominal aorta, and one underwent a staged repair of the thoracic and subsequently the abdominal aorta. Six true aneurysms and six pseudoaneurysms were repaired. Eight patients had previous aortic surgery, including four with multiple aortic operations. For the 12 aneurysms treated, technical success was achieved in 11 (91.7%). One technical failure occurred due to a small iliac access vessel, requiring an eventual iliac conduit for insertion. Early complications (<30 days) occurred in three patients. Type I or III endoleak developed following two repairs (16.7%). Aneurysm expansion occurred following one repair (8.3%). No aneurysm-related deaths occurred during follow-up. EVSG repair of aortic aneurysms is feasible and can be safely performed in patients with arteriopathies. Long-term durability in this younger group of patients who carry an ongoing risk of arterial degeneration remains to be determined.

Interagency registry for mechanically assisted circulatory support report on the total artificial heart.

PubMed

Arabía, Francisco A; Cantor, Ryan S; Koehl, Devin A; Kasirajan, Vigneshwar; Gregoric, Igor; Moriguchi, Jaime D; Esmailian, Fardad; Ramzy, Danny; Chung, Joshua S; Czer, Lawrence S; Kobashigawa, Jon A; Smith, Richard G; Kirklin, James K

2018-04-26

We sought to better understand the patient population who receive a temporary total artificial heart (TAH) as bridge to transplant or as bridge to decision by evaluating data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database. We examined data related to survival, adverse events, and competing outcomes from patients who received TAHs between June 2006 and April 2017 and used hazard function analysis to explore risk factors for mortality. Data from 450 patients (87% men; mean age, 50 years) were available in the INTERMACS database. The 2 most common diagnoses were dilated cardiomyopathy (50%) and ischemic cardiomyopathy (20%). Risk factors for right heart failure were present in 82% of patients. Most patients were INTERMACS Profile 1 (43%) or 2 (37%) at implantation. There were 266 patients who eventually underwent transplantation, and 162 died. Overall 3-, 6-, and 12-month actuarial survival rates were 73%, 62%, and 53%, respectively. Risk factors for death included older age (p = 0.001), need for pre-implantation dialysis (p = 0.006), higher creatinine (p = 0.008) and lower albumin (p < 0.001) levels, and implantation at a low-volume center (≤10 TAHs; p < 0.001). Competing-outcomes analysis showed 71% of patients in high-volume centers were alive on the device or had undergone transplantation at 12 months after TAH implantation vs 57% in low-volume centers (p = 0.003). Patients receiving TAHs have rapidly declining cardiac function and require prompt intervention. Experienced centers have better outcomes, likely related to patient selection, timing of implantation, patient care, and device management. Organized transfer of knowledge to low-volume centers could improve outcomes. Copyright © 2018 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.

Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma.

PubMed

Kong, Victor Y; Jeetoo, Damon; Naidoo, Leah C; Oosthuizen, George V; Clarke, Damian L

2015-01-01

The clinical significance of isolated free fluid (FF) without solid organ injury on computed to- mography (CT) continues to pose significant dilemma in the management of patients with blunt abdominal trauma (BAT). We reviewed the incidence of FF and the clinical outcome amongst patients with blunt abdominal trauma in a metropolitan trauma service in South Africa. We performed a retrospective study of 121 consecutive CT scans over a period of 12 months to determine the incidence of isolated FF and the clinical outcome of patients managed in a large metropolitan trauma service. Of the 121 CTs, FF was identified in 36 patients (30%). Seven patients (6%) had isolated FF. Of the 29 patients who had free fluid and associated organ injuries, 33 organ injuries were identified. 86% (25/ 29) of all 29 patients had a single organ injury and 14% had multiple organ injuries. There were 26 solid organ injuries and 7 hollow organ injuries. The 33 organs injured were: spleen, 12; liver, 8; kidney, 5; pancreas, 2; small bowel, 4; duodenum, 1. Six (21%) patients required operative management for small bowel perforations in 4 cases and pancreatic tail injury in 2 cases. All 7 patients with isolated FF were initially observed, and 3 (43%) were eventually subjected to operative intervention. They were found to have an intra-peritoneal bladder rupture in 1 case, a non-expanding zone 3 haematoma in 1 case, and a negative laparotomy in 1 case. Four (57%) patients were successfully managed without surgical interventions. Isolated FF is uncommon and the clinical significance remains unclear. Provided that reli- able serial physical examination can be performed by experienced surgeons, an initial non-operative approach should be considered.

Workstation Segment Specification for the World-Wide Military Command and Control (WWMCCS) Information System (WIS)

DTIC Science & Technology

1989-07-01

software eventually, and which indicate the general thrust of evolution and growth capabilities required of the workstation segment. These GRAY sections...configuration control over the evolution of the system. (" - The transition from the WWMCCS Standard ADP system to WIS will be gradual and will be...has been designed to support the workstation needs required for most WIS users, and is the workstation that will support the long-term evolution of

Drivers license display system

NASA Astrophysics Data System (ADS)

Prokoski, Francine J.

1997-01-01

Carjackings are only one of a growing class of law enforcement problems associated with increasingly violent crimes and accidents involving automobiles plays weapons, drugs and alcohol. Police traffic stops have become increasingly dangerous, with an officer having no information about a vehicle's potentially armed driver until approaching him. There are 15 million alcoholics in the US and 90 percent of them have drivers licenses. Many of them continue driving even after their licenses have ben revoked or suspended. There are thousands of unlicensed truck drivers in the country, and also thousands who routinely exceed safe operating periods without rest; often using drugs in an attempt to stay alert. MIKOS has developed the Drivers License Display Systems to reduce these and other related risks. Although every state requires the continuous display of vehicle registration information on every vehicle using public roads, no state yet requires the display of driver license information. The technology exists to provide that feature as an add-on to current vehicles for nominal cost. An initial voluntary market is expected to include: municipal, rental, and high value vehicles which are most likely to be mis-appropriated. It is anticipated that state regulations will eventually require such systems in the future, beginning with commercial vehicles, and then extending to high risk drivers and eventually all vehicles. The MIKOS system offers a dual-display approach which can be deployed now, and which will utilize all existing state licenses without requiring standardization.

Myelodysplastic Syndrome Occurring in a Patient with Gorlin Syndrome.

PubMed

Mull, Jamie L; Madden, Lisa M; Bayliss, Susan J

2016-07-01

We report a case of myelodysplastic syndrome (MDS) occurring in an African American boy with Gorlin syndrome with a novel PTCH1 mutation. Before developing MDS, the patient had been treated with chemotherapy and radiation for a medulloblastoma. He received a bone marrow transplant for the MDS and eventually died of treatment complications. Secondary hematologic malignancies are a known complication of certain chemotherapeutics, although whether a patient with Gorlin syndrome has a greater propensity for the development of such malignancies is unclear. © 2016 Wiley Periodicals, Inc.

[Bioethical aspects of the Health Care Reform in Chile. The problems of access and costs of resources ].

PubMed

Rosselot, Eduardo

2003-09-01

During the process of health reforms there is always the concern that patients rights might be harmed. The bill that is being discussed in the Chilean Parliament contains an special issue dedicated to patient's obligations and rights. However, on the author's opinion, the best protection for patient rights rests on adequate financing and access to a reasonably, good and qualified health care. A thorough revision of the proposals contained in the reform will allow an objective assessment of the eventual ethical problems that it might imply.

Disseminated nocardiosis in a patient on infliximab and methylprednisolone for treatment-resistant Sweet's syndrome

PubMed Central

Drone, Elizabeth R.; McCrory, Allison L.; Lane, Natalie; Fiala, Katherine

2014-01-01

A 62-year-old white man with a 10-year history of treatment-refractory Sweet's syndrome was admitted to the hospital with the onset of purpuric lesions. Methylprednisolone and infliximab were administered. Our patient developed disseminated Nocardia infection and eventually succumbed. Opportunistic infections such as Nocardia have been associated with infliximab and other tumour necrosis factor (TNF)-α inhibitors. The astute clinician should be aware of the risk of rare opportunistic infections, particularly in patients on TNF-α inhibitors and systemic corticosteroids. PMID:25165648

Disseminated nocardiosis in a patient on infliximab and methylprednisolone for treatment-resistant Sweet's syndrome.

PubMed

Drone, Elizabeth R; McCrory, Allison L; Lane, Natalie; Fiala, Katherine

2014-07-01

A 62-year-old white man with a 10-year history of treatment-refractory Sweet's syndrome was admitted to the hospital with the onset of purpuric lesions. Methylprednisolone and infliximab were administered. Our patient developed disseminated Nocardia infection and eventually succumbed. Opportunistic infections such as Nocardia have been associated with infliximab and other tumour necrosis factor (TNF)-α inhibitors. The astute clinician should be aware of the risk of rare opportunistic infections, particularly in patients on TNF-α inhibitors and systemic corticosteroids.

Study partners should be required in preclinical Alzheimer's disease trials.

PubMed

Grill, Joshua D; Karlawish, Jason

2017-12-06

In an effort to intervene earlier in Alzheimer's disease (AD), clinical trials are testing promising candidate therapies in preclinical disease. Preclinical AD trial participants are cognitively normal, functionally independent, and autonomous decision-makers. Yet, like AD dementia trials, preclinical trials require dual enrollment of a participant and a knowledgeable informant, or study partner. The requirement of dyadic enrollment is a barrier to recruitment and may present unique ethical challenges. Despite these limitations, the requirement should continue. Study partners may be essential to ensure participant safety and wellbeing, including overcoming distress related to biomarker disclosure and minimizing risk for catastrophic reactions and suicide. The requirement may maximize participant retention and ensure data integrity, including that study partners are the source of data that will ultimately instruct whether a new treatment has a clinical benefit and meaningful impact on the population health burden associated with AD. Finally, study partners are needed to ensure the scientific and clinical value of trials. Preclinical AD will represent a new model of care, in which persons with no symptoms are informed of probable cognitive decline and eventual dementia. The rationale for early diagnosis in symptomatic AD is equally applicable in preclinical AD-to minimize risk, maximize quality of life, and ensure optimal planning and communication. Family members and other sources of support will likely be essential to the goals of this new model of care for preclinical AD patients and trials must instruct this clinical practice.

Analysis of volumetric response of pituitary adenomas receiving adjuvant CyberKnife stereotactic radiosurgery with the application of an exponential fitting model

PubMed Central

Yu, Yi-Lin; Yang, Yun-Ju; Lin, Chin; Hsieh, Chih-Chuan; Li, Chiao-Zhu; Feng, Shao-Wei; Tang, Chi-Tun; Chung, Tzu-Tsao; Ma, Hsin-I; Chen, Yuan-Hao; Ju, Da-Tong; Hueng, Dueng-Yuan

2017-01-01

Abstract Tumor control rates of pituitary adenomas (PAs) receiving adjuvant CyberKnife stereotactic radiosurgery (CK SRS) are high. However, there is currently no uniform way to estimate the time course of the disease. The aim of this study was to analyze the volumetric responses of PAs after CK SRS and investigate the application of an exponential decay model in calculating an accurate time course and estimation of the eventual outcome. A retrospective review of 34 patients with PAs who received adjuvant CK SRS between 2006 and 2013 was performed. Tumor volume was calculated using the planimetric method. The percent change in tumor volume and tumor volume rate of change were compared at median 4-, 10-, 20-, and 36-month intervals. Tumor responses were classified as: progression for >15% volume increase, regression for ≤15% decrease, and stabilization for ±15% of the baseline volume at the time of last follow-up. For each patient, the volumetric change versus time was fitted with an exponential model. The overall tumor control rate was 94.1% in the 36-month (range 18–87 months) follow-up period (mean volume change of −43.3%). Volume regression (mean decrease of −50.5%) was demonstrated in 27 (79%) patients, tumor stabilization (mean change of −3.7%) in 5 (15%) patients, and tumor progression (mean increase of 28.1%) in 2 (6%) patients (P = 0.001). Tumors that eventually regressed or stabilized had a temporary volume increase of 1.07% and 41.5% at 4 months after CK SRS, respectively (P = 0.017). The tumor volume estimated using the exponential fitting equation demonstrated high positive correlation with the actual volume calculated by magnetic resonance imaging (MRI) as tested by Pearson correlation coefficient (0.9). Transient progression of PAs post-CK SRS was seen in 62.5% of the patients receiving CK SRS, and it was not predictive of eventual volume regression or progression. A three-point exponential model is of potential predictive value according to relative distribution. An exponential decay model can be used to calculate the time course of tumors that are ultimately controlled. PMID:28121913

Electrical storm in patients with an implanted defibrillator: a matter of definition.

PubMed

Israel, Carsten W; Barold, S Serge

2007-10-01

The term "electrical storm" (ES) indicates a state of cardiac electrical instability manifested by several episodes of ventricular tachyarrhythmias (VTs) within a short time. In patients with an implantable cardioverter defibrillator (ICD), ES is best defined as 3 appropriate VT detections in 24 h, treated by antitachycardia pacing, shock or eventually untreated but sustained in a VT monitoring zone. The number of shocks and inappropriate detections are irrelevant for the definition. ES occurs in approximately 25% of ICD patients within 3 years, with typically 5-55 individual VTs within one storm. Potential triggers can be found in approximately 66% of patients and include new/worsened heart failure, changes in antiarrhythmic medication, context with other illness, psychological stress, diarrhea, and hypokalemia. In most patients, ES consists of monomorphic VT indicating the presence of reentry while ventricular fibrillation indicating acute ischemia is rare. ES seems to have a low immediate mortality (1%) but frequently (50-80%) leads to hospitalization. Long-term prognostic implications of ES are unclear. The key intervention in ES is reduction of the elevated sympathetic tone by beta blockers and frequently benzodiazepines. Amiodarone i.v. has also been successful and azimilide seems promising while class I antiarrhythmic drugs are usually unsuccessful. Substrate mapping and VT ablation may be useful in treatment and prevention of ES. Prevention of ES requires ICD programming systematically avoiding unnecessary shocks (long VT detection, antitachycardia pacing where ever possible) which otherwise can fuel the sympathetic tone and prolong ES.

Esophageal replacement by gastric transposition: A single surgeon's experience from a tertiary pediatric surgical center.

PubMed

Foster, Jake D; Hall, Nigel J; Keys, S Charles; Burge, David M

2018-06-02

Many pediatric surgeons have limited experience of esophageal replacement. This study reports outcomes of esophageal replacement by gastric transposition performed by a single UK-based pediatric surgeon. Consecutive patients were identified who underwent esophageal replacement by gastric transposition over a 28 year period. Clinical and demographic data were collected. Weight-for-age Z-scores were calculated for esophageal atresia patients. Nineteen patients were identified. Indication in the majority was long-gap esophageal atresia (n = 17; 10 with tracheoesophageal fistula). At surgery, median age was 8.5 months (range 2-55); median weight was 7.4 kg (range 4.0-17.4 kg). A right-sided thoracotomy or transhiatal approach was used. Median postoperative length of stay was 17.5 days (range 7-130); median intensive care stay was three days (range 1-63). There were no deaths. Anastomotic leak rate at 30 days was 10.5% (n = 2). One patient required early stricture dilatation. Median weight-for-age Z-score increased from -2.17 at one year of age to -1.86, -1.70 and -1.93 at 5, 10 and 15 years. Esophageal replacement by gastric transposition offers a potentially life-changing treatment; however, it is associated with significant morbidity. The majority of patients eventually achieve full oral feeding and maintenance of weight gain trajectory. A right-sided approach to the esophagus is feasible. Treatment Study. IV. Copyright © 2018 Elsevier Inc. All rights reserved.

Considerations for diabetes: treatment with insulin pen devices.

PubMed

Cuddihy, Robert M; Borgman, Sarah K

2013-01-01

Insulin is essential for the treatment of type 1 diabetes, and most patients with type 2 diabetes will eventually require insulin for glycemic control. Several barriers contribute to delays in initiating insulin therapy in type 2 diabetes. Furthermore, insulin-treated patients often miss doses or otherwise fail to self-administer their insulin as prescribed, placing themselves at the risk of developing complications. Insulin pens can help overcome barriers to initiating insulin therapy and can facilitate the self-management of diabetes. Compared with the vial and syringe, insulin pens are more accurate, associated with greater adherence, and preferred by patients because of their convenience and ease of use. Large database analyses suggest that insulin pens may reduce the rate of occurrence of hypoglycemic events in patients with type 2 diabetes. Despite higher costs of insulin pens vs vials and syringes, studies suggest little or no increase in total health care costs and decreases in diabetes-related costs associated with reduced health care utilization with pens. Interestingly, the use of insulin pens within the United States lags far behind the use of pens in Europe and Japan. Insulin pens may be disposable or refillable, and some pens have special features [eg, audible clicks, large-dose selector and dial, memory function, half-unit dosing, high dosing (ie, 80 U)] that offer the opportunity to individualize treatment by meeting patients' needs. This review compares available insulin pens, describes strategies to facilitate their usage, and discusses how insulin pens can improve self-management of diabetes while reducing cost.

Depression and cardiovascular disease: a clinical review.

PubMed

Hare, David L; Toukhsati, Samia R; Johansson, Peter; Jaarsma, Tiny

2014-06-01

Cardiovascular disease (CVD) and depression are common. Patients with CVD have more depression than the general population. Persons with depression are more likely to eventually develop CVD and also have a higher mortality rate than the general population. Patients with CVD, who are also depressed, have a worse outcome than those patients who are not depressed. There is a graded relationship: the more severe the depression, the higher the subsequent risk of mortality and other cardiovascular events. It is possible that depression is only a marker for more severe CVD which so far cannot be detected using our currently available investigations. However, given the increased prevalence of depression in patients with CVD, a causal relationship with either CVD causing more depression or depression causing more CVD and a worse prognosis for CVD is probable. There are many possible pathogenetic mechanisms that have been described, which are plausible and that might well be important. However, whether or not there is a causal relationship, depression is the main driver of quality of life and requires prevention, detection, and management in its own right. Depression after an acute cardiac event is commonly an adjustment disorder than can improve spontaneously with comprehensive cardiac management. Additional management strategies for depressed cardiac patients include cardiac rehabilitation and exercise programmes, general support, cognitive behavioural therapy, antidepressant medication, combined approaches, and probably disease management programmes. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: journals.permissions@oup.com.

Limitations of Medical Research and Evidence at the Patient-Clinician Encounter Scale

PubMed Central

Ioannidis, John P. A.

2013-01-01

We explore some philosophical and scientific underpinnings of clinical research and evidence at the patient-clinician encounter scale. Insufficient evidence and a common failure to use replicable and sound research methods limit us. Both patients and health care may be, in part, complex nonlinear chaotic systems, and predicting their outcomes is a challenge. When trustworthy (credible) evidence is lacking, making correct clinical choices is often a low-probability exercise. Thus, human (clinician) error and consequent injury to patients appear inevitable. Individual clinician decision-makers operate under the philosophical influence of Adam Smith’s “invisible hand” with resulting optimism that they will eventually make the right choices and cause health benefits. The presumption of an effective “invisible hand” operating in health-care delivery has supported a model in which individual clinicians struggle to practice medicine, as they see fit based on their own intuitions and preferences (and biases) despite the obvious complexity, errors, noise, and lack of evidence pervading the system. Not surprisingly, the “invisible hand” does not appear to produce the desired community health benefits. Obtaining a benefit at the patient-clinician encounter scale requires human (clinician) behavior modification. We believe that serious rethinking and restructuring of the clinical research and care delivery systems is necessary to assure the profession and the public that we continue to do more good than harm. We need to evaluate whether, and how, detailed decision-support tools may enable reproducible clinician behavior and beneficial use of evidence. PMID:23546485

Limitations of medical research and evidence at the patient-clinician encounter scale.

PubMed

Morris, Alan H; Ioannidis, John P A

2013-04-01

We explore some philosophical and scientific underpinnings of clinical research and evidence at the patient-clinician encounter scale. Insufficient evidence and a common failure to use replicable and sound research methods limit us. Both patients and health care may be, in part, complex nonlinear chaotic systems, and predicting their outcomes is a challenge. When trustworthy (credible) evidence is lacking, making correct clinical choices is often a low-probability exercise. Thus, human (clinician) error and consequent injury to patients appear inevitable. Individual clinician decision-makers operate under the philosophical influence of Adam Smith's "invisible hand" with resulting optimism that they will eventually make the right choices and cause health benefits. The presumption of an effective "invisible hand" operating in health-care delivery has supported a model in which individual clinicians struggle to practice medicine, as they see fit based on their own intuitions and preferences (and biases) despite the obvious complexity, errors, noise, and lack of evidence pervading the system. Not surprisingly, the "invisible hand" does not appear to produce the desired community health benefits. Obtaining a benefit at the patient-clinician encounter scale requires human (clinician) behavior modification. We believe that serious rethinking and restructuring of the clinical research and care delivery systems is necessary to assure the profession and the public that we continue to do more good than harm. We need to evaluate whether, and how, detailed decision-support tools may enable reproducible clinician behavior and beneficial use of evidence.

Dietetic treatment with hypercaloric and hyperprotein intake in patients following severe brain injury.

PubMed

Balzola, F; Boggio Bertinet, D; Solerio, A; Rizzonato, P; Urciuoli, R; Piazza, A

1980-01-01

Sixty four patients, following severe acute brain injury were fed according to a strict dietetic therapy at the Intensive Care Unit at the Institute of Neurological Surgery, University of Turin. We used mixtures composed of simple nutritional elements consisting of carbohydrate as glucose polymers from 7 to 15 units, free aminoacids and MCT oil, integrated with natural elements. The solutions were administered via a nasogastric tube with the maximum caloric intake of 6.000 Kcal and 186 grams proteins/24 hr. After recording a series of hematochemical and clinical parameters we obtained the following results: 1) the average blood sugar level was always found to be pathological among the 11 patients who eventually died during their hospitalization, while 30% of the discharged patients had normal blood sugar values; 2) kidney function was significantly more affected among eventually deceased patients than among discharged ones; 3) the hospitalization time had a negative influence on the hepatic functions. Total serum albumins and proteins cease their decline respectively at average values of 2 and 5.5% gr, cholesterol maintains a constant level between 180 and 200% gr, calcium between 8 and 9 mg% and phosphorous around 3 mg%. Alkaline phosphatase in all patients rose significantly to pathological values only after a week of hospitalization. All other tests presented an irregular course. The survival period of our group of patients was significantly longer than that of control group. Within our group the survival rate was better among patients who received, within 10 days from cerebral damages, a hypercaloric and hyperprotein diet of more than 5.000 Kcal and 120 grams of proteins in 24 h, as compared to those whom the same diet was administered more gradually or following a longer period of time after having sustained cerebral damage.

TDRSS multimode transponder program S-band modification

NASA Technical Reports Server (NTRS)

Mackey, J. E.

1975-01-01

The S-Band TDRS multimode transponder and its associated ground support equipment is described. The transponder demonstrates candidate modulation techniques to provide the required information for the design of an eventual S-band transponder suitable for installation in a user satellite, capable of operating as part of a Tracking and Data Relay Satellite (TDRS) system.

78 FR 27010 - Airworthiness Directives; The Boeing Company Airplanes

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-09

... flap, and corrective actions if necessary; and eventual rework of the flap track assembly and rear spar... rework of the flap track assembly and rear spar attachments. The NPRM published in the Federal Register... data to support the rework requirements of paragraphs (s) and (t) of the NPRM (77 FR 61542, October 10...

Overview of Stress Effects on Body and Stress Prevention Techniques.

ERIC Educational Resources Information Center

McManus, John L.

Definitions of stress all imply that stress is a condition resulting from some change or imbalance that requires individual adjustment. When this does not occur, stress becomes an adverse condition which may eventually cause serious harm. Numerous studies have established the connection between unrelieved stress and adverse body reactions such as…

System for Odorless Disposal of Human Waste

NASA Technical Reports Server (NTRS)

Jennings, Dave; Lewis, Tod

1987-01-01

Conceptual system provides clean, hygienic storage. Disposal system stores human wastes compactly. Releases no odor or bacteria and requires no dangerous chemicals or unpleasant handling. Stabilizes waste by natural process of biodegradation in which microbial activity eventually ceases and ordors and bacteria reduced to easily contained levels. Simple and reliable and needs little maintenance.

Online Language Teaching: Teacher Perceptions of Effective Communication Tools, Required Skills and Challenges of Online Teaching

ERIC Educational Resources Information Center

De Paepe, Liesbeth; Zhu, Chang; Depryck, Koen

2018-01-01

To date, teacher perceptions of online language teaching have attracted very little attention. However, these perceptions may influence decisions regarding instructional design, teaching practices and eventually the learning experience. Furthermore, teacher perceptions can contribute to the design of teacher training programs. This study provides…

High prevalence of known and unknown pulmonary diseases in patients with claudication during exercise oximetry: A retrospective analysis.

PubMed

Colas-Ribas, Christophe; Signolet, Isabelle; Henni, Samir; Feuillloy, Mathieu; Gagnadoux, Frédéric; Abraham, Pierre

2016-10-01

The prevalence of pulmonary disease in patients with peripheral artery disease (PAD) has not been extensively studied. Recent evidence has shown that ∼20% of the patients have an atypical chest transcutaneous oxygen pressure (TcpO2) pattern during exercise, which suggests walking-induced hypoxemia. The main objectives of this study were to: (1) describe in a retrospective way the characteristics of the patients suffering from claudication, who attended a treadmill testing in our laboratory, (2) assess the prevalence of known or unknown pulmonary disease. The second aim of this study was to evaluate the impact of the therapeutic interventions on the walking capacities, after treatment, of the eventually detected pulmonary disorders.We retrospectively analyzed 1482 exercise TcpO2 test results. Patients that had no history of pulmonary disease, but either reported severe dyspnea or showed atypical profiles on their chest exercise-TcpO2, were advised to refer to the department of pneumology for additional investigations.In addition to the 166 patients with a history of pulmonary disease, 158 patients were suspected of unknown pulmonary disease from the result of their TcpO2 test. Many patients (n = 99/158, 62.7%) did not attend a pulmonologist visit. A pulmonary disease was established in 55 (93.2%) of the other 59 patients. Obstructive sleep apnea syndrome (OSAS) was the one and only diagnosis retained in 42/59 patients (71.2%). Among the 47 patients who had a second evaluation of their walking capacity on treadmill, 38 had treatment of the pulmonary disease found, vascular surgery treatment or a severe restricted diet, 9 had no treatment. Only the "treated" group showed a significant improvement in the maximal walking distance on treadmill between the 2 evaluations, 313 ± 251 m to 433 ± 317 m (P = 0.03).This retrospective pilot study underlines the high prevalence of both known and unknown pulmonary disease in patients whose primary complaint was lower limb claudication. Systematic screening and treatment of pulmonary disease in patients with claudication might be justified, to improve walking ability of such patients and possibly reduce or delay the requirement for revascularization. Prospective studies are required to confirm these preliminary results.

Early Prediction of Cancer Progression by Depth-Resolved Nanoscale Mapping of Nuclear Architecture from Unstained Tissue Specimens.

PubMed

Uttam, Shikhar; Pham, Hoa V; LaFace, Justin; Leibowitz, Brian; Yu, Jian; Brand, Randall E; Hartman, Douglas J; Liu, Yang

2015-11-15

Early cancer detection currently relies on screening the entire at-risk population, as with colonoscopy and mammography. Therefore, frequent, invasive surveillance of patients at risk for developing cancer carries financial, physical, and emotional burdens because clinicians lack tools to accurately predict which patients will actually progress into malignancy. Here, we present a new method to predict cancer progression risk via nanoscale nuclear architecture mapping (nanoNAM) of unstained tissue sections based on the intrinsic density alteration of nuclear structure rather than the amount of stain uptake. We demonstrate that nanoNAM detects a gradual increase in the density alteration of nuclear architecture during malignant transformation in animal models of colon carcinogenesis and in human patients with ulcerative colitis, even in tissue that appears histologically normal according to pathologists. We evaluated the ability of nanoNAM to predict "future" cancer progression in patients with ulcerative colitis who did and did not develop colon cancer up to 13 years after their initial colonoscopy. NanoNAM of the initial biopsies correctly classified 12 of 15 patients who eventually developed colon cancer and 15 of 18 who did not, with an overall accuracy of 85%. Taken together, our findings demonstrate great potential for nanoNAM in predicting cancer progression risk and suggest that further validation in a multicenter study with larger cohorts may eventually advance this method to become a routine clinical test. ©2015 American Association for Cancer Research.

Redox Regulation in Bone Marrow Failure

DTIC Science & Technology

2012-06-01

Fanconi anemia mutation for hematopoietic senescence. J Cell Sci, 2007. 120(Pt 9): p. 1572-83. 2. Aylon, Y. and M. Oren, Living with p53, dying of p53...aplastic anemia patients with a p38 MAPK inhibitor can restore defective hematopoietic activity, suggesting the critical role of p38 in bone marrow...hematopoietic stem cells, and eventually leading to bone marrow failure [7, 8] [9] [10]. On the other hand, treating aplastic anemia patients with a p38

Nipple piercing may be contraindicated in male patients with chest implants.

PubMed

de Kleer, N; Cohen, M; Semple, J; Simor, A; Antonyshyn, O

2001-08-01

The authors present a man who underwent chest augmentation and nipple piercing. The patient developed chronic nipple infection, which led to unnecessary invasive diagnostic procedures, serious implant infection, and eventually urgent explantation. This unfavorable scenario illustrates the distinct features of the procedure in men, which includes close proximity of the nipple to the implant and reduced awareness by health care providers. Based on this case the authors recommend avoiding nipple piercing in men with chest implants.

Gamma Knife surgery for clival epidural-osseous dural arteriovenous fistulas.

PubMed

Lee, Cheng-Chia; Chen, Ching-Jen; Chen, Shao-Ching; Yang, Huai-Che; Lin, Chung Jung; Wu, Chih-Chun; Chung, Wen-Yuh; Guo, Wan-Yuo; Hung-Chi Pan, David; Shiau, Cheng-Ying; Wu, Hsiu-Mei

2018-05-01

OBJECTIVE Clival epidural-osseous dural arteriovenous fistula (DAVF) is often associated with a large nidus, multiple arterial feeders, and complex venous drainage. In this study the authors report the outcomes of clival epidural-osseous DAVFs treated using Gamma Knife surgery (GKS). METHODS Thirteen patients with 13 clival epidural-osseous DAVFs were treated with GKS at the authors' institution between 1993 and 2015. Patient age at the time of GKS ranged from 38 to 76 years (median 55 years). Eight DAVFs were classified as Cognard Type I, 4 as Type IIa, and 1 as Type IIa+b. The median treatment volume was 17.6 cm 3 (range 6.2-40.3 cm 3 ). The median prescribed margin dose was 16.5 Gy (range 15-18 Gy). Clinical and radiological follow-ups were performed at 6-month intervals. Patient outcomes after GKS were categorized as 1) complete improvement, 2) partial improvement, 3) stationary, and 4) progression. RESULTS All 13 patients demonstrated symptomatic improvement, and on catheter angiography 12 of the 13 patients had complete obliteration and 1 patient had partial obliteration. The median follow-up period was 26 months (range 14-186 months). The median latency period from GKS to obliteration was 21 months (range 8-186 months). There was no intracranial hemorrhage during the follow-up period, and no deaths occurred. Two adverse events were observed following treatment, and 2 patients required repeat GKS treatment with eventual complete obliteration. CONCLUSIONS Gamma Knife surgery offers a safe and effective primary or adjuvant treatment modality for complex clival epidural-osseous DAVFs. All patients in this case series demonstrated symptomatic improvement, and almost all patients attained complete obliteration.

Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes.

PubMed

Zbeda, Robert M; Sculco, Peter K; Urch, Ekaterina Y; Lazaro, Lionel E; Borens, Olivier; Williams, Riley J; Lorich, Dean G; Wellman, David S; Helfet, David L

2015-07-01

Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. Case series; Level of evidence, 4. Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal. © 2015 The Author(s).

Reconstructive Management of Devastating Electrical Injuries to the Face.

PubMed

Janis, Jeffrey E; Khansa, Ibrahim; Lehrman, Craig R; Orgill, Dennis P; Pomahac, Bohdan

2015-10-01

Devastating fourth-degree electrical injuries to the face and head pose significant reconstructive challenges. To date, there have been few peer-reviewed articles in the literature that describe those reconstructive challenges. The authors present the largest case series to date that describes the management of these injuries, including the incorporation of face transplantation. A retrospective case series was conducted of patients with devastating electrical injuries to the face who were managed at two level-1 trauma centers between 2007 and 2011. Data describing patient injuries, initial management, and reconstructive procedures were collected. Five patients with devastating electrical injuries to the face were reviewed. After initial stabilization and treatment of life-threatening injuries, all five underwent burn excision and microsurgical reconstruction using distant flaps. Two of the patients eventually underwent face transplantation. The authors describe differences in management between the two trauma centers, one of which had the availability for composite tissue allotransplantation; the other did not. Also described is how initial attempts at traditional reconstruction affected the eventual face transplantation. The care of patients with complex electrical burns must be conducted in a multidisciplinary fashion. As with all other trauma, the initial priority should be management of the airway, breathing, and circulation. Additional considerations include cardiac arrhythmias and renal impairment attributable to myoglobinuria. Before embarking on aggressive reconstruction attempts, it is advisable to determine early whether the patient is a candidate for face transplantation in order to avoid antigen sensitization, loss of a reconstructive "lifeboat," surgical plane disruption, and sacrifice of potential recipient vessels. Therapeutic, V.

TU-G-303-03: Machine Learning to Improve Human Learning From Longitudinal Image Sets

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

Veeraraghavan, H.

‘Radiomics’ refers to studies that extract a large amount of quantitative information from medical imaging studies as a basis for characterizing a specific aspect of patient health. Radiomics models can be built to address a wide range of outcome predictions, clinical decisions, basic cancer biology, etc. For example, radiomics models can be built to predict the aggressiveness of an imaged cancer, cancer gene expression characteristics (radiogenomics), radiation therapy treatment response, etc. Technically, radiomics brings together quantitative imaging, computer vision/image processing, and machine learning. In this symposium, speakers will discuss approaches to radiomics investigations, including: longitudinal radiomics, radiomics combined with othermore » biomarkers (‘pan-omics’), radiomics for various imaging modalities (CT, MRI, and PET), and the use of registered multi-modality imaging datasets as a basis for radiomics. There are many challenges to the eventual use of radiomics-derived methods in clinical practice, including: standardization and robustness of selected metrics, accruing the data required, building and validating the resulting models, registering longitudinal data that often involve significant patient changes, reliable automated cancer segmentation tools, etc. Despite the hurdles, results achieved so far indicate the tremendous potential of this general approach to quantifying and using data from medical images. Specific applications of radiomics to be presented in this symposium will include: the longitudinal analysis of patients with low-grade gliomas; automatic detection and assessment of patients with metastatic bone lesions; image-based monitoring of patients with growing lymph nodes; predicting radiotherapy outcomes using multi-modality radiomics; and studies relating radiomics with genomics in lung cancer and glioblastoma. Learning Objectives: Understanding the basic image features that are often used in radiomic models. Understanding requirements for reliable radiomic models, including robustness of metrics, adequate predictive accuracy, and generalizability. Understanding the methodology behind radiomic-genomic (’radiogenomics’) correlations. Research supported by NIH (US), CIHR (Canada), and NSERC (Canada)« less

TU-G-303-04: Radiomics and the Coming Pan-Omics Revolution

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

El Naqa, I.

‘Radiomics’ refers to studies that extract a large amount of quantitative information from medical imaging studies as a basis for characterizing a specific aspect of patient health. Radiomics models can be built to address a wide range of outcome predictions, clinical decisions, basic cancer biology, etc. For example, radiomics models can be built to predict the aggressiveness of an imaged cancer, cancer gene expression characteristics (radiogenomics), radiation therapy treatment response, etc. Technically, radiomics brings together quantitative imaging, computer vision/image processing, and machine learning. In this symposium, speakers will discuss approaches to radiomics investigations, including: longitudinal radiomics, radiomics combined with othermore » biomarkers (‘pan-omics’), radiomics for various imaging modalities (CT, MRI, and PET), and the use of registered multi-modality imaging datasets as a basis for radiomics. There are many challenges to the eventual use of radiomics-derived methods in clinical practice, including: standardization and robustness of selected metrics, accruing the data required, building and validating the resulting models, registering longitudinal data that often involve significant patient changes, reliable automated cancer segmentation tools, etc. Despite the hurdles, results achieved so far indicate the tremendous potential of this general approach to quantifying and using data from medical images. Specific applications of radiomics to be presented in this symposium will include: the longitudinal analysis of patients with low-grade gliomas; automatic detection and assessment of patients with metastatic bone lesions; image-based monitoring of patients with growing lymph nodes; predicting radiotherapy outcomes using multi-modality radiomics; and studies relating radiomics with genomics in lung cancer and glioblastoma. Learning Objectives: Understanding the basic image features that are often used in radiomic models. Understanding requirements for reliable radiomic models, including robustness of metrics, adequate predictive accuracy, and generalizability. Understanding the methodology behind radiomic-genomic (’radiogenomics’) correlations. Research supported by NIH (US), CIHR (Canada), and NSERC (Canada)« less

Air Force System Safety Handbook, Designing the Safest Possible Systems Consistent with Mission Requirements and Cost Effectiveness

DTIC Science & Technology

2000-07-01

acceptance is not as simple a matter as it may first appear. Several points must be kept in mind. (1) Risk is a fundamental reality . (2) Risk...1) Proper preparation of an SSPP requires coming to grips with the hard realities of program execution. It involves the exami- nation and...Interfaces. (32:48) Since the conduct of a system safety program will eventually touch on virtually every other element of a system devel- opment program, a

Improving Employees' Safety Awareness in Healthcare Organizations Using the DMAIC Quality Improvement Approach.

PubMed

Momani, Amer; Hirzallah, Muʼath; Mumani, Ahmad

Occupational injuries and illnesses in healthcare can cause great human suffering, incur high cost, and have an adverse impact on the quality of patient care. One of the most effective solutions for addressing health and safety issues and improving decisions at the point of care rests in raising employees' safety awareness to recognize, avoid, or respond to potential problems before they arise. In this article, the DMAIC Six Sigma model (Define, Measure, Analyze, Improve, Control) is used as a systematic program to measure, improve, and sustain employees' safety awareness in healthcare organizations. We report on a case study using the model, which was implemented and validated at a local hospital. First, the occupational health and safety knowledge that each job requires was identified. Next, the degree of competence of jobholders to meet these requirements was assessed. Based on the assessment, different awareness-raising efforts were proposed and implemented. The results showed significant improvement in the overall safety awareness compliance assessed: from 74.2% to 84.4% (p < .001) after the intervention. The proposed model ensures that the organization's awareness-raising efforts serve its actual needs and produce optimized and sustained results that eventually lead to safer healthcare service.

Is Repeat PTA of a Failing Hemodialysis Fistula Durable?

PubMed

Bountouris, Ioannis; Kristmundsson, Thorarinn; Dias, Nuno; Zdanowski, Zbigniew; Malina, Martin

2014-01-01

Purpose. Our objective was to evaluate the outcome of percutaneous transluminal angioplasty (PTA) and particularly rePTA in a failing arteriovenous fistula (AV-fistula). Are multiple redilations worthwhile? Patients and Methods. All 159 stenoses of AV fistulas that were treated with PTA, with or without stenting, during 2008 and 2009, were included. Occluded fistulas that were dilated after successful thrombolysis were also included. Median age was 68 (interquartile range 61.5-78.5) years and 75% were male. Results. Seventy-nine (50%) of the primary PTAs required no further reintervention. The primary patency was 61% at 6 months and 42% at 12 months. Eighty (50%) of the stenoses needed at least one reintervention. Primary assisted patency (defined as patency after subsequent reinterventions) was 89% at 6 months and 85% at 12 months. The durability of repeated PTAs was similar to the durability of the primary PTA. However, an early primary PTA carried a higher risk for subsequent reinterventions. Successful dialysis was achieved after 98% of treatments. Nine percent of the stenoses eventually required surgical revision and 13% of the fistulas failed permanently. Conclusion. The present study suggests that most failing AV-fistulas can be salvaged endovascularly. Repeated PTA seems similarly durable as the primary PTA.

Combination Therapy Improves Survival in Prostate Cancer Model | Center for Cancer Research

Cancer.gov

Surgery and radiotherapy are the recommended treatments for localized prostate cancer. Recurrent prostate cancer, however, is often treated with androgen-deprivation therapy. Most patients who undergo this type of therapy eventually develop castration-resistant prostate cancer (CRPC). Though initially androgen-related therapies for CRPC had been thought to be ineffective,

HIP collapse. Don't blame doctors & patients.

PubMed

Sinagra, J

1999-11-01

While HIP's eventual insolvency was the culmination of several years of financial deterioration, certain events caused this to accelerate. This event is a long overdue impetus for change. The state has learned some hard lessons from the HIP/PHP debacle. The authors proposes a package of bills that will avoid a repeat of this issue.

Severity of Mental Health Impairment and Trajectories of Improvement in an Integrated Primary Care Clinic

ERIC Educational Resources Information Center

Bryan, Craig J.; Corso, Meghan L.; Corso, Kent A.; Morrow, Chad E.; Kanzler, Kathryn E.; Ray-Sannerud, Bobbie

2012-01-01

Objective: To model typical trajectories for improvement among patients treated in an integrated primary care behavioral health service, multilevel models were used to explore the relationship between baseline mental health impairment level and eventual mental health functioning across follow-up appointments. Method: Data from 495 primary care…

Confidentiality, Informed Consent, and Ethical Considerations in Reviewing the Client's Psychotherapy Records

ERIC Educational Resources Information Center

Blunt, David R.

2006-01-01

Ethical dilemmas that break the confidentiality of the client eventually test the psychologist's boundaries such that not taking action may place the patient in a position where they suffer, hurt themselves, or others. The effectiveness in obtaining a valid informed consent might depend upon the therapists training, experience, and sound judgment…

Subliminal (latent) processing of pain and its evolution to conscious awareness

PubMed Central

Borsook, David; Youssef, Andrew M.; Barakat, Nadia; Sieberg, Christine B.; Elman, Igor

2018-01-01

By unconscious or covert processing of pain we refer to nascent interactions that affect the eventual deliverance of pain awareness. Thus, internal processes (viz., repeated nociceptive events, inflammatory kindling, re-organization of brain networks, genetic) or external processes (viz., environment, socioeconomic levels, modulation of epigenetic status) contribute to enhancing or inhibiting the presentation of pain awareness. Here we put forward the notion that for many patients, ongoing sub-conscious changes in brain function are significant players in the eventual manifestation of chronic pain. In this review, we provide clinical examples of nascent or what we term pre-pain processes and the neurobiological mechanisms of how these changes may contribute to pain, but also potential opportunities to define the process for early therapeutic interventions. PMID:29476771

Subliminal (latent) processing of pain and its evolution to conscious awareness.

PubMed

Borsook, David; Youssef, Andrew M; Barakat, Nadia; Sieberg, Christine B; Elman, Igor

2018-05-01

By unconscious or covert processing of pain we refer to nascent interactions that affect the eventual deliverance of pain awareness. Thus, internal processes (viz., repeated nociceptive events, inflammatory kindling, reorganization of brain networks, genetic) or external processes (viz., environment, socioeconomic levels, modulation of epigenetic status) contribute to enhancing or inhibiting the presentation of pain awareness. Here we put forward the notion that for many patients, ongoing sub-conscious changes in brain function are significant players in the eventual manifestation of chronic pain. In this review, we provide clinical examples of nascent or what we term pre-pain processes and the neurobiological mechanisms of how these changes may contribute to pain, but also potential opportunities to define the process for early therapeutic interventions. Copyright © 2018. Published by Elsevier Ltd.

Gastrointestinal dysfunction in idiopathic Parkinsonism: A narrative review

PubMed Central

Salari, Mehri; Fayyazi, Emad; Mirmosayyeb, Omid

2016-01-01

Currently, gastrointestinal (GI) dysfunctions in Parkinson's disease (PD) are well-recognized problems and are known to be the initial symptoms in the pathological process that eventually results in PD. Many types of PD-associated GI dysfunctions have been identified, including weight loss, nausea, hypersalivation, dysphagia, dyspepsia, abdominal pain, intestinal pseudo-obstruction, constipation, defecatory dysfunction, and small intestinal bacterial overgrowth. These symptoms can influence on other PD symptoms and are the second most significant predictor of the quality of life of these patients. Recognition of GI symptoms requires vigilance on the part of clinicians. Health-care providers should routinely ask direct questions about GI symptoms during office visits so that efforts can be directed at appropriate management of these distressing manifestations. Multiple system atrophy (MSA) and progressive supranuclear palsy are two forms of neurodegenerative Parkinsonism. Symptoms of autonomic dysfunctions such as GI dysfunction are common in patients with parkinsonian disorders. Despite recent progress in the recognition of GI dysfunctions, there are a few reviews on the management of GI dysfunction and GI symptoms in idiopathic Parkinsonism. In this review, the clinical presentation, pathophysiology, and treatment of each GI symptom in PD, MSA, and prostate-specific antigen will be discussed. PMID:28331512

[Classification in medicine. An introductory reflection on its aim and object].

PubMed

Giere, W

2007-07-01

Human beings are born with the ability to recognize Gestalt and to classify. However, all classifications depend on their circumstances and intentions. There is no ultimate classification, and there is no one correct classification in medicine either. Examples for classifications of diagnoses, symptoms and procedures are discussed. The path to gaining knowledge and the basic difference between collecting data (patient file) and sorting data (register) will be illustrated using the BAIK information model. Additionally the model shows how the doctor can profit from the active electronic patient file which automatically offers him other relevant information for his current decision and saves time. "Without classification no new knowledge, no new knowledge through classification". This paradox will be solved eventually: a change of paradigms requires the overcoming of the currently valid classification system in medicine as well. Finally more precise recommendations will be given on how doctors can be freed from the burden of the need to classify and how the whole health system can gain much more valid data without limiting the doctors' freedom and creativity through co-ordinated use of IT, all while saving money at the same time.

Transverse maxillary distraction with a bone-anchored appliance: dento-periodontal effects and clinical and radiological results.

PubMed

Ramieri, G A; Spada, M C; Austa, M; Bianchi, S D; Berrone, S

2005-06-01

In 29 adult patients presenting with maxillary deficiency, a bone-anchored palatal distractor (Surgi-Tec NV, Brugge, Belgium) was applied after osteotomy of the anterolateral walls of the maxillary sinuses, midpalatal suture, and, eventually, separation of the pterygomaxillary sutures. Expansion proceeded at a rate of 0.33-0.66 mm per day and the device was retained for 4-6 months for consolidation. Active orthodontic therapy was started after 8-10 weeks. The increment of arch width and the perimeter were evaluated using dental casts. Tooth thermal sensitivity and the periodontal side effects of treatment were monitored clinically after distraction, at device removal, and after 1 year. Bone healing was also investigated during the procedure using conventional radiological techniques. This experience confirms that transverse maxillary distraction is an effective technique in adult patients, leading to the formation of new bone. There were no noticeable intraoperative complications, but postsurgical periodontal side effects were documented. The procedure offers advantages over traditional teeth-borne appliances in terms of rapidity of treatment and the absence of mechanical forces acting on the teeth. Further evaluation is required to assess the long-term stability and periodontal consequences of this technique.

Severe and Rapid Progression in Very Early-Onset Chronic Granulomatous Disease-Associated Colitis.

PubMed

Kawai, Toshinao; Arai, Katsuhiro; Harayama, Shizuko; Nakazawa, Yumiko; Goto, Fumihiro; Maekawa, Takanobu; Tamura, Eiichiro; Uchiyama, Toru; Onodera, Masafumi

2015-08-01

Chronic granulomatous disease (CGD) is a primary immunodeficiency disease that leads to recurrent infection and hyper-inflammation, occasionally represented by CGD-associated colitis (CGD colitis). Although clinical symptoms of CGD colitis mimic those of ulcerative colitis (UC), there is no reliable standard measurement of disease activity or standard therapeutic strategy for CGD colitis. Here, we examined the clinical manifestation of CGD colitis based on severity using a noninvasive measure of disease activity, the Pediatric Ulcerative Colitis Activity Index (PUCAI), which has been validated and widely used for pediatric UC. Sixteen of 35 CGD patients, who were diagnosed with CGD colitis based on colonoscopic and histological findings, were examined using the PUCAI. Both the PUCAI and the physician global assessment (PGA) tool were retrospectively scored by reviewing medical records. Disease activity defined by PUCAI was correlated with PGA, and increased at diagnosis of CGD colitis, especially in patients who were younger than 6 years of age (very early-onset CGD colitis: VEO-CGD colitis) when diagnosed with CGD colitis. All severe patients had a more progressive form of VEO-CGD colitis. Unlike mild and moderate patients, severe patients required multidrug therapy of corticosteroids and immunomodulator/immunosuppressants, and some were eventually treated with hematopoietic stem cell transplantation. Although the validation of PUCAI in CGD colitis should be considered for future use, our results indicate that noninvasive measures could be effective to measure disease activity and help to determine suitable treatment for CGD colitis. In patients with VEO-CGD colitis, multidrug therapy would need to be considered at an early stage on the basis of disease activity.

Multifaceted impairments in impulsivity and brain structural abnormalities in opioid dependence and abstinence.

PubMed

Tolomeo, S; Gray, S; Matthews, K; Steele, J D; Baldacchino, A

2016-10-01

Chronic opioid exposure, as a treatment for a variety of disorders or as drug of misuse, is common worldwide, but behavioural and brain abnormalities remain under-investigated. Only a small percentage of patients who receive methadone maintenance treatment (MMT) for previous heroin misuse eventually achieve abstinence and studies on such patients are rare. The Cambridge Neuropsychological Test Automated Battery and T1 weighted magnetic resonance imaging (MRI) were used to study a cohort of 122 male individuals: a clinically stable opioid-dependent patient group receiving MMT (n = 48), an abstinent previously MMT maintained group (ABS) (n = 24) and healthy controls (n = 50). Stable MMT participants deliberated longer and placed higher bets earlier in the Cambridge Gambling Task (CGT) and showed impaired strategic planning compared with healthy controls. In contrast, ABS participants showed impairment in choosing the least likely outcome, delay aversion and risk adjustment on the CGT, and exhibited non-planning impulsivity compared with controls. MMT patients had widespread grey matter reductions in the orbitomedial prefrontal cortex, caudate, putamen and globus pallidus. In contrast, ABS participants showed midbrain-thalamic grey matter reductions. A higher methadone dose at the time of scanning was associated with a smaller globus pallidus in the MMT group. Our findings support an interpretation of heightened impulsivity in patients receiving MMT. Widespread structural brain abnormalities in the MMT group and reduced brain structural abnormality with abstinence suggest benefit of cessation of methadone intake. We suggest that a longitudinal study is required to determine whether abstinence improves abnormalities, or patients who achieve abstinence have reduced abnormalities before methadone cessation.

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

PubMed

Estes, Christine; Sulica, Lucian

2014-05-01

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

Urinary Procollagen III Aminoterminal Propeptide (PIIINP): A Fibrotest for the Nephrologist

PubMed Central

Ghoul, Balsam El; Squalli, Tarek; Servais, Aude; Elie, Caroline; Meas-Yedid, Vannary; Trivint, Christine; Vanmassenhove, Jill; Grünfeld, Jean-Pierre; Olivo-Marin, Jean-Christophe; Thervet, Eric; Noël, Laure-Hélène; Prié, Dominique

2010-01-01

Background and objectives: Kidney biopsy (KB), to date the only tool for the evaluation of renal fibrosis, carries specific risks, and its relevance is limited by the small size of renal parenchyma assessed. Thus, a noninvasive alternative to KB is required. Collagen type III amino-terminal propeptide (PIIINP) is a degradation product of collagen type III, the increase of which may reflect an ongoing fibrotic process. Design, setting, participants, & measurements: In a prospective study including 199 patients with various stages of chronic kidney disease (CKD), the association between urinary PIIINP/creatinine ratio (UPIIINP/Cr), patients' characteristics, and renal fibrosis was assessed. Results: A total of 118 of the patients had UPIIINP/Cr measured simultaneously with the performance of a KB. In patients, median UPIIINP/Cr was 290 ng/mmol versus 93.7 ng/mmol in controls. In univariate analysis, UPIIINP/Cr was correlated with serum creatinine, estimated GFR, CKD stage, presence of coronary artery disease, and nephropathy type (glomerulonephritis versus other types). In multivariate analysis, only estimated GFR and nephropathy type were correlated with UPIIINP/Cr. UPIIINP/Cr was closely correlated with the extent of interstitial fibrosis in KB assessed using two different methods. Moreover, UPIIINP/Cr >800 ng/mmol had a negative predictive value of 94% to detect patients in whom KB will eventually prove “noninformative” (KB leading neither to a definite diagnosis of nephropathy nor to specific treatment). Conclusions: UPIIINP/Cr is a promising fibro-test for the kidney and may alleviate the need for KB in some patients with CKD. Its predictive value for CKD progression deserves evaluation in prospective studies. PMID:20089486

Novel device and technique for minimally invasive intracerebral hematoma evacuation in the same setting of a ruptured intracranial aneurysm: combined treatment in the neurointerventional angiography suite.

PubMed

Turner, Raymond D; Vargas, Jan; Turk, Aquilla S; Chaudry, M Imran; Spiotta, Alejandro M

2015-03-01

The presence of intracerebral hematoma from aneurysm rupture is an indication for craniotomy for clot evacuation and aneurysm clipping. Some centers have begun securing aneurysms with coil embolization followed by clot evacuation in the operating room. This approach requires transporting a patient from the angiography suite to the operating room, which can take valuable time and resources. To report our experience with 3 cases in which a novel technique for minimally invasive evacuation of intracerebral hematomas after endovascular treatment of ruptured intracranial aneurysms was used. The Penumbra Apollo system can be used in the angiography suite in conjunction with neuroendovascular techniques to simultaneously address a symptomatic hematoma associated with a ruptured aneurysm. Standard preoperative computed tomography angiography was performed on arrival to the emergency department. The patients underwent diagnostic cerebral angiography followed by balloon-assisted coil embolization and then remained in the neurointerventional suite for intracerebral hematoma evacuation with the Apollo system. All patients tolerated coil embolization and hematoma evacuation well. The combined procedures lasted <3 hours in both cases. Two patients were eventually discharged to acute rehabilitation facilities less than a month after their initial insult, and 1 has been cleared to return to work. The other patient was transferred to hospice care. The Apollo aspiration system appears to be a safe and effective minimally invasive option for intracerebral hematoma evacuation, particularly when coupled with endovascular embolization of ruptured intracranial aneurysms. Future work will address which patient population is most likely to benefit from this promising technique.

The selective conservative management of small traumatic pneumothoraces following stab injuries is safe: experience from a high-volume trauma service in South Africa.

PubMed

Kong, V Y; Oosthuizen, G V; Clarke, D L

2015-02-01

The selective conservative management of small pneumothoraces (PTXs) following stab injuries is controversial. We reviewed a cohort of patients managed conservatively in a high volume trauma service in South Africa. A retrospective review over a 2-year period identified 125 asymptomatic patients with small PTXs measuring <2 cm on chest radiograph who were managed conservatively. Of the 125 patients included in the study, 92% were male (115/125), and the median age for all patients was 21 years (19-24). Ninety-seven per cent (121/125) of the weapons involved were knives, and 3% (4/125) were screwdrivers. Sixty-one per cent of all injuries were on the left side. Eighty-two per cent (102/125) sustained a single stab, and 18% (23/125) had multiple stabs. Thirty-nine per cent (49/125) had a PTX <0.5 cm (Group A), 26% (32/125) were ≥ 0.5 to <1 cm (Group B), 19% (24/125) were ≥ 1 to <1.5 cm (Group C) and 15% (20/125) were ≥ 1.5 to <2 cm (Group D). Three per cent of all patients (4/125) eventually required ICDs (one in Group C, three in Group D). All four patients had ICDs in situ for 24 h. The remaining 97% (121/125) were all managed successfully by active clinical observation alone. There were no subsequent readmissions, morbidity or mortality as a direct result of our conservative approach. The selective conservative management of asymptomatic small PTXs from stab injuries is safe if undertaken in the appropriate setting.

Surgery in the nursing home patient.

PubMed

Zenilman, M E

1994-02-01

Will a Geriatric Surgical Consult Service eventually develop into yet another surgical subspecialty? Precedent has been set in surgical fields such as pediatric and plastic surgery, and surely the expanding patient population will demand that some surgeons take care of the geriatric surgical patient full time. Those surgeons doing so will therefore become recognized experts and will be frequently consulted. The surgical problems faced by this unique patient population observed in our small series are most often straightforward. More complicated issues related to wound and intravenous line care, breast disease, and alimentary tract disease should be easily handled by an aggressive, conscientious, well-trained general surgeon.

Vancomycin-resistant Enterococcus in pediatric oncology patients: balancing infection prevention and family-centered care.

PubMed

Singh, Jasjit; Esparza, Samuel; Patterson, Melanie; Vogel, Kate; Patel, Bijal; Gornick, Wendi

2013-04-01

In February 2007, we experienced an abrupt 8-fold increase in vancomycin-resistant Enterococcus (VRE)-positive pediatric hematology/oncology patients in isolation per day, peaking at 12 patients in isolation per day in June 2007. We enforced and expanded infection prevention practices and initiated a rigorous 6-month clearance process. After noting an eventual decrease, we modified clearance to a 3-month process, maintaining <1 patient/day in isolation by June 2009, subjectively improving family and staff satisfaction after this 2-year process. VRE infection was relatively uncommon (7.8%), although continued VRE colonization portended an overall poorer prognosis.

Medical Science Liaisons in Real-World Evidence Studies: Experience of AstraZeneca Russia.

PubMed

Suvorov, Nikolay; Karaseva, Vera; Stukalina, Ekaterina; Sanay, Elkhan; Petrakovskaya, Vera; Bulatov, Vladimir

2018-01-01

There is no doubt that real-world evidence studies have the potential to improve and accelerate the development and delivery of safe and cost-effective innovative medicines to patients as well as influence the way we approach health and health care. Real-world evidence studies are a great challenge in terms of development and conduct, so there should be a good collaboration between the study team and clinical sites at all times, resulting eventually in timely and efficient enrollment. Engaging the sites and key external experts as early as possible during feasibility and routine visits, as well as highlighting the science rationale behind AstraZeneca's portfolio at investigator meetings and during medical science liaison (MSL) interactions, can create a positive impact on physician perception of a particular study and prioritization of patient recruitment in such studies. Therefore, we would like to underline the important role of MSLs in the risk-based monitoring setting of real-world evidence studies, with special attention to the studies with complicated patient profiles, tough timelines, and/or seasonal factors. This approach will be used further for other real world evidence projects of AstraZeneca Russia MC to ensure timelines and budget deliverables are met for the generation of high-quality evidence and eventually better health care for all of us.

Staged lengthening arthroplasty for pediatric osteosarcoma around the knee.

PubMed

Kong, Chang-Bae; Lee, Soo-Yong; Jeon, Dae-Geun

2010-06-01

Orthopaedic oncologists often must address leg-length discrepancy after resection of tumors in growing patients with osteosarcoma. There are various alternatives to address this problem. We describe a three-stage procedure: (1) temporary arthrodesis, (2) lengthening by Ilizarov apparatus, and (3) tumor prosthesis. We asked (1) to what extent are affected limbs actually lengthened; (2) how many of the patients who undergo a lengthening procedure eventually achieve joint arthroplasty; and (3) can the three-stage procedure give patients a functioning joint with equalization of limb length? We reviewed 56 patients (younger than 14 years) with osteosarcoma who had staged lengthening arthroplasty between 1991 and 2004. Thirty-five of the 56 patients (63%) underwent soft tissue lengthening, and of these 35, 28 (50% of the original group of 56) had implantation of a mobile joint. Three of the 28 prostheses were later removed owing to infection after arthroplasty. The overall average length gained was 7.8 cm (range, 4-14 cm), and 25 (71%) of the 35 patients had a mobile joint at final followup. The average Musculoskeletal Tumor Society functional score was 23.2 (range, 15-28) and limb-length discrepancy at final followup was 2.6 cm (range, 0-6.5 cm). Although most mobile joints had an acceptable ROM (average, 74.2 degrees ; range, 35 degrees -110 degrees ), extension lag was frequent. Our approach is one option for skeletally immature patients, especially in situations where an expandable prosthesis is not available. However, this technique requires multiple stages and would be inappropriate for patients who cannot accept prolonged functional deficit owing to a limited lifespan or other reasons. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Experience with Guillain-Barré syndrome in a neurological Intensive Care Unit.

PubMed

González, P; García, X; Guerra, A; Arango, J C; Delgado, H; Uribe, C S; Sará, J; López de Mesa, J C; Hernández, O

2016-01-01

Guillain-Barré syndrome, an acute polyradiculoneuropathy that presents with weakness and areflexia, is the most common cause of acute flaccid paralysis. In certain patients, respiratory failure is secondary to this disorder, eventually causing patients to require mechanical ventilation and experience additional complications due to diminished respiratory support and related mobility limitations. Prognoses for most of these cases are positive; treatment consists of basic support combined with plasmapheresis or administration of immunoglobulins. This study sought to describe the socio-demographic, clinical, laboratory and neurophysiological characteristics of patients with Guillain-Barré syndrome who were hospitalised in the Intensive Care Unit of the Neurological Institute of Colombia between 2006 and 2012. This study presents a case series. We surveyed 25 patients (32% female and 68% male) with Guillain-Barré syndrome and an average age of 54 years. Sixty per cent of these patients were admitted between days 3 and 7 after symptom onset; 64% had a history of respiratory infection and 20% had a history of intestinal infection. In addition, 84% of the patients presented with albuminocytological dissociation. We observed the following clinical subtypes of Guillain-Barré syndrome: inflammatory demyelinating polyneuropathy in 32%, acute motor-sensory axonal neuropathy in 28%, acute motor axonal neuropathy in 28%, and Miller Fisher syndrome in 12%. In this descriptive study of a group of critical care patients with GBS, results depended on patients' clinical severity at time of admission. Our findings are similar to results published in the international literature. Copyright © 2014 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

GPR98 mutations cause Usher syndrome type 2 in males.

PubMed

Ebermann, I; Wiesen, M H J; Zrenner, E; Lopez, I; Pigeon, R; Kohl, S; Löwenheim, H; Koenekoop, R K; Bolz, H J

2009-04-01

Mutations in the large GPR98 gene underlie Usher syndrome type 2C (USH2C), and all patients described to date have been female. It was speculated that GPR98 mutations cause a more severe, and eventually lethal, phenotype in males. We describe for the first time two male patients with USH2 with novel GPR98 mutations. Clinical characterization of a male patient and his affected sister revealed a typical USH2 phenotype in both. GPR98 may have been excluded from systematic investigation in previous studies, and the proportion of patients with USH2C probably underestimated. GPR98 should be considered in patients with USH2 of both sexes.

Outcomes of Open Dorsal Wrist Ganglion Excision in Active-Duty Military Personnel.

PubMed

Balazs, George C; Donohue, Michael A; Drake, Matthew L; Ipsen, Derek; Nanos, George P; Tintle, Scott M

2015-09-01

To examine the most common presenting complaints of active-duty service members with isolated dorsal wrist ganglions and to determine the rate of return to unrestricted duty after open excision. Surgical records at 2 military facilities were screened to identify male and female active duty service members undergoing isolated open excision of dorsal wrist ganglions from January 1, 2006 to January 1, 2014. Electronic medical records and service disability databases were searched to identify the most common presenting symptoms and to determine whether patients returned to unrestricted active duty after surgery. Postoperative outcomes examined were pain persisting greater than 4 weeks after surgery, stiffness requiring formal occupational therapy treatment, surgical wound complications, and recurrence. A total of 125 active duty military personnel (Army, 54; Navy, 43; and Marine Corps, 28) met criteria for inclusion. Mean follow-up was 45 months. Fifteen percent (8 of 54) of the Army personnel were given permanent waivers from performing push-ups owing to persistent pain and stiffness. Pain persisting greater than 4 weeks after surgery was an independent predictor of eventual need for a permanent push-up waiver. The overall recurrence incidence was 9%. No demographic or perioperative factors were associated with recurrence. Patients whose occupation or activities require forceful wrist extension should be counseled on the considerable risk of residual pain and functional limitations that may occur after open dorsal wrist ganglion excision. Therapeutic IV. Published by Elsevier Inc.

Personalized medicine in thrombosis: back to the future

PubMed Central

Nagalla, Srikanth

2016-01-01

Most physicians believe they practiced personalized medicine prior to the genomics era that followed the sequencing of the human genome. The focus of personalized medicine has been primarily genomic medicine, wherein it is hoped that the nucleotide dissimilarities among different individuals would provide clinicians with more precise understanding of physiology, more refined diagnoses, better disease risk assessment, earlier detection and monitoring, and tailored treatments to the individual patient. However, to date, the “genomic bench” has not worked itself to the clinical thrombosis bedside. In fact, traditional plasma-based hemostasis-thrombosis laboratory testing, by assessing functional pathways of coagulation, may better help manage venous thrombotic disease than a single DNA variant with a small effect size. There are some new and exciting discoveries in the genetics of platelet reactivity pertaining to atherothrombotic disease. Despite a plethora of genetic/genomic data on platelet reactivity, there are relatively little actionable pharmacogenetic data with antiplatelet agents. Nevertheless, it is crucial for genome-wide DNA/RNA sequencing to continue in research settings for causal gene discovery, pharmacogenetic purposes, and gene-gene and gene-environment interactions. The potential of genomics to advance medicine will require integration of personal data that are obtained in the patient history: environmental exposures, diet, social data, etc. Furthermore, without the ritual of obtaining this information, we will have depersonalized medicine, which lacks the precision needed for the research required to eventually incorporate genomics into routine, optimal, and value-added clinical care. PMID:26847245

Aortic annulus sizing using watershed transform and morphological approach for CT images

NASA Astrophysics Data System (ADS)

Mohammad, Norhasmira; Omar, Zaid; Sahrim, Mus'ab

2018-02-01

Aortic valve disease occurs due to calcification deposits on the area of leaflets within the human heart. It is progressive over time where it can affect the mechanism of the heart valve. To avoid the risk of surgery for vulnerable patients especially senior citizens, a new method has been introduced: Transcatheter Aortic Valve Implantation (TAVI), which places a synthetic catheter within the patient's valve. This entails a procedure of aortic annulus sizing, which requires manual measurement of the scanned images acquired from Computed Tomographic (CT) by experts. The step requires intensive efforts, though human error may still eventually lead to false measurement. In this research, image processing techniques are implemented onto cardiac CT images to achieve an automated and accurate measurement of the heart annulus. The image is first put through pre-processing for noise filtration and image enhancement. Then, a marker image is computed using the combination of opening and closing operations where the foreground image is marked as a feature while the background image is set to zero. Marker image is used to control the watershed transformation and also to prevent oversegmentation. This transformation has the advantage of fast computational and oversegmentation problems, which usually appear with the watershed transform can be solved with the introduction of marker image. Finally, the measurement of aortic annulus from the image data is obtained through morphological operations. Results affirm the approach's ability to achieve accurate annulus measurements compared to conventional techniques.

Familial Churg-Strauss Syndrome in a Sister and Brother.

PubMed

Alyasin, Soheyla; Khoshkhui, Maryam; Amin, Reza

2015-06-01

Churg-Strauss syndrome (CSS) is a granulomatous small vessel vasculitis. It is characterized by asthma, allergic granulomatosis and vasculitis. This syndrome is rare in children. A 5 years old boy was admitted with cough, fever and dyspnea for 2 weeks. On the basis of laboratory data (peripheral eosinophilia), associated with skin biopsy, and history of CSS in his sister, this disease was eventually diagnosed. The patient had good response to corticosteroid. In every asthmatic patient with prolonged fever, eosinophilia and multisystemic involvment, CSS should be considered.

[Fibromyalgia syndrome after comprehensive treatment of breast cancer: a case report].

PubMed

Ding, Xia; Li, Yan; Cui, Yiyi; Shen, Yingying; Gu, Jianzhong; Guo, Yong

2016-05-25

Fibromyalgia syndrome after comprehensive treatment of breast cancer is rare and seldom reported. Here we present a case of a 50-year-old female patient,who was admitted to the hospital because of generalized fibromyalgia for 3 months and brain metastasis after the right breast carcinoma surgery for 1 month, and the clinical diagnosis was brain metastasis from breast carcinoma combined with fibromyalgia syndrome. The fibromyalgia were relieved with proper symptomatic treatment but the patient eventually died of tumor progression.

Predicted versus executed surgical orthognathic treatment.

PubMed

Falter, B; Schepers, S; Vrielinck, L; Lambrichts, I; Politis, C

2013-10-01

This study aimed to analyse combined surgical-orthodontic treatment plans, compare them with the actual surgery performed, and define factors resulting in changes of the original plan during orthodontic pre-surgical preparation. The clinical files of 312 orthognathic surgery patients, operated between January 2008 and December 2010, were retrospectively reviewed. Of these 312 patients, 129 had a bimaxillary operation. One hundred sixty patients had osteotomy of the lower jaw only and 23 had osteotomy of the upper jaw only. Factors analysed in the study include Angle Class malocclusion, patient sex, and age. Lip-to-incisor relationship, overjet, overbite and midline deviations of the upper and lower jaw were recorded. Effects of surgical assisted rapid palatal expansion (SARPE) on the eventual surgery were also investigated. Reasons for changing the original treatment plan at the time of the finished pre-surgical-orthodontic alignment were analysed. The original treatment plan was changed in 42 of the 312 patients (13.5%). Changes occurred generally in case of a larger interval between set-up of the first treatment plan and the eventual operation (average 22.4 versus 16.4 months for patients with changed versus unchanged treatment plan, respectively). All Class I patients had surgery performed as planned. Class III patients had a significantly higher rate of altered treatment plan (27.3%) than Class II patients (7.6%). More men (52.4%) saw their treatment plan changed, although there were more women than men in the study population (59.6 versus 40.4%). One in seven patients (13.5%) had a different operation than was planned at the start of treatment. Class III patients with small overjet and overbite commonly have a treatment plan for a monomaxillary operation that, after decompensation, needs to be adapted to a bimaxillary operation. Copyright © 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Anti-Jk3 in a Filipino man.

PubMed

McCaskill, Shaina; Wise, Scott; Tinsley, Sheila

2015-01-01

A 62-year-old Filipino man with a history of chronic obstructive pulmonary disease, hypertension, and hyperlipidemia was admitted to the emergency department at Hospital A with recurrent fevers, weakness, and jaundice. The patient was evaluated and eventually discharged with a diagnosis of possible drug-induced hepatitis. One month later, the patient was admitted to Hospital B for recurrent fevers and weakness. The patient's hemoglobin was 3.8 g/dL. Six units of packed red blood cells (RBCs) were ordered for transfusion. The patient's sample typed as group B, D+, and the antibody screen was negative. All six units of packed RBCs appeared compatible (at immediate spin) and were transfused to the patient. His hemoglobin level 4 days post-transfusion was 9.3 g/dL, and the patient was discharged. The patient returned after a week for follow-up and his hemoglobin was found to have dropped to 8.5 g/dL, which continued to fall until it reached 7.0 g/dL. Additional packed RBCs were ordered for transfusion. during subsequent pre-transfusion compatibility testing, the antibody screen was found to be positive (all screening cells reactive at the antihuman globulin phase). An antibody identification panel was performed.The patient's serum was found to react with all panel cells tested, including the autocontrol tube. A direct antiglobulin test revealed the presence of both anti-IgG and anti-C3 coating the patient's RBCs. The specimen was then sent to a reference laboratory for further testing. Results from the reference lab testing revealed the presence of anti-Jk3 in the patient's serum. the patient was placed on steroids, and his reticulocyte count increased with no further signs of extravascular hemolysis. No additional transfusions were necessary. he was eventually discharged with a hemoglobin of 13.6 g/dL. the purpose of this case study is to report the findings of an extremely rare but clinically significant antibody, anti-Jk3.

Stereotactic Radiosurgery for Patients With Brain Metastases From Small Cell Lung Cancer

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

Wegner, Rodney E.; Olson, Adam C.; Kondziolka, Douglas

2011-11-01

Background: Patients with small-cell lung cancer have a high likelihood of developing brain metastases. Many of these patients will have prophylactic cranial irradiation (PCI) or eventually undergo whole brain radiation therapy (WBRT). Despite these treatments, a large number of these patients will have progression of their intracranial disease and require additional local therapy. Stereotactic radiosurgery (SRS) is an important treatment option for such patients. Methods: We retrospectively reviewed the charts of 44 patients with brain metastases from small-cell lung cancer treated with gamma knife SRS. Multivariate analysis was used to determine significant prognostic factors influencing survival. Results: The median follow-upmore » from SRS in this patient population was 9 months (1-49 months). The median overall survival (OS) was 9 months after SRS. Karnofsky performance status (KPS) and combined treatment involving WBRT and SRS within 4 weeks were the two factors identified as being significant predictors of increased OS (p = 0.033 and 0.040, respectively). When comparing all patients, patients treated with a combined approach had a median OS of 14 months compared to 6 months if SRS was delivered alone. We also compared the OS times from the first definitive radiation: WBRT, WBRT and SRS if combined therapy was used, and SRS if the patient never received WBRT. The median survival for those groups was 12, 14, and 13 months, respectively, p = 0.19. Seventy percent of patients had follow-up magnetic resonance imaging available for review. Actuarial local control at 6 months and 12 months was 90% and 86%, respectively. Only 1 patient (2.2%) had symptomatic intracranial swelling related to treatment, which responded to a short course of steroids. New brain metastases outside of the treated area developed in 61% of patients at a median time of 7 months; 81% of these patients had received previous WBRT. Conclusions: Stereotactic radiosurgery for small-cell lung carcinoma brain metastases provided safe and effective local tumor control in the majority of patients.« less

Designating wilderness areas: A framework for examining lessons from the States

Treesearch

Gary Bryner

2007-01-01

Although wilderness designations require congressional action, state-level political decisions usually determine whether and when Congress formally acts to designate new wilderness areas. In some cases, such as in Alaska, the issue of wilderness protection becomes nationalized and a wide range of interests beyond the borders of the state shape the eventual policy. But...

75 FR 10186 - Beauveria bassiana HF23; Amendment of Exemption from the Requirement of a Tolerance

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-05

... commodities when used to treat chicken and livestock facilities, from which manure will eventually be... for chicken manure treatment in the Federal Register on January 10, 2007 (72 FR 1177) (FRL-8108-4... used to treat chicken manure (72FR 1177, January 10, 2007). The toxicological profile of this active...

Incorporation of National Universities in Korea: Dynamic Forces, Key Features, and Challenges

ERIC Educational Resources Information Center

Rhee, Byung-Shik

2007-01-01

Education reform has become more popular than ever, and the incorporation of public institutions of higher education is one such reform. Eventually, Korea will see its national universities being incorporated. The legislature passed a law on March 7, 2007 that requires a new national university to be established as a National University…

Managing uncertainty in climate-driven ecological models to inform adaptation to climate change

Treesearch

Jeremy S. Littell; Donald McKenzie; Becky K. Kerns; Samuel Cushman; Charles G. Shaw

2011-01-01

The impacts of climate change on forest ecosystems are likely to require changes in forest planning and natural resource management. Changes in tree growth, disturbance extent and intensity, and eventually species distributions are expected. In natural resource management and planning, ecosystem models are typically used to provide a "best estimate" about how...

Breaking through the Bar

ERIC Educational Resources Information Center

Gray, Katti

2011-01-01

Howard University School of Law had a problem, and school officials knew it. Over a 20-year period, 40 percent of its graduates who took the Maryland bar exam failed it on their first try. During the next 24 months--the time frame required to determine its "eventual pass rate"--almost 90 percent of the students did pass. What they did…

78 FR 63463 - Intent To Prepare a Regional Environmental Impact Statement for Surface Coal and Lignite Mining...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-10-24

... Environmental Impact Statement for Surface Coal and Lignite Mining in the State of Texas AGENCY: Department of..., indirect, and cumulative effects associated with a decision to develop and assess data and information with... responsibility. These coal and lignite mining activities may eventually require authorization from the USACE...

The use of antigravity suits in the treatment of idiopathic orthostatic hypotension

NASA Technical Reports Server (NTRS)

Landmark, K.; Kravik, S.

1980-01-01

Idiopathic orthostatic hypotension is an uncommon disease characterized by a drop in blood pressure when going from a recumbent to a standing position. Treatment by medication generally produces poor results. Three patients at the Royal Hospital in Oslo were treated with antigravity suits and all were able to maintain adequate blood pressures in the standing position. One patient improved dramatically and was able to take short walks while wearing the suit. The two other patients, however, felt that wearing the suits eventually became uncomfortable. This treatment represents a useful treatment alternative for intractable cases.

Ketoconazole hepatotoxicity in a patient treated for environmental illness and systemic candidiasis

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

Brusko, C.S.; Marten, J.T.

1991-12-01

Environmental illness, a hypothesized disease caused by exposure to substances such as combustion products, pesticides, food additives, and Candida albicans, is discussed. The case of a patient with environmental illness and systemic candidiasis for six weeks with ketoconazole, liver enzyme concentrations increased. One month after discontinuation of ketoconazole, the liver enzyme concentrations decreased; however, over the next five months, liver enzymes and bilirubin increased. The patient developed encephalopathy and eventually was transferred to a medical center for possible liver transplant. A review of the literature pertaining to ketoconazole hepatotoxicity is also presented.16 references.

Adeno-Associated Virus Vectors and Stem Cells: Friends or Foes?

PubMed

Brown, Nolan; Song, Liujiang; Kollu, Nageswara R; Hirsch, Matthew L

2017-06-01

The infusion of healthy stem cells into a patient-termed "stem-cell therapy"-has shown great promise for the treatment of genetic and non-genetic diseases, including mucopolysaccharidosis type 1, Parkinson's disease, multiple sclerosis, numerous immunodeficiency disorders, and aplastic anemia. Stem cells for cell therapy can be collected from the patient (autologous) or collected from another "healthy" individual (allogeneic). The use of allogenic stem cells is accompanied with the potentially fatal risk that the transplanted donor T cells will reject the patient's cells-a process termed "graft-versus-host disease." Therefore, the use of autologous stem cells is preferred, at least from the immunological perspective. However, an obvious drawback is that inherently as "self," they contain the disease mutation. As such, autologous cells for use in cell therapies often require genetic "correction" (i.e., gene addition or editing) prior to cell infusion and therefore the requirement for some form of nucleic acid delivery, which sets the stage for the AAV controversy discussed herein. Despite being the most clinically applied gene delivery context to date, unlike other more concerning integrating and non-integrating vectors such as retroviruses and adenovirus, those based on adeno-associated virus (AAV) have not been employed in the clinic. Furthermore, published data regarding AAV vector transduction of stem cells are inconsistent in regards to vector transduction efficiency, while the pendulum swings far in the other direction with demonstrations of AAV vector-induced toxicity in undifferentiated cells. The variation present in the literature examining the transduction efficiency of AAV vectors in stem cells may be due to numerous factors, including inconsistencies in stem-cell collection, cell culture, vector preparation, and/or transduction conditions. This review summarizes the controversy surrounding AAV vector transduction of stem cells, hopefully setting the stage for future elucidation and eventual therapeutic applications.

Underwater colorectal EMR: remodeling endoscopic mucosal resection.

PubMed

Curcio, Gabriele; Granata, Antonino; Ligresti, Dario; Tarantino, Ilaria; Barresi, Luca; Liotta, Rosa; Traina, Mario

2015-05-01

Underwater EMR (UEMR) has been reported as a new technique for the removal of large sessile colorectal polyps without need for submucosal injection. To evaluate (1) outcomes of UEMR, (2) whether UEMR can be easily performed by an endoscopist skilled in traditional EMR without specific dedicated training in UEMR, and (3) whether EUS is required before UEMR. Prospective, observational study. Single, tertiary-care referral center. Underwater EMR. Complete resection and adverse events. A total of 72 consecutive patients underwent UEMR of 81 sessile colorectal polyps. EUS was performed before UEMR in 9 cases (11.1%) with a suspicious mucosal/vascular pattern. The mean polyp size was 18.7 mm (range 10-50 mm); the mean UEMR time was 11.8 minutes. Fifty-five polyps (68%) were removed en bloc, and 26 (32%) were removed with a piecemeal technique. Histopathology consisted of tubular adenomas (25.9%), tubulovillous adenomas (5%), adenomas with high-grade dysplasia (42%), serrated polyps (4.9%), carcinoma in situ (13.6%), and hyperplastic polyps (8.6%). Surveillance colonoscopy was scheduled at 3 months. Complete resection was successful in all patients. No adverse events or recurrence was recorded in any of the patients. Limited follow-up; single-center, uncontrolled study. Interventional endoscopists skilled in conventional EMR performed UEMR without specific dedicated training. EUS may not be required for lesions with no invasive features on high-definition narrow-band imaging. UEMR appears to be an effective and safe alternative to traditional EMR and could eventually improve the way in which we can effectively and safely treat colorectal lesions. Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.

Efficacy of immediate replacement of cranial bone graft following drainage of intracranial empyema.

PubMed

Lajthia, Orgest; Chao, Jerry W; Mandelbaum, Max; Myseros, John S; Oluigbo, Chima; Magge, Suresh N; Zarella, Christopher S; Oh, Albert K; Rogers, Gary F; Keating, Robert F

2018-06-22

OBJECTIVE Intracranial empyema is a life-threatening condition associated with a high mortality rate and residual deleterious neurological effects if not diagnosed and managed promptly. The authors present their institutional experience with immediate reimplantation of the craniotomy flap and clarify the success of this method in terms of cranial integrity, risk of recurrent infection, and need for secondary procedures. METHODS A retrospective analysis of patients admitted for management of intracranial empyema during a 19-year period (1997-2016) identified 33 patients who underwent emergency drainage and decompression with a follow-up duration longer than 6 months, 23 of whom received immediate bone replacement. Medical records were analyzed for demographic information, extent and location of the infection, bone flap size, fixation method, need for further operative intervention, and duration of intravenous antibiotics. RESULTS The mean patient age at surgery was 8.7 ± 5.7 years and the infections were largely secondary to sinusitis (52.8%), with the most common location being the frontal/temporal region (61.3%). Operative intervention involved removal of a total of 31 bone flaps with a mean surface area of 22.8 ± 26.9 cm 2 . Nearly all (96.8%) of the bone flaps replaced at the time of the initial surgery were viable over the long term. Eighteen patients (78.3%) required a single craniotomy in conjunction with antibiotic therapy to address the infection, whereas the remaining 21.7% required more than 1 surgery. Partial bone flap resorption was noted in only 1 (3.2%) of the 31 successfully replaced bone flaps. This patient eventually had his bone flap removed and received a split-calvaria bone graft. Twenty-one patients (91.3%) received postoperative CT scans to evaluate bone integrity. The mean follow-up duration of the cohort was 43.9 ± 54.0 months. CONCLUSIONS The results of our investigation suggest that immediate replacement and stabilization of the bone flap after craniectomy for drainage of intracranial empyemas has a low risk of recurrent infection and is a safe and effective way to restore bone integrity in most patients.

Conceptual Design of a Communications Relay Satellite for a Lunar Sample Return Mission

NASA Technical Reports Server (NTRS)

Brunner, Christopher W.

2005-01-01

In 2003, NASA solicited proposals for a robotic exploration of the lunar surface. Submissions were requested for a lunar sample return mission from the South Pole-Aitken Basin. The basin is of interest because it is thought to contain some of the oldest accessible rocks on the lunar surface. A mission is under study that will land a spacecraft in the basin, collect a sample of rock fragments, and return the sample to Earth. Because the Aitken Basin is on the far side of the Moon, the lander will require a communications relay satellite (CRS) to maintain contact with the Earth during its surface operation. Design of the CRS's orbit is therefore critical. This paper describes a mission design which includes potential transfer and mission orbits, required changes in velocity, orbital parameters, and mission dates. Several different low lunar polar orbits are examined to compare their availability to the lander versus the distance over which they must communicate. In addition, polar orbits are compared to a halo orbit about the Earth-Moon L2 point, which would permit continuous communication at a cost of increased fuel requirements and longer transmission distances. This thesis also examines some general parameters of the spacecraft systems for the mission under study. Mission requirements for the lander dictate the eventual choice of mission orbit. This mission could be the first step in a period of renewed lunar exploration and eventual human landings.

Clinical Skills Assessment: The Effects of Moving Certification Requirements Into Neurology, Child Neurology, and Psychiatry Residency Training

PubMed Central

Juul, Dorthea; Brooks, Beth Ann; Jozefowicz, Ralph; Jibson, Michael; Faulkner, Larry

2015-01-01

Background A few years ago, when the American Board of Psychiatry and Neurology decided to phase out the patient-based oral examinations in its 3 primary specialties, requirements for assessing clinical skills during residency training were instituted. Objective The purpose of this report is to describe the experiences of training program directors and graduates with these new credentialing requirements (labeled CSEs) as well as other effects on the specialties. Methods Surveys were administered electronically in 2012 to all current neurology, child neurology, and psychiatry program directors, and to a convenience sample of graduates who applied for the 2012 certification examinations. Results Response rates for graduates were similar across the 3 specialties but low (28%–33%). Response rates were higher for program directors (53%–62%) and were similar across the 3 specialties. The results indicated that the CSEs were usually administered early in training, were completed toward the end, were often passed on first attempt, generally took place during routine clinical assignments, were used to assess additional competencies, almost always included feedback to the residents, and did not often lead to remediation. Furthermore, the CSEs were perceived to be useful components in the assessment of clinical skills. Conclusions The results obtained from the early implementation of the CSEs suggest that they provide an opportunity to assess clinical skills with the additional benefit of feedback to trainees. Other effects included eventual incorporation into training program requirements, milestones, and related faculty development and research efforts. PMID:26217432

Clinical Skills Assessment: The Effects of Moving Certification Requirements Into Neurology, Child Neurology, and Psychiatry Residency Training.

PubMed

Juul, Dorthea; Brooks, Beth Ann; Jozefowicz, Ralph; Jibson, Michael; Faulkner, Larry

2015-03-01

A few years ago, when the American Board of Psychiatry and Neurology decided to phase out the patient-based oral examinations in its 3 primary specialties, requirements for assessing clinical skills during residency training were instituted. The purpose of this report is to describe the experiences of training program directors and graduates with these new credentialing requirements (labeled CSEs) as well as other effects on the specialties. Surveys were administered electronically in 2012 to all current neurology, child neurology, and psychiatry program directors, and to a convenience sample of graduates who applied for the 2012 certification examinations. Response rates for graduates were similar across the 3 specialties but low (28%-33%). Response rates were higher for program directors (53%-62%) and were similar across the 3 specialties. The results indicated that the CSEs were usually administered early in training, were completed toward the end, were often passed on first attempt, generally took place during routine clinical assignments, were used to assess additional competencies, almost always included feedback to the residents, and did not often lead to remediation. Furthermore, the CSEs were perceived to be useful components in the assessment of clinical skills. The results obtained from the early implementation of the CSEs suggest that they provide an opportunity to assess clinical skills with the additional benefit of feedback to trainees. Other effects included eventual incorporation into training program requirements, milestones, and related faculty development and research efforts.

Tissue Engineering Strategies for Myocardial Regeneration: Acellular Versus Cellular Scaffolds?

PubMed

Domenech, Maribella; Polo-Corrales, Lilliana; Ramirez-Vick, Jaime E; Freytes, Donald O

2016-12-01

Heart disease remains one of the leading causes of death in industrialized nations with myocardial infarction (MI) contributing to at least one fifth of the reported deaths. The hypoxic environment eventually leads to cellular death and scar tissue formation. The scar tissue that forms is not mechanically functional and often leads to myocardial remodeling and eventual heart failure. Tissue engineering and regenerative medicine principles provide an alternative approach to restoring myocardial function by designing constructs that will restore the mechanical function of the heart. In this review, we will describe the cellular events that take place after an MI and describe current treatments. We will also describe how biomaterials, alone or in combination with a cellular component, have been used to engineer suitable myocardium replacement constructs and how new advanced culture systems will be required to achieve clinical success.

Toward a virtual platform for materials processing

NASA Astrophysics Data System (ADS)

Schmitz, G. J.; Prahl, U.

2009-05-01

Any production is based on materials eventually becoming components of a final product. Material properties being determined by the microstructure of the material thus are of utmost importance both for productivity and reliability of processing during production and for application and reliability of the product components. A sound prediction of materials properties therefore is highly important. Such a prediction requires tracking of microstructure and properties evolution along the entire component life cycle starting from a homogeneous, isotropic and stress-free melt and eventually ending in failure under operational load. This article will outline ongoing activities at the RWTH Aachen University aiming at establishing a virtual platform for materials processing comprising a virtual, integrative numerical description of processes and of the microstructure evolution along the entire production chain and even extending further toward microstructure and properties evolution under operational conditions.

Discontinuation of penicillamine in the absence of alternative orphan drugs (trientine-zinc): a case of decompensated liver cirrhosis in Wilson's disease.

PubMed

Ping, C C; Hassan, Y; Aziz, N A; Ghazali, R; Awaisu, A

2007-02-01

To report a case of early-decompensated liver cirrhosis secondary to discontinuation of penicillamine therapy in a patient with Wilson's disease. A 33-year-old Chinese female patient was diagnosed with Wilson's disease, for which penicillamine 250 mg p.o. once daily was prescribed. However, the patient developed intolerance and penicillamine was discontinued without alternative treatment. Five months later, she developed decompensated liver cirrhosis with hepatic encephalopathy. Eventually, the patient died because of the complications of sepsis and decompensated liver failure. Chelating agent is the mainstay of treatment in Wilson's disease, which is an inherited disorder of hepatic copper metabolism. Therapy must be instituted and continued for life once diagnosis is confirmed. Interruption of therapy can be fatal or cause irreversible relapse. Penicillamine given orally is the chelating agent of first choice. However, its unfavourable side-effects profile leads to discontinuation of therapy in 20-30% of patients. In most case reports, cessation of penicillamine without replacement treatment causes rapid progression to fulminant hepatitis, which is fatal unless liver transplantation is performed. In this, we highlight a case of discontinuation of penicillamine in a patient with Wilson's disease without substitution with alternative regimen. This was caused by unavailability of the alternative agents such as trientine in our country. Consequently, the patient progressed to decompensated liver cirrhosis with encephalopathy and eventually passed-away within 5 months. One recent study supports a combination of trientine and zinc in treating patient with decompensated liver cirrhosis. This combination is capable of reversing liver failure and prevents the need of liver transplantation. Both trientine and zinc are not registered in Malaysia. Therefore, liver transplantation was probably the only treatment option for this patient. Hence, non-availability of orphan drugs in clinical practice is certainly a subject of serious concern. Systems for better management of patients with rare diseases need to be instituted by all the institutions concerned.

Long-lasting response to oral therapy in a young male with monogenic diabetes as part of HNF1B-related disease.

PubMed

Carrillo, Elena; Lomas, Amparo; Pinés, Pedro J; Lamas, Cristina

2017-01-01

Mutations in hepatocyte nuclear factor 1β gene ( HNF1B ) are responsible for a multisystemic syndrome where monogenic diabetes (classically known as MODY 5) and renal anomalies, mostly cysts, are the most characteristic findings. Urogenital malformations, altered liver function tests, hypomagnesemia or hyperuricemia and gout are also part of the syndrome. Diabetes in these patients usually requires early insulinization. We present the case of a young non-obese male patient with a personal history of renal multicystic dysplasia and a debut of diabetes during adolescence with simple hyperglycemia, negative pancreatic autoimmunity and detectable C-peptide levels. He also presented epididymal and seminal vesicle cysts, hypertransaminasemia, hyperuricemia and low magnesium levels. In the light of these facts we considered the possibility of a HNF1B mutation. The sequencing study of this gene confirmed a heterozygous mutation leading to a truncated and less functional protein. Genetic studies of his relatives were negative; consequently, it was classified as a de novo mutation. In particular, our patient maintained good control of his diabetes on oral antidiabetic agents for a long period of time. He eventually needed insulinization although oral therapy was continued alongside, allowing reduction of prandial insulin requirements. The real prevalence of mutations in HNF1B is probably underestimated owing to a wide phenotypical variability. As endocrinologists, we should consider this possibility in young non-obese diabetic patients with a history of chronic non-diabetic nephropathy, especially in the presence of some of the other characteristic manifestations. HNF1B mutations are a rare cause of monogenic diabetes, often being a part of a multisystemic syndrome.The combination of young-onset diabetes and genitourinary anomalies with slowly progressive nephropathy of non-diabetic origin in non-obese subjects should rise the suspicion of such occurrence. A family history may not be present.Once diagnosis is made, treatment of diabetes with oral agents is worth trying, since the response can be sustained for a longer period than the one usually described. Oral treatment can help postpone insulinization and, once this is necessary, can help reduce the required doses.

Molecular diagnostics of inflammatory disease: New tools and perspectives.

PubMed

Garzorz-Stark, Natalie; Lauffer, Felix

2017-08-01

This essay reviews current approaches to establish novel molecular diagnostic tools for inflammatory skin diseases. Moreover, it highlights the importance of stratifying patients according to molecular signatures and revising current outdated disease classification systems to eventually reach the goal of personalized medicine. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Prediction of treatment refractoriness in ulcerative colitis and Crohn's disease--do we have reliable markers?

PubMed

Gelbmann, C M

2000-05-01

Treatment refractoriness is a severe problem in the management of patients with ulcerative colitis and Crohn's disease. Despite some promising new therapeutic approaches, corticosteroids are still the preferential primary treatment for moderate to severe Crohn's disease and of severe ulcerative colitis. However, clinical response to corticosteroids varies, and many patients are resistant to such treatment. Since corticosteroids have frequent and even severe side effects, and toxicity increases with chronic steroid intake, factors predictive of response to such treatment would be very helpful for decisions on further management of these patients. At least in severe attacks of ulcerative colitis, the consensus seems to be that a high frequency of bowel movements as well as a high C-reactive protein and low serum albumin recorded after a few days of intensive medical treatment are important signs for early prediction of treatment failure in the majority of the patients. In Crohn's disease thus far, data on predictive factors are conflicting. No reliable marker with sufficient predictive value for treatment refractoriness could be identified. This might be due to the tremendous heterogeneity of Crohn's disease with many clinical phenotypes, which requires subgroup analysis with sufficient numbers of patients. Corticosteroids as well as other immunomodulating and immunosuppressive medications interfere with the immune system, which plays a central role in the mediation of intestinal inflammation. Treatment refractoriness might have its origin in specific immunological peculiarities eventually reflected in abnormal immunological, biochemical, and clinical parameters. Further exploration of those parameters to predict treatment refractoriness in patients with ulcerative colitis or Crohn's disease is of great clinical importance for safe and efficient management of patients.

Proteomics as a Guide for Personalized Adjuvant Chemotherapy in Patients with Early Breast Cancer.

PubMed

Lumachi, Franco; Chiara, Giordano B; Foltran, Luisa; Basso, Stefano M M

2015-01-01

Proteomics allows for better understanding of the function and regulation of cancer cells mediated by intra- and extracellular signaling networks. Integrating such information with clinicopathological characteristics of the tumor may lead to either detection of disease biomarkers useful to differentiate high-from low-risk patients, or to identification of new drug targets. Adjuvant chemotherapy is currently a personalized treatment strategy, especially for breast cancer (BC) patients, and the risk assessment of each patient influences its use because the benefit strictly correlates with the level of risk. Luminal A BCs are endocrine therapy (ET)-sensitive but exhibit low sensitivity to chemotherapy, while luminal B cancers, according to the Ki-67 proliferation rate may require for chemotherapy in addition to ET, and HER2-positive tumors derive benefit from adjuvant chemotherapy containing an anthracycline, a taxane and trastuzumab for one year. Triple-negative BCs have a high degree of genomic instability exhibiting a more aggressive clinical course with respect to other types of BC, and the anthracycline-taxane regimen constitutes the standard approach. Studies considering the use of targeted approaches (drugs), including poly (ADP-ribose) polymerase (PARP-1), vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR) inhibitors, or EFGR and HER2 blockers, are still under evaluation. In the genomic era, promising new targeted-therapies are worthy of further investigation, and mTOR inhibitors have been used for patients with high-risk ER-positive and HER2-negative tumors. In the near future, genetic and molecular profiling of BC will help to better-categorize patients, determine the choice of chemotherapy in low-risk, or intensify the treatment in high-risk cancer patients, eventually revealing new targeted agents. Copyright© 2015, International Institute of Anticancer Research (Dr. John G. Delinasios), All rights reserved.

Endoscopic lung volume reduction coil treatment in patients with chronic hypercapnic respiratory failure: an observational study.

PubMed

Simon, Marcel; Harbaum, Lars; Oqueka, Tim; Kluge, Stefan; Klose, Hans

2017-01-01

Endoscopic lung volume reduction coil (LVRC) treatment is an option for selected patients with severe emphysema. In the advanced stages, emphysema leads to respiratory failure: hypoxemia and eventually chronic hypercapnic respiratory failure. It can be hypothesized that LVRC treatment, a procedure targeting hyperinflation and thereby reducing ventilatory workload, may be especially beneficial in patients with chronic hypercapnic respiratory failure. This study was conducted to gain first insights into the effects and the safety of LVRC treatment in patients with emphysema and chronic hypercapnic respiratory failure. A retrospective observational study conducted in the Department of Respiratory Medicine at the University Medical Center Hamburg-Eppendorf, Germany on all patients with chronic hypercapnic respiratory failure in whom bilateral LVRC treatment was performed between 1 April 2012 and 30 September 2015. During the study period, bilateral LVRC treatment was performed in 10 patients with chronic hypercapnic respiratory failure. Compared with baseline, bilateral LVRC treatment led to a significant increase in mean forced expiratory volume in one second (FEV 1 ) from 0.5 ± 0.1 l to 0.6 ± 0.2 l ( p = 0.004), a decrease in residual volume (RV) from 6.1 ± 0.9 l to 5.6 ± 1.1 l ( p = 0.02) and a reduction in partial pressure of carbon dioxide in arterial blood (PaCO 2 ) from 53 ± 5 mmHg to 48 ± 4 mmHg ( p = 0.03). One case of hemoptysis requiring readmission to hospital was the only severe adverse event. LVRC treatment was safe and effective in patients with nonsevere chronic hypercapnic respiratory failure. It led not only to an improvement in lung function but also to a significant decrease in PaCO 2 .

The evolving role of the total artificial heart in the management of end-stage congenital heart disease and adolescents.

PubMed

Ryan, Thomas D; Jefferies, John L; Zafar, Farhan; Lorts, Angela; Morales, David L S

2015-01-01

Advances in medical therapies have yielded improvement in morbidity and a decrease in mortality for patients with congenital heart disease, both surgically palliated and uncorrected. An unintended consequence is a cohort of adolescent and adult patients with heart failure who require alternative therapies. One intriguing option is placement of a total artificial heart (TAH) either as a bridge to transplant or as a destination therapy. Of the 1091 Jarvik-7 type TAH (Symbion, CardioWest and SynCardia) placed between 1985 and 2012, only 24 have been performed in patients with congenital heart disease, and a total of 51 were placed in patients younger than 21. At our institution, the SynCardia TAH was implanted in a 19-year-old patient with cardiac allograft failure because of chronic rejection and related multisystem organ failure including need for hemodialysis. Over the next year, she was nutritionally and physically rehabilitated, as were her end organs, allowing her to come off dialysis, achieve normal renal function and eventually be successfully transplanted. Given the continued growth of adolescent and adult congenital heart disease populations with end-stage heart failure, the TAH may offer therapeutic options where previously there were few. In addition, smaller devices such as the SynCardia 50/50 will open the door for applications in smaller children. The Freedom Driver offers the chance for patients to leave the hospital with a TAH, as does the AbioCor, which is a fully implantable TAH option. In this report, we review the history of the TAH and potential applications in adolescent patients and congenital heart disease.

Clinical trials with velnacrine: (PROPP) the physician reference of predicted probabilities--a statistical model for the estimation of hepatotoxicity risk with velnacrine maleate.

PubMed

Hardiman, S; Miller, K; Murphy, M

1993-01-01

Safety observations during the clinical development of Mentane (velnacrine maleate) have included the occurrence of generally asymptomatic liver enzyme elevations confined to patients with Alzheimer's disease (AD). The clinical presentation of this reversible hepatocellular injury is analogous to that reported for tetrahydroaminoacridine (THA). Direct liver injury, possibly associated with the production of a toxic metabolite, would be consistent with reports of aberrant xenobiotic metabolism in Alzheimer's disease patients. Since a patient related aberration in drug metabolism was suspected, a biostatistical strategy was developed with the objective of predicting hepatotoxicity in individual patients prior to exposure to velnacrine maleate. The method used logistic regression techniques with variable selection restricted to those items which could be routinely and inexpensively accessed at screen evaluation for potential candidates for treatment. The model was to be predictive (a marker for eventual hepatotoxicity) rather than a causative model, and techniques employed "goodness of fit", percentage correct, and positive and negative predictive values. On the basis of demographic and baseline laboratory data from 942 patients, the PROPP statistic was developed (the Physician Reference Of Predicted Probabilities). Main effect variables included age, gender, and nine hematological and serum chemistry variables. The sensitivity of the current model is approximately 49%, specificity approximately 88%. Using prior probability estimates, however, in which the patient's likelihood of liver toxicity is presumed to be at least 30%, the positive predictive value ranged between 64-77%. Although the clinical utility of this statistic will require refinements and additional prospective confirmation, its potential existence speaks to the possibility of markers for idiosyncratic drug metabolism in patients with Alzheimer's disease.

Serum decoy receptor 3 is a useful predictor for the active status of chronic hepatitis B in hepatitis B e antigen-negative patients.

PubMed

Hou, Yanqiang; Xu, Ping; Lou, Xiaoli; Liang, Dongyu; Zhang, Mei; Zhang, Zhenhuan; Zhang, Lurong

2013-08-01

Hepatitis B virus (HBV) infection is a global public health problem, because patients with chronic hepatitis B (CHB) may progress to liver cirrhosis and eventually evolve into hepatocellular carcinoma. Decoy receptor 3 (DcR3) is a soluble receptor of the tumor necrosis factor receptor superfamily, and has been implicated in anti-apoptotic and anti-inflammatory pathways. In this study, we explored the clinical value of serum DcR3 in predicting the active status of CHB in hepatitis B e antigen-negative patients (active HBeAg (-) CHB), which was determined with ELISA. The serum level of DcR3 in active HBeAg (-) CHB patients (1.92 ± 0.68 ng/ml) was higher than that in healthy controls (0.80 ± 0.25 ng/ml, p < 0.0001) and that in inactive status of HBeAg (-) CHB (inactive hepatitis B surface antigen carrier, HBsAg-IaC) patients (0.95 ± 0.26 ng/ml, p < 0.0001). DcR3 level was correlated with HBV DNA level (r = 0.819, p < 0.0001) and alanine transaminase level (ALT, r = 0.704, p < 0.0001) in active HBeAg (-) CHB patients. The area under the Receiver Operating Characteristics curve of DcR3 for detecting the active status of HBeAg (-) CHB patients was 0.914 (95% confidence interval, 0.851-0.977). The optimal cut-off value for DcR3 to predict active HBeAg (-) CHB was 1.22 ng/ml, which had a sensitivity of 87.5% and a specificity of 84.4%. These results suggest that serum DcR3 level may be useful for detecting HBeAg (-) CHB in the active stage, which requires medical treatment.

Prognostic significance of ventricular late potentials in patients with pulmonary sarcoidosis.

PubMed

Yodogawa, Kenji; Seino, Yoshihiko; Ohara, Toshihiko; Iwasaki, Yu-Ki; Hayashi, Meiso; Miyauchi, Yasushi; Azuma, Arata; Shimizu, Wataru

2018-06-01

Early detection of cardiac involvement in sarcoidosis is difficult but essential to achieve optimal treatment. Signal-averaged electrocardiography (SAECG) can detect subtle cardiac electrical abnormalities termed late potentials (LPs) and would be useful for the early diagnosis of cardiac involvement. This study aims to investigate the prognostic significance of LP in patients with pulmonary sarcoidosis. We prospectively studied 74 patients with pulmonary sarcoidosis without overt electrocardiographic abnormalities. All participants underwent SAECG, cardiac echocardiography, and 24-hour ambulatory Holter monitoring. Serum angiotensin-converting enzyme and B-type natriuretic peptide levels were also evaluated. We followed these patients for the evaluation of incidence of cardiac events including cardiac death, arrhythmias, and heart failure requiring hospital admission. Of the studied population, 29 patients (39.2%) had detectable LP. During a mean follow-up period of 9.8 years, 8 patients with LPs had cardiovascular events, including development of complete atrioventricular block (n = 4), ventricular tachycardia (n = 2), and heart failure (n = 2). Meanwhile, only 1 of 45 patients without LP developed cardiac event (heart failure). Multivariate analyses revealed that LPs were associated with an increased risk of developing cardiac events (hazard ratio 9.66; 95% confidence interval 1.20-78.01; P = .033) whereas age, sex, serum angiotensin-converting enzyme and B-type natriuretic peptide levels, number of premature ventricular contractions on 24-hour Holter monitoring, and echocardiographic parameters were not associated with subsequent cardiac events. SAECG might possibly be useful for the early detection of cardiac sarcoidosis and, if independently validated, could eventually be considered as a screening test for further risk stratification. Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Acute virus control mediated by licensed NK cells sets primary CD8+ T cell dependence on CD27 costimulation1,2,3

PubMed Central

Teoh, Jeffrey J.; Gamache, Awndre E.; Gillespie, Alyssa L.; Stadnisky, Michael D.; Yagita, Hideo; Bullock, Timothy N.J.; Brown, Michael G.

2016-01-01

Natural killer (NK) cells represent a critical first-line of immune defense against a bevy of viral pathogens, and infection can provoke them to mediate both supportive and suppressive effects on virus-specific adaptive immunity. In mice expressing MHC I Dk, a major MCMV resistance factor and self-ligand of the inhibitory Ly49G2 (G2) receptor, licensed G2+ NK cells provide essential host resistance against murine (M)CMV infection. Additionally G2+ NK cell responses to MCMV increase the rate and extent of dendritic cell (DC) recovery, as well as early priming of CD8+ T-cell effectors in response to MCMV. However, relatively little is known about the NK-cell effect on co-stimulatory ligand patterns displayed by DCs, or ensuing effector and memory T-cell responses. Here we found that CD27-dependent CD8+ T-cell priming and differentiation is shaped by the efficiency of NK responses to virus infection. Surprisingly, differences in specific NK responses to MCMV in Dk-disparate mice failed to distinguish early DC co-stimulatory patterns. Nonetheless, while CD27 deficiency did not impede licensed NK-mediated resistance, both CD70 and CD27 were required to efficiently prime and regulate effector CD8+ T-cell differentiation in response to MCMV, which eventually resulted in biased memory T-cell precursor formation in Dk mice. In contrast, CD8+ T-cells accrued more slowly in non-Dk mice, and eventually differentiated into terminal effector cells regardless of CD27 stimulation. Disparity in this requirement for CD27 signaling indicates that specific virus control mediated by NK cells can shape DC co-stimulatory signals needed to prime CD8+ T cells and eventual T-cell fate decisions. PMID:27798162

Future Perspectives for Management of Stage A Heart Failure.

PubMed

Tanaka, Hidekazu

2018-05-07

Patients with Stage A heart failure (HF) show no HF symptoms but have related comorbid diseases with a high risk of progressing to HF. Screening for comorbid diseases warrants closer attention because of the growing interest in addressing Stage A HF as the best means of preventing eventual progression to overt HF such as Stages C and D. The identification of individuals of Stage A HF is potentially useful for the implementation of HF-prevention strategies; however, not all Stage A HF patients develop left ventricular (LV) structural heart disease or symptomatic HF, which lead to advanced HF stages. Therefore, Stage A HF requires management with the long-term goal of avoiding HF development; likewise, Stage B HF patients are ideal targets for HF prevention. Although the early detection of subclinical LV dysfunction is, thus, essential for delaying the progression to HF, the assessment of subclinical LV dysfunction can be challenging. Global longitudinal strain (GLS) as assessed by speckle-tracking echocardiography has recently been reported to be a sensitive marker of early subtle LV myocardial abnormalities, helpful for the prediction of the outcomes for various cardiac diseases, and superior to conventional echocardiographic indices. GLS reflects LV longitudinal myocardial systolic function, and can be assessed usually by means of two-dimensional speckle-tracking. This article reviews the importance of the assessment of subclinical LV dysfunction in Stage A HF patients by means of GLS, and its current potential to prevent progression to later stage HF.

Proactive enteral tube feeding in pediatric patients undergoing chemotherapy.

PubMed

Sacks, Nancy; Hwang, Wei-Ting; Lange, Beverly J; Tan, Kay-See; Sandler, Eric S; Rogers, Paul C; Womer, Richard B; Pietsch, John B; Rheingold, Susan R

2014-02-01

To determine feasibility and safety of proactive enteral tube feeding (ETF) in pediatric oncology patients. Pediatric patients with newly diagnosed brain tumors, myeloid leukemia or high-risk solid tumors were eligible. Subjects agreeing to start ETF before cycle 2 chemotherapy were considered proactive participants (PPs). Those who declined could enroll as chart collection receiving nutritional standard of care. Nutritional status was assessed using standard anthropometric measurements. Episodes of infection and toxicity related to ETF were documented from diagnosis to end of therapy. A descriptive comparison between PPs and controls was conducted. One hundred four eligible patients were identified; 69 enrolled (20 PPs and 49 controls). At diagnosis, 17% of all subjects were underweight and 26% overweight. Barriers to enrollment included physician, subject and/or family refusal, and inability to initiate ETF prior to cycle 2 of chemotherapy. Toxicity of ETF was minimal, but higher percentage of subjects in the proactive group had episodes of infection than controls. Thirty-nine percent of controls eventually started ETF and were twice as likely to receive parenteral nutrition. PPs experienced less weight loss at ETF initiation than controls receiving ETF and were the only group to demonstrate improved nutritional status at end of study. Proactive ETF is feasible in children with cancer and results in improved nutritional status at end of therapy. Episodes of infection in this study are concerning; therefore, a larger randomized trial is required to further delineate infectious risks and toxicities that may be mitigated by improved nutritional status. © 2013 Wiley Periodicals, Inc.

New therapeutic horizons: mapping the future of glycemic control with incretin-based therapy.

PubMed

Campbell, R Keith; Miller, Sara

2009-01-01

More than 24 million adults and children in the United States are living with diabetes, and the vast majority of those individuals have type 2 diabetes. The clinical benefits of good glycemic control have been well established. Most patients eventually require the use of multiple hyperglycemic drugs in combination to approach or achieve the American Diabetes Association's recommended target A1C value of 7%. The role of incretin-based therapies for both glycemic control and beta-cell protection has become an area of intense interest and development. Although current practice guidelines do not include specific recommendations about when and how to incorporate incretin-based agents, a consensus statement published by the American Diabetes Association/European Association for the Study of Diabetes suggests the addition of a glucagon-like peptide-1 (GLP-1) agonist for patients not at goal A1C with metformin and lifestyle changes. The goal of this article is to review this class of agents, discuss their role in the treatment of type 2 diabetes, and address the practical aspects of integrating incretin-based agents into the management of patients with diabetes. Currently, 3 incretin-based therapies are available and widely used in clinical practice. Several more agents are either under review by the Food and Drug Administration (FDA) or are in the very late stages of development. For diabetes educators trying to help their patients understand the differences among their antidiabetic medications, a comprehensive understanding of these agents and their role in therapy is imperative.

Risk Factors for Erosion of Artificial Urinary Sphincters: A Multicenter Prospective Study

PubMed Central

Brant, William O.; Erickson, Bradley A.; Elliott, Sean P.; Powell, Christopher; Alsikafi, Nejd; McClung, Christopher; Myers, Jeremy B.; Voelzke, Bryan B.; Smith, Thomas G.; Broghammer, Joshua A.

2015-01-01

OBJECTIVE To evaluate the short- to medium-term outcomes after artificial urinary sphincter (AUS) placement from a large, multi-institutional, prospective, follow-up study. We hypothesize that along with radiation, patients with any history of a direct surgery to the urethra will have higher rates of eventual AUS explantation for erosion and/or infection. MATERIALS AND METHODS A prospective outcome analysis was performed on 386 patients treated with AUS placement from April 2009 to December 2012 at 8 institutions with at least 3 months of follow-up. Charts were analyzed for preoperative risk factors and postoperative complications requiring explantation. RESULTS Approximately 50% of patients were considered high risk. High risk was defined as patients having undergone radiation therapy, urethroplasty, multiple treatments for bladder neck contracture or urethral stricture, urethral stent placement, or a history of erosion or infection in a previous AUS. A total of 31 explantations (8.03%) were performed during the follow-up period. Overall explantation rates were higher in those with prior radiation and prior UroLume. Men with prior AUS infection or erosion also had a trend for higher rates of subsequent explantation. Men receiving 3.5-cm cuffs had significantly higher explantation rates than those receiving larger cuffs. CONCLUSION This outcomes study confirms that urethral risk factors, including radiation history, prior AUS erosion, and a history of urethral stent placement, increase the risk of AUS explantation in short-term follow-up. PMID:25109562

Meningitis due to Moraxella nonliquefaciens in a paediatric patient: a case report and review of the literature

PubMed Central

Szymczak, Wendy; Munjal, Iona

2017-01-01

Introduction. Moraxella nonliquefaciens is an unusual organism to be isolated from cerebral spinal fluid (CSF) and there exists only one case report of M. nonliquefaciens meningitis from a neonate. Moraxella species normally exist as part of the human upper respiratory tract flora and rarely cause invasive human disease. There are only a handful of case reports implicating the organism as a cause of endocarditis, bacteraemia, septic arthritis and endophthalmitis. Identification to the species level based on routine laboratory techniques has been challenging, with final identification often made through 16S rRNA sequencing. With the use of a newer diagnostic tool, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) MS, we were able to rapidly identify the organism and initiate appropriate treatment. Case presentation. We present a rare care of M. nonliquefaciens meningitis in a paediatric patient with an underlying cranial anatomical defect due to Crouzon syndrome. She had been admitted to hospital 3 months previously with Streptococcus pneumoniae meningitis and mastoiditis, and returned to the emergency department with meningismus. CSF culture grew M. nonliquefaciens. She was treated with ceftriaxone with rapid improvement and eventually was taken for endoscopic surgical repair of a right encephalocele defect. Conclusion. The use of MALDI-TOF MS allowed for the rapid identification of the organism. The patient recovered with appropriate antimicrobial therapy and eventual surgical correction. An underlying anatomical defect should be considered in all patients who present with meningitis due to this unusual organism. PMID:28348808

Re-engineering primary epithelial cells from rhesus monkey parotid glands for use in developing an artificial salivary gland.

PubMed

Tran, Simon D; Sugito, Takayuki; Dipasquale, Giovanni; Cotrim, Ana P; Bandyopadhyay, Bidhan C; Riddle, Kathryn; Mooney, David; Kok, Marc R; Chiorini, John A; Baum, Bruce J

2006-10-01

There is no satisfactory conventional treatment for patients who experience irreversible salivary gland damage after therapeutic radiation for head and neck cancer or because of Sjögren's syndrome. Additionally, if most parenchyma is lost, these patients also are not candidates for evolving gene transfer strategies. To help such patients, several years ago we began to develop an artificial salivary gland. In the present study, we used a non-human primate tissue source, parotid glands from rhesus monkeys, to obtain potential autologous graft cells for development of a prototype device for in situ testing. Herein, we present 3 major findings. First, we show that primary cultures of rhesus parotid gland (RPG) cells are capable of attaining a polarized orientation, with Na(+)/K(+)-adenosine triphosphatase, zonula occludens-1, and claudin-1 distributed in specific domains appropriate for epithelial cells. Second, we show that RPG cells exhibit 2 essential epithelial functions required for graft cells in an artificial salivary gland device (i.e., an effective barrier to paracellular water flow and the generation of a moderate transepithelial electrical resistance). Third, we show that RPG cells can express functional water channels, capable of mediating directional fluid movement, after transduction by adenoviral and adeno-associated virus type 2 vectors. Together these results demonstrate that it is feasible to individually prepare RPG cells for eventual use in a prototype artificial salivary gland.

A qualitative study on healthcare professionals' perceived barriers to insulin initiation in a multi-ethnic population.

PubMed

Lee, Yew Kong; Lee, Ping Yein; Ng, Chirk Jenn

2012-07-04

Nationwide surveys have shown that the prevalence of diabetes rates in Malaysia have almost doubled in the past ten years; yet diabetes control remains poor and insulin therapy is underutilized. This study aimed to explore healthcare professionals' views on barriers to starting insulin therapy in people with type 2 diabetes. Healthcare professionals consisting of general practitioners (n = 11), family medicine specialists (n = 10), medical officers (n = 8), government policy makers (n = 4), diabetes educators (n = 3) and endocrinologists (n = 2) were interviewed. A semi-structured topic guide was used to guide the interviews by trained facilitators. The interviews were transcribed verbatim and analysed using a thematic analysis approach. Insulin initiation was found to be affected by patient, healthcare professional and system factors. Patients' barriers include culture-specific barriers such as the religious purity of insulin, preferred use of complementary medication and perceived lethality of insulin therapy. Healthcare professionals' barriers include negative attitudes towards insulin therapy and the 'legacy effect' of old insulin guidelines; whilst system barriers highlight the lack of resources, language and communication challenges. Tackling the issue of insulin initiation should not only happen during clinical consultations. It requires health education to emphasise the progressive nature of diabetes and the eventuality of insulin therapy at early stage of the illness. Healthcare professionals should be trained how to initiate insulin and communicate effectively with patients from various cultural and religious backgrounds.

Laparoscopic esophagomyotomy for achalasia in children: A review

PubMed Central

Pandian, T Kumar; Naik, Nimesh D; Fahy, Aodhnait S; Arghami, Arman; Farley, David R; Ishitani, Michael B; Moir, Christopher R

2016-01-01

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care. PMID:26839646

Mentor-mentee Relationship: A Win-Win Contract In Graduate Medical Education.

PubMed

Toklu, Hale Z; Fuller, Jacklyn C

2017-12-05

Scholarly activities (i.e., the discovery of new knowledge; development of new technologies, methods, materials, or uses; integration of knowledge leading to new understanding) are intended to measure the quality and quantity of dissemination of knowledge. A successful mentorship program is necessary during residency to help residents achieve the six core competencies (patient care, medical knowledge, practice-based learning and improvement, systems-based practice, professionalism, interpersonal and communication skills) required by the Accreditation Council for Graduate Medical Education (ACGME). The role of the mentor in this process is pivotal in the advancement of the residents' knowledge about evidence-based medicine. With this process, while mentees become more self-regulated, exhibit confidence in their performance, and demonstrate more insight and aptitude in their jobs, mentors also achieve elevated higher self-esteem, enhanced leadership skills, and personal gratification. As such, we may conclude that mentoring is a two-sided relationship; i.e., a 'win-win' style of commitment between the mentor and mentee. Hence, both parties will eventually advance academically, as well as professionally.

Is hydroxyapatite a reliable fixation option in unicompartmental knee arthroplasty? A 5- to 13-year experience with the hydroxyapatite-coated unix prosthesis.

PubMed

Epinette, Jean-Alain; Manley, Michael T

2008-10-01

Hydroxyapatite-coated unicompartmental knee arthroplasty (UKA) is a debatable approach to unicompartmental knee arthritis because UKA isoften viewed as a short-term solution, at best, fora condition that will eventually require a total knee arthroplasty (TKA). Unicompartmental knee arthroplasty is a more technically demanding procedure than TKA, and appropriate patient selection, careful surgical technique, and correct choice of implant geometry are all critical components to its success. A fundamental issue surrounding UKA is whether hydroxyapatite-coated unicompartmental components can provide a long-term solution to unicondylar arthritis. We address this issue in the current study, which is based on a prospective series of 125 hydroxyapatite-coated Unix knee prostheses implanted consecutively between 1994 and 2002, with a 5-year minimum follow-up and a 13-year maximum follow-up. The results of our study indicate that uncemented hydroxyapatite-coated UKA can be successful in the long term.

The management of acute and chronic pancreatitis.

PubMed

Banks, Peter A; Conwell, Darwin L; Toskes, Phillip P

2010-02-01

Pancreatitis, which is most generally described as any inflammation of the pancreas, is a serious condition that manifests in either acute or chronic forms. Chronic pancreatitis results from irreversible scarring of the pancreas, resulting from prolonged inflammation. Six major etiologies for chronic pancreatitis have been identified: toxic/ metabolic, idiopathic, genetic, autoimmune, recurrent and severe acute pancreatitis, and obstruction. The most common symptom associated with chronic pancreatitis is pain localized to the upper-to-middle abdomen, along with food malabsorption, and eventual development of diabetes. Treatment strategies for acute pancreatitis include fasting and short-term intravenous feeding, fluid therapy, and pain management with narcotics for severe pain or nonsteroidal anti-inflammatories for milder cases. Patients with chronic disease and symptoms require further care to address digestive issues and the possible development of diabetes. Dietary restrictions are recommended, along with enzyme replacement and vitamin supplementation. More definitive outcomes may be achieved with surgical or endoscopic methods, depending on the role of the pancreatic ducts in the manifestation of disease.

Phenotypic variations of cartilage hair hypoplasia: granulomatous skin inflammation and severe T cell immunodeficiency as initial clinical presentation in otherwise well child with short stature.

PubMed

McCann, Liza J; McPartland, Jo; Barge, Dawn; Strain, Lisa; Bourn, David; Calonje, Eduardo; Verbov, Julian; Riordan, Andrew; Kokai, George; Bacon, Chris M; Wright, Michael; Abinun, Mario

2014-01-01

We report a child with short stature since birth who was otherwise well, presenting at 2.8 years with progressive granulomatous skin lesions when diagnosed with severe T cell immunodeficiency. When previously investigated for short stature, and at the time of current investigations, she had no radiological skeletal features characteristics for cartilage hair hypoplasia, but we found a disease causing RMRP (RNase mitochondrial RNA processing endoribonuclease) gene mutation. Whilst search for HLA matched unrelated donor for haematopoietic stem cell transplantation (HSCT) was underway, she developed rapidly progressive EBV-related lymphoproliferative disorder requiring laparotomy and small bowel resection, and was treated with anti-B cell monoclonal antibody and eventually curative allogeneic HSCT. Screening for RMRP gene mutations should be part of immunological evaluation of patients with 'severe and/or combined' T cell immunodeficiency of unknown origin, especially when associated with short stature and regardless of presence or absence of radiological skeletal features.

Extended Experience with Neuroendoscopic Lavage for Posthemorrhagic Hydrocephalus in Neonates.

PubMed

d'Arcangues, Charlotte; Schulz, Matthias; Bührer, Christoph; Thome, Ulrich; Krause, Matthias; Thomale, Ulrich-Wilhelm

2018-05-03

Previous studies have described neuroendoscopic lavage (NEL) as a procedure for the treatment of posthemorrhagic hydrocephalus in newborn infants. This report describes complications and results in an extended case series from 2 separate hospitals. Patient records were screened for NEL procedures performed on infants with posthemorrhagic hydrocephalus between September 2010 and May 2016 (minimum follow-up period of 12 months). Efficacy of blood removal-as assessed with cerebral ultrasound, complications, eventual shunt placement rate, and subsequent shunt revisions-were recorded. Fifty-six patients (35 male) underwent NEL at a postmenstrual median age of 31 weeks and 2 days (range, 26 weeks and 1 day to 52 weeks and 3 days) and a median weight of 1523 g (range, 734-4360 g). Median follow-up was 34 months (range, 12-80). Three patients died, and 31 patients required permanent ventriculoperitoneal shunting. There was no significant correlation between the need for ventriculoperitoneal shunting and gestational age (P = 0.05), birth weight (P = 0.07), age (P = 0.17), or weight (P = 0.59) after NEL. The median number of surgical interventions per patient was 2 (range, 1-7 interventions). Revision-free shunt survival was 63.6% at 12 and 56.2% at 24 months. NEL avoided shunt placement in 43% of newborn infants with posthemorrhagic hydrocephalus. In the shunted cohort, NEL may have also decreased the frequency of subsequent shunt revisions. The influence of NEL on neurodevelopment and safety remains to be investigated further in a multicenter setup. Copyright © 2018 Elsevier Inc. All rights reserved.

Computer-based assessment of right ventricular regional ejection fraction in patients with repaired Tetralogy of Fallot

NASA Astrophysics Data System (ADS)

Teo, S.-K.; Wong, S. T.; Tan, M. L.; Su, Y.; Zhong, L.; Tan, Ru-San

2015-03-01

After surgical repair for Tetralogy of Fallot (TOF), most patients experience long-term complications as the right ventricle (RV) undergoes progressive remodeling that eventually affect heart functions. Thus, post-repair surgery is required to prevent further deterioration of RV functions that may result in malignant ventricular arrhythmias and mortality. The timing of such post-repair surgery therefore depends crucially on the quantitative assessment of the RV functions. Current clinical indices for such functional assessment measure global properties such as RV volumes and ejection fraction. However, these indices are less than ideal as regional variations and anomalies are obscured. Therefore, we sought to (i) develop a quantitative method to assess RV regional function using regional ejection fraction (REF) based on a 13-segment model, and (ii) evaluate the effectiveness of REF in discriminating 6 repaired TOF patients and 6 normal control based on cardiac magnetic resonance (CMR) imaging. We observed that the REF for the individual segments in the patient group is significantly lower compared to the control group (P < 0.05 using a 2-tail student t-test). In addition, we also observed that the aggregated REF at the basal, mid-cavity and apical regions for the patient group is significantly lower compared to the control group (P < 0.001 using a 2-tail student t-test). The results suggest that REF could potentially be used as a quantitative index for assessing RV regional functions. The computational time per data set is approximately 60 seconds, which demonstrates our method's clinical potential as a real-time cardiac assessment tool.

Optimal management of immune-related adverse events resulting from treatment with immune checkpoint inhibitors: a review and update.

PubMed

Nagai, Hiroki; Muto, Manabu

2018-06-01

Over the last two decades, molecular-targeted agents have become mainstream treatment for many types of malignancies and have improved the overall survival of patients. However, most patients eventually develop resistance to these targeted therapies. Recently, immunotherapies such as immune checkpoint inhibitors have revolutionized the treatment paradigm for many types of malignancies. Immune checkpoint inhibitors have been approved for treatment of melanoma, non-small cell lung cancer, renal cell carcinoma, head and neck squamous cell carcinoma, Hodgkin's lymphoma, bladder cancer and gastric cancer. However, oncologists have been faced with immune-related adverse events caused by immune checkpoint inhibitors; these are generally mild but can be fatal in some cases. Because immune checkpoint inhibitors have distinct toxicity profiles from those of chemotherapy or targeted therapy, many oncologists are not familiar with the principles for optimal management of immune-related adverse events, which require early recognition and appropriate treatment without delay. To achieve this, oncologists must educate patients and health-care workers, develop checklists of appropriate tests for immune-related adverse events and collaborate closely with organ specialists. Clinical questions that remain include whether immune checkpoint inhibitors should be administered to patients with autoimmune disease and whether patients for whom immune-related adverse events lead to delays in immunotherapy should be retreated. In addition, the predicted use of combination immunotherapies in the near future means that oncologists will face a higher incidence and severity of immune-related adverse events. This review provides an overview of the optimal management of immune-related adverse events attributed to immune checkpoint inhibitors.

Arthroscopic Removal and Rotator Cuff Repair Without Acromioplasty for the Treatment of Symptomatic Calcifying Tendinitis of the Supraspinatus Tendon.

PubMed

Ranalletta, Maximiliano; Rossi, Luciano Andrés; Bongiovanni, Santiago Luis; Tanoira, Ignacio; Piuzzi, Nicolas; Maignon, Gastón

2015-04-01

Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. Although most patients respond well to conservative treatment, some eventually require surgical treatment. To evaluate the clinical outcome with arthroscopic removal of calcific deposit and rotator cuff repair without acromioplasty for the treatment of calcific tendinitis of the supraspinatus tendon. Case series; Level of evidence, 4. This study retrospectively evaluated 30 consecutive patients with a mean age of 49.2 years. The mean follow-up was 35 months (range, 24-88 months). Pre- and postoperative functional assessment was performed using the Constant score, University of California Los Angeles (UCLA) score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH). Pain was assessed by visual analog scale (VAS). Radiographs and magnetic resonance imaging (MRI) were performed to evaluate the recurrence of calcifications and the indemnity of the supraspinatus tendon repair. Significant improvement was obtained for pain (mean VAS, 8.7 before surgery to 0.8 after; P < .001). The mean Constant score increased from 23.9 preoperatively to 85.3 postoperatively (P < .001), the mean Quick DASH score decreased from 47.3 preoperatively to 8.97 postoperatively (P < .001), and the UCLA score increased from 15.8 preoperatively to 32.2 postoperatively (P < .001). MRI examination at last follow-up (70% of patients) showed no tendon tears, and 96.2% of patients were satisfied with their results. Arthroscopic removal and rotator cuff repair without acromioplasty can lead to good results in patients with symptomatic calcifying tendonitis of the supraspinatus tendon.

Modified Puestow procedure for the management of chronic pancreatitis in children.

PubMed

Laje, Pablo; Adzick, N Scott

2013-11-01

To present our experience with the modified Puestow procedure in the management of children with chronic pancreatitis. Retrospective chart review of patients treated between 2003 and 2012. Six patients underwent a modified Puestow procedure (lateral pancreaticojejunostomy) for the management of chronic pancreatitis, three females and three males. Four patients had hereditary pancreatitis (three with confirmed N34S mutation in the SPINK1 gene), one patient had chronic pancreatitis of unknown etiology, and one patient with annular pancreas developed obstructive chronic pancreatitis. The pancreatic duct was dilated in all cases, with a maximum diameter of 5 to 10mm. Median time between onset of pain and surgery was 4 years (range: 1-9). Median age at surgery was 7.5 years (range: 5-15). Median hospital stay was 12 days (range: 9-28). Median follow up was 4.5 years (range: 5 months to 9 years). All patients had temporary postoperative improvement of their abdominal pain. In two patients the pain recurred at 6 months and 2 years postoperatively and eventually required total pancreatectomy to treat intractable pain, 3 and 8 years after surgery. Two patients were pain free for two years and subsequently developed occasional episodes of pain. The two most recent patients are pain free at 1 year (obstructive chronic pancreatitis) and 5 months (hereditary pancreatitis) follow-up. Two patients developed type I diabetes mellitus 10 and 12 months postoperatively (one with hereditary and one with idiopathic chronic pancreatitis). We conclude that the modified Puestow procedure in children is feasible and safe. It seems to provide definitive pain control and prevent further damage to the pancreas in patients with obstructive chronic pancreatitis. However, in patients with hereditary pancreatitis, pain control outcomes are variable and the operation may not abrogate the progression of disease to pancreatic insufficiency. Copyright © 2013 Elsevier Inc. All rights reserved.

Heart transplantation in Fontan patients across Australia and New Zealand.

PubMed

Shi, William Y; Yong, Matthew S; McGiffin, David C; Jain, Pankaj; Ruygrok, Peter N; Marasco, Silvana F; Finucane, Kirsten; Keogh, Anne; d'Udekem, Yves; Weintraub, Robert G; Konstantinov, Igor E

2016-07-15

Patients with Fontan physiology may eventually require heart transplantation (HT). We determined the rates and outcomes of HT in a national, population-based multicentre study. From 1990 to 2015, 1369 patients underwent the Fontan procedure as recorded in the Australia and New Zealand Fontan Registry. We identified those who underwent HT and analysed their outcomes. We compared rates of HT between two catchment areas. In area 1 (n=721), patients were referred to the national paediatric HT programme or its associated adult programme. In area 2 (n=648), patients were referred to the national paediatric HT programme or one of the other adult HT programmes. Mean follow-up time post-Fontan was 11±8 years. Freedom from Fontan failure was 74%±3.9% at 20 years. HT was performed in 34 patients. Patients living in area 1 were more likely to have HT (4.0%, 29/721 vs 0.8%, 5/648, p<0.001) with a cumulative proportion of 3.4% vs 0.7% at 10 years and 6.8% vs 1.2% at 20 years (p=0.002). Area 1 patients were more likely to undergo HT (hazard ratio 4.7, 95% CI 1.7 to 13.5, p=0.003) on multivariable regression. Post-HT survival at 1, 5 and 10 years was 91%, 78% and 71%, respectively. Compared with other patients with congenital heart disease (n=87), Fontan patients had similar in-hospital outcomes and long-term survival. Although HT after the Fontan procedure can be achieved with excellent outcomes, most patients with Fontan failure do not undergo HT. Significant regional differences in rates of HT in Fontan patients exist. 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/

Ruptured intracranial aneurysms: the outcome of surgical treatment in experienced hands in the period prior to the advent of endovascular coiling

PubMed Central

Lafuente, J; Maurice-Williams, R

2003-01-01

Objectives: To evaluate the results of treatment of patients with a ruptured intracranial aneurysm treated by a single experienced vascular neurosurgeon in the period prior to the introduction of endovascular coiling. Methods: Over a mean (SD) period of 9 (2) years, between January 1990 and June 1999, 245 consecutive patients with ruptured intracranial aneurysms were treated. Patients' details were obtained from a database that had been constructed prospectively. The patients consisted of all those patients treated by the senior author (Mr Maurice-Williams) over this period—that is, every third day on call at his unit. During this period, all patients under the age of 75 years with a diagnosis of subarachnoid haemorrhage were admitted to the neurosurgical unit as soon as was practicable regardless of clinical grade. Results: Of 245 patients, 190 (77.6%) underwent treatment by open surgery using standard microsurgical techniques. At 1 year, the mortality of the operated patients was 2.6%, while 89.5% of the patients had a Glasgow Outcome Score (GOS) of 4 and 5. The overall management outcome (all patients treated, including operated and non-operated cases) at 1 year was: 17.1 % dead while 74.3% had GOS 4 and 5. Of the 190 patients who underwent surgery, 38 (20%) required additional operations, totalling 72 operations in all. Of these, 32 were for hydrocephalus and 17 for the evacuation of intracranial haematomas/collections. Complications of surgery occurred in 56 patients (29.5%). Conclusion: Open surgery, despite good eventual results, is associated with a significant rate of re-operations and complications that would probably be largely avoided with endovascular treatment. Nevertheless, although endovascular coiling has these immediate advantages over surgery it is still not certain that the long term results will be superior to surgery which leads to permanent obliteration of the aneurysm. There may still be a need for open surgery in the future. PMID:14638889

Is the disease course predictable in inflammatory bowel diseases?

PubMed Central

Lakatos, Peter Laszlo; Kiss, Lajos S

2010-01-01

During the course of the disease, most patients with Crohn’s disease (CD) may eventually develop a stricturing or a perforating complication, and a significant number of patients with both CD and ulcerative colitis will undergo surgery. In recent years, research has focused on the determination of factors important in the prediction of disease course in inflammatory bowel diseases to improve stratification of patients, identify individual patient profiles, including clinical, laboratory and molecular markers, which hopefully will allow physicians to choose the most appropriate management in terms of therapy and intensity of follow-up. This review summarizes the available evidence on clinical, endoscopic variables and biomarkers in the prediction of short and long-term outcome in patients with inflammatory bowel diseases. PMID:20518079

Selective Teacher Attention in Lower-Income Countries: A Phenomenon Linked to Dropout and Illiteracy?

ERIC Educational Resources Information Center

Abadzi, Helen; Llambiri, Stavri

2011-01-01

In lower-income countries students face an important challenge that has not been well documented: selective teacher attention. In classes with many low-income students, teachers may concentrate on those few who can perform and neglect those who require more help. The latter may fail to learn, attend school less often, and eventually drop out.…

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

Abudureyimu, Reheman; Huang, Chunning; Liu, Yun

We report on a first experimental demonstration of locking a doubly-resonant Fabry-Perot cavity to burst-mode picosecond ultraviolet (UV) pulses by using a temperature controlled dispersion compensation method. This technique will eventually enable the intra cavity power enhancement of burst-mode 402.5MHz/50ps UV laser pulses with a MW level peak power required for the laser assisted H- beam stripping experiment at the Spallation Neutron Source.

A study of spaceraft technology and design concepts, volume 1

NASA Technical Reports Server (NTRS)

Zylius, F. A.

1985-01-01

Concepts for advancing the state of the art in the design of unmanned spacecraft, the requirements that gave rise to its configuration, and the programs of technology that are suggested as leading to its eventual development are examined. Particular technology issues discussed include: structures and materials; thermal control; propulsion; electrical power; communications; data management; and guidance, navigation, and control.

New-onset neonatal pulmonary hypertension associated with a rhinovirus infection.

PubMed

Patel, Nishit; The, Tiong G

2012-01-01

A 3.5-week-old male neonate who developed an upper and lower respiratory tract rhinovirus infection that was temporally associated with the development of severe pulmonary hypertension is described. Rhinovirus has not previously been associated with pulmonary hypertension. This child developed severe pulmonary hypertension with right ventricular failure, requiring mechanical ventilation, nitric oxide inhalation and, eventually, extracorporeal membrane oxygenation.

Interactive videoconsultation is a feasible method for neurological in-patient assessment.

PubMed

Craig, J; Patterson, V; Russell, C; Wootton, R

2000-11-01

To evaluate the feasibility of interactive videoconsultation (IATV) as a means by which neurologists might assess patients admitted with neurological symptoms to hospitals distant from a neurological centre, we studied 25 unselected patients using interactive videoconsultation (IATV) and then validated the IATV diagnoses and management plans at a later face-to-face consultation. IATV consultation led to an eventual diagnosis in 23 out of 25 patients, with one diagnosis being changed and one remaining uncertain. The IATV management plans were felt to be appropriate for all patients in study. Twelve patients were able to be discharged from hospital on the same day as IATV on the advice of the neurologist. It is therefore practical to assess patients admitted with neurological symptoms to distant hospitals using IATV and this may result in more efficient use of in-patient resources.

New directions for space solar power

NASA Astrophysics Data System (ADS)

Mankins, John C.

2009-07-01

Several of the central issues associated with the eventual realization of the vision of solar power from space for terrestrial markets resolve around the expect costs associated with the assembly, inspection, maintenance and repair of future solar power satellite (SPS) stations. In past studies (for example, NASA's "Fresh Look Study", c. 1995-1997) efforts were made to reduce both the scale and mass of large, systems-level interfaces (e.g., the power management and distribution (PMAD) system) and on-orbit fixed infrastructures through the use of modular systems strategies. These efforts have had mixed success (as reflected in the projected on-orbit mass of various systems concepts. However, the author remains convinced of the importance of modular strategies for exceptionally large space systems in eventually realizing the vision of power from space. This paper will introduce some of the key issues associated with cost-competitive space solar power in terrestrial markets. It will examine some of the relevant SPS concepts and will assess the 'pros and cons' of each in terms of space assembly, maintenance and servicing (SAMS) requirements. The paper discusses at a high level some relevant concepts and technologies that may play r role in the eventual, successful resolution of these challenges. The paper concludes with an example of the kind of novel architectural approach for space solar power that is needed.

Diverse cutaneous adverse eruptions caused by anti-programmed cell death-1 (PD-1) and anti-programmed cell death ligand-1 (PD-L1) immunotherapies: clinical features and management.

PubMed

Shen, John; Chang, Jason; Mendenhall, Melody; Cherry, Grace; Goldman, Jonathan W; Kulkarni, Rajan P

2018-01-01

The anti-programmed cell death-1 (PD-1) and anti-programmed cell death ligand-1 (PD-L1) immunotherapies have shown exceptional activity in many cancers. However, these immunotherapies can also result in diverse adverse cutaneous eruptions that need to be better characterized for ongoing management. The objective was to provide clinical and histopathologic descriptions of the variety of cutaneous adverse events seen in patients who received anti-PD-1/PD-L1 treatment and discuss their management. Patients with advanced cancers in clinical trials at University of California Los Angeles (UCLA), receiving anti-PD-1/PD-L1 treatment between 2012 and 2016 who developed cutaneous eruptions and were evaluated in the dermatology clinic were included in this retrospective case series study. A total of 16 patients were included in this study; of these, five were treated with pembrolizumab alone, two with avelumab alone, eight with nivolumab plus ipilimumab and one with nivolumab plus T-Vec. Of these 16 patients, eight had received systemic chemotherapy, six had received radiotherapy, and one had received trememlimumab prior to the immunotherapies described in this study. Cutaneous eruptions occurred at variable times, from week 1 to 88, with a median of 11.5 weeks; the morphologies included lichenoid, bullous, psoriasiform, macular, morbiliform appearances, and alopecia which were confirmed histopathologically in several of the cases. All cutaneous immune-related adverse events were either grade 1 or 2. Ten patients were treated with topical corticosteroids, and one also received NBUVB. Four patients eventually required systemic steroids. Three required discontinuation of their anti-PD-1/PD-L1 therapy secondary to the cutaneous eruptions. There are several different types of adverse cutaneous morphologies that may be seen with administration of PD-1 and PD-L1 inhibitors. Identifying the patterns of eruption may assist in prompt treatment. Most eruptions could be managed with topical corticosteroids and without discontinuation of the systemic treatment.

[Cholera in children. A report of 8 cases].

PubMed

Lezama-Basulto, L A; Mota-Hernández, F; Bravo-Barrios, E

1993-11-01

Cholera is an acute intestinal infection caused by Vibrio cholerae 01. When an infected person presents severe dehydration and is not adequately treated, he or she will develop hypovolemic shock and eventually could died. There is scarce information concerning this disease in the Pediatric group. Herein we report on eight cases of Pediatric cholera, in children 17 month to four years of age. Seven patients out of eight were admitted presenting dehydration. Four presenting mild or moderate dehydration and three presenting hypovolemic shock. These three patients were rehydrated by intravenous route and thereafter the hydration was maintained by oral therapy. The outcome was uneventful in six patients. One patient developed abdominal distention probably due to hypopotassemia, and another patient presented hyponatremia and seizures. All the patients recovered within five days after admission.

Surgical Treatment of Crohn Colitis Involving More Than 2 Colonic Segments

PubMed Central

Lee, Jong Lyul; Yu, Chang Sik; Lim, Seok-Byung; Park, In Ja; Yoon, Yong Sik; Kim, Chan Wook; Yang, Suk-Kyun; Kim, Jin Cheon

2016-01-01

Abstract The incidence of primary Crohn colitis is uncommon and surgical treatment has remained controversial, although most patients with Crohn colitis eventually require surgical intervention. This study aims to compare the operative outcomes of patients who underwent segmental versus either total colectomy or total proctocolectomy for Crohn colitis and to assess potential risk factors associated with clinical and surgical recurrence-free survivals. This is a retrospective study of 116 patients who underwent primary surgery for Crohn colitis between August 1997 and July 2011. Patients were classified based on the type of surgery: segmental colectomy (SC group; n = 71) or either total colectomy or total proctocolectomy (TC group; n = 45). There were no significant differences in postoperative complications or the nutritional state between the SC and TC groups. Patients in TC group had a significantly higher clinical recurrence-free survival (CRFS). Among the 54 patients with multisegmental Crohn colitis, the TC group had a significantly increased CRFS and surgical recurrence-free survival (SRFS), compared with patients in the SC group (5-year CRFS: 82.0% ± 5.8% vs 22.2% ± 13.9%, P = 0.001; 5-year SRFS: 88.1% ± 5.0% vs 44.4% ± 16.6%, P = 0.001). By multivariate analysis of patients with multisegments involved, SC was a risk factor for SRFS and CRFS (hazard ratio [HR] = 4.637, 95% confidence interval [CI] = 1.387–15.509, P = 0.013 and HR = 32.407, 95% CI = 2.873–365.583, P = 0.005). TC patients have significantly increased CRFS and TC in patients with multisegment involvement may affect improved SRFS and CRFS. Among patients with multisegmental Crohn colitis, SC is an independent risk factor for CRFS and SRFS. PMID:27258512

Multiple drilling compared with standard core decompression for avascular necrosis of the femoral head in sickle cell disease patients.

PubMed

Al Omran, Abdullah

2013-05-01

Sickle cell disease (SCD) is the most common cause of avascular necrosis of femoral head (ANFH) in childhood. Advances in medical treatment led to improved life expectancy of such patients. SCD-related ANFH frequently progress to total collapse of the femoral head necessitating hip replacement. However, SCD patient are at more risk of intra- and post-operative complications and suboptimal outcome of total hip arthroplasty. Hence, it is imperative to preserve the femoral head as long as possible. Between September 1992 and June 2007, 94 core decompression procedures were done to SCD patients who had modified Ficat stage I, IIA and IIB ANFH. Sixty one patients underwent a classical 8-mm drilling and 33 patients underwent 3.2-mm diameter MD technique. Patients were followed up for minimum of 2 years and were evaluated for clinical and Harris Hip Score improvement and for radiological progression. All 19 hips that had Ficat stage I had significant reduction of pain and improvement of Harris Hip Score. No patient has required further surgery. Among the 39 hips with Ficat IIA at time of procedure, 80 % of hips which underwent CD and 78 % of MD cases had significant reduction of pain and improvement of HHS. Those patients showed no radiographic progression of the disease. The remaining, 20 % CD and 22 % MD eventually progressed radiologically to grade III or grade IV and had HHS less than 75 at last visit. In the 36 cases with Ficat IIB, 52 % CD and 52.8 % MC had significant reduction of pain and improvement of HHS. The rest showed no improvement in pain and function, and progressed to stage IV; 11 of them underwent THA and one patient refused surgery. While multiple drilling is safer and less invasive than single coring in SCD, there is no statistically significant difference in outcome or complication rate between both procedures done for ANFH in patients with SCD.

[A new method of endoscopic harvesting of the great saphenous vein in an open system].

PubMed

Vecherskiĭ, Iu Iu; Zatolokin, V V; Petlin, K A; Akhmedov, Sh D; Shipulin, V M

We examined a total of 246 patients subjected to coronary artery bypass grafting with the use of the great saphenous vein (GSV). The patients were subdivided into two groups. Group One (n=121) patients endured procurement of the great saphenous vein by a new endoscopic technique in an open system with the help of the equipment Karl Storz and electric dissector Ligasure. In Group Two (n=125) patients the vein was harvested by means of the traditional open method. In all patients we evaluated complications in the early postoperative period 13±2.5 days after the operation. The rate of relapsing angina pectoris in both Groups turned out to be low and did not differ (1.65% in Group One and 1.6% in Group Two). Patients of the both groups differed significantly by the incidence of postoperative complications on the lower limbs in the zone of procurement of the GSV (9.09% in Group One and 26.4% in Group Two, p=0.131). Group Two patients (open method of procurement of the GSV) were considerably more often found to have developed cases of lymphorrhoea, haematomas, disjunction of the sutures (21.6%) compared with Group One (endoscopic method) patients (3.3%) (p=0.167), which in 10.4% of cases required secondary surgical debridement of wounds in patients after the open harvest of the GSV. Eventually, the length of hospital stay for Group Two patients increased significantly (15 ± 4.5 days) compared with Group One patients (8±1.1 days) (p=0.361). Hence, the endoscopic method of harvesting the GSV in the open CO2 system makes it possible to obtain a good cosmetic effect on the lower limbs after the operation, to considerably decrease the complications rate, thus reducing the length of hospital stay.

Pneumocystis jirovecii dihydropteroate synthase gene mutations in a group of HIV-negative immunocompromised patients with Pneumocystis pneumonia

PubMed Central

LONG, YINGJIAO; ZHANG, CHENG; SU, LI; QUE, CHENGLI

2014-01-01

The purpose of this study was to investigate dihydropteroate synthase (DHPS) mutations and their clinical context in non-HIV-infected patients with Pneumocystis pneumonia (PCP). DHPS genes in respiratory samples collected from HIV-negative patients with PCP presented between January 2008 and April 2011 were amplified by polymerase chain reaction (PCR) and sequenced. Basic clinical data from the medical records of the patients were also reviewed. The most common point mutations, which result in Thr55Ala and Pro57Ser amino acid substitutions, were not detected in the Pneumocystis jirovecii sampled from the HIV-negative patients. Two other point mutations, which result in nonsynonymous mutation, Asp90Asn and Glu98Lys, were identified in P. jirovecii from two patients. Among the patients, the levels of lactate dehydrogenase (LDH), C-reactive protein (CRP) and plasma (1–3) β-D-glucan were elevated in 75, 92.31 and 42.86% of patients, respectively. The percentage of circulating lymphocytes was significantly lower in non-survivors than in survivors [4.2%, interquartile range (IQR) 2.4–5.85 versus 10.1%, IQR 5.65–23.4; P=0.019]. The neutrophil proportion in bronchoalveolar lavage fluid (BALF) was significantly higher in non-survivors than in survivors (49.78±27.67 versus 21.33±15.03%; P=0.047). Thirteen patients had received adjunctive corticosteroids (1 mg/kg/day prednisone equivalent) and nine (69.23%) of them eventually experienced treatment failure. No common DHPS gene mutations of P. jirovecii were detected in the HIV-negative PCP patients. However, other mutations did exist, the significance of which remains to be further identified. The elevation of neutrophil counts in BALF and reduction of the number of lymphocytes in peripheral blood may be associated with poor outcome. The efficacy of adjunctive steroid therapy in HIV-negative patients with P. jirovecii infection requires further investigation. PMID:25371739

Single-specialty management and reconstruction of necrotizing fasciitis of the upper extremities: clinical and economic benefits from a case series.

PubMed

Mattison, Gennaya; Leis, Amber R; Gupta, Subhas C

2014-05-01

Patients with necrotizing fasciitis are managed with multiple prompt, radical surgical debridements and critical care support. Debridement and reconstruction are often provided by different surgical teams. Anecdotally, single-specialty management seemed to be a more efficient management strategy. This study aimed to investigate and compare the outcomes of management by plastic surgery versus multiple disciplines through a retrospective economic and clinical analysis of patients with necrotizing fasciitis treated over 8 years. We also present 3 index cases for which our service functioned as the primary management team. Necrotizing fasciitis cases evaluated and treated by our department, covering both Level I and Level II Trauma Centers, were reviewed for total charges, length of hospital stay, length of intensive care unit (ICU) stay, and number of procedures. The admission Acute Physiology and Chronic Health Evaluation II score was calculated for each patient. Three comparative index cases of upper extremity necrotizing fasciitis managed primarily by the plastic surgery team are presented in greater detail. Patients managed primarily by the plastic surgery service had equivalent Acute Physiology and Chronic Health Evaluation II scores to patients managed by multiple services for their necrotizing fasciitis, with the average score higher for patients managed by plastic surgery alone. In a case-matched series of upper extremity necrotizing fasciitis, the patients admitted directly to plastic surgery had shorter average lengths of hospital and ICU stays as well as decreased total number of procedures, resulting in decreased average total hospital charges. There were no amputations among the cases treated primarily by the plastic surgery. The patients also required smaller areas of reconstruction with skin grafting despite large initial areas of debridement compared to those whose reconstructive teams differed from the team performing the debridement. Improved economic and clinical outcomes-as indicated by the reduced lengths of overall and ICU stay, the reduced number of procedures, none of the cases requiring amputation, and the reduced need for skin grafting-may be attainable when the surgeon eventually performing the reconstruction is involved early in management. We propose that, in the interest of improving patient care, a closer collaboration should be established between the reconstructive and primary managing teams.

EUropean prospective cohort study on Enterobacteriaceae showing REsistance to CArbapenems (EURECA): a protocol of a European multicentre observational study.

PubMed

Gutiérrez-Gutiérrez, Belén; Sojo-Dorado, Jesús; Bravo-Ferrer, José; Cuperus, Nienke; de Kraker, Marlieke; Kostyanev, Tomislav; Raka, Lul; Daikos, George; Feifel, Jan; Folgori, Laura; Pascual, Alvaro; Goossens, Herman; O'Brien, Seamus; Bonten, Marc J M; Rodríguez-Baño, Jesús

2017-04-03

The rapid worldwide spread of carbapenem-resistant Enterobacteriaceae (CRE) constitutes a major challenge. The aim of the EUropean prospective cohort study on Enterobacteriaceae showing REsistance to CArbapenems (EURECA), which is part of the Innovative Medicines Initiative Joint Undertaking (IMI JU) funded COMBACTE-CARE project, is to investigate risk factors for and outcome determinants of CRE infections to inform randomised clinical trial designs and to provide a historical cohort that could eventually be used for future comparisons with new drugs targeting CRE. A multicentre (50 sites), multinational (11 European countries), analytical observational project was designed, comprising 3 studies. The aims of study 1 (a prospective cohort study) include characterising the features, clinical management and outcomes of hospitalised patients with intra-abdominal infection, pneumonia, complicated urinary tract infections and bloodstream infections caused by CRE (202 patients in each group). The main outcomes will be 30-day all-cause mortality and clinical response. Study 2 (a nested case-control study) will identify the risk factors for target infections caused by CRE; 248 selected patients from study 1 will be matched with patients with carbapenem-susceptible Enterobacteriaceae (1:1) and with hospitalised patients (1:3) and will provide a historical cohort of patients with CRE infections. Study 3 (a matched cohort study) will follow patients in study 2 in order to assess mortality, length of stay and hospital costs associated with CRE. All patients will be followed for 30 days. Different, up-to-date statistical methods will be applied to come to unbiased estimates for all 3 studies. Before-study sites will be initiated, approval will be sought from appropriate regulatory agencies and local Ethics Committees of Research or Institutional Review Boards (IRBs) to conduct the study in accordance with regulatory requirements. This is an observational study and therefore no intervention in the diagnosis, management or treatment of the patients will be required on behalf of the investigation. Any formal presentation or publication of data collected from this study will be considered as a joint publication by the participating physician(s) and will follow the recommendations of the International Committee of Medical Journal Editors (ICMJE) for authorship. NCT02709408. 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 Unique Case of Malignant Pleuropericardial Effusion: HHV-8-Unrelated PEL-Like Lymphoma—A Case Report and Review of the Literature

PubMed Central

Mohammad, Farhan; Siddique, Muhammad Neaman; Siddiqui, Faraz; Popalzai, M.; Asgari, Masoud; Odaimi, Marcel

2014-01-01

Primary effusion lymphoma (PEL) or body cavity lymphoma is a rare type of extra nodal lymphoma of B-cell origin that presents as lymphomatous effusion(s) without any nodal enlargement or tumor masses. It belongs to the group of AIDS related non-Hodgkin's lymphomas. First described in 1996 in HIV infected individuals who were coinfected with Kaposi's sarcoma-associated herpesvirus (KSHV) or HHV-8 virus, it was included as a separate entity in WHO classification of tumors of hematopoietic and lymphoid tissue in the year 2001. The definition included association with HHV-8 virus as a mandatory diagnostic criterion. However, cases were later reported where PEL-like disease process was diagnosed in HHV-8 negative patients. This was eventually recognized as a rare but distinct entity termed as “HHV-8-unrelated PEL-like lymphoma”. Herein, we are reporting a case of an elderly patient who presented with a large pleuropericardial effusion and was eventually diagnosed with this entity. Till date, only around 50 cases of HHV-8-unrelated PEL-like lymphoma have been reported and our case being EBV, HIV, and Hepatitis C negative makes it very unique and rare occurrence. We are also presenting a review of relevant literature focused mainly on comparing outcomes in patients treated with and without chemotherapy. PMID:24716045

Hypersomnia as presenting symptom of anti-Ma2-associated encephalitis: case study.

PubMed

Rojas-Marcos, Iñigo; Graus, Francesc; Sanz, Gema; Robledo, Arturo; Diaz-Espejo, Carlos

2007-01-01

We describe a patient who presented with excessive daytime sleepiness (EDS) and was eventually diagnosed with anti-Ma2 encephalitis. Neurological examination disclosed somnolence, left palpebral ptosis, and vertical gaze paresis. A brain MRI showed high signal intensity in the hypothalamus and each hippocampus. Ma2 antibodies were found in the patient's serum, and fiberbronchoscopy disclosed a lung carcinoma. After three months of steroid treatment, the results of the patient's neurological exam became normal. We conclude that anti-Ma2 encephalitis may present with mostly isolated EDS and that it may respond to steroids despite old age and the presence of an untreated lung cancer.

Magnetic resonance imaging for pain after surgical treatment for athletic pubalgia and the "sports hernia".

PubMed

Zoga, Adam C; Meyers, William C

2011-09-01

Magnetic resonance (MR) imaging technique and findings in the setting of athletic pubalgia, including injury at the rectus abdominis/adductor aponeurosis, are becoming widely recognized. A subset of these patients is treated with various pelvic floor repairs, mesh reinforcements, and tendon releases. Most of these patients do well after intervention, but some have persistent or refractory groin pain, and others eventually develop new injuries in the pubic region or elsewhere about the pelvic girdle. This review describes the expected and some unexpected MRI findings in patients with recurrent or persistent groin pain after a "sports hernia" repair. © Thieme Medical Publishers.

Vascular complications of transcatheter aortic valve replacement: A concise literature review

PubMed Central

Chaudhry, Muhammad Ali; Sardar, Muhammad Rizwan

2017-01-01

Transcatheter aortic valve replacement (TAVR) is a relatively newer therapeutic modality which offers a promising alternative to surgical aortic valve replacement for patients with prohibitive, high and intermediate surgical risk. The increasing trend to pursue TAVR in these patients has also led to growing awareness of the associated potential vascular complications. The significant impact of these complications on eventual clinical outcome and mortality makes prompt recognition and timely management a critical factor in TAVR patients. We hereby present a concise review with emphasis on diverse vascular complications associated with TAVR and their effective management to improve overall clinical outcomes. PMID:28824787

[The clinical history in surgical processes. Bioethical aspects and basic professional ethics].

PubMed

Collazo Chao, Eliseo

2008-11-01

Surgeons are increasingly facing multiple civil liability claims from their patients. Against this background and taking any eventual liability claims into account, surgeons must be increasingly aware of the importance of maintaining patient medical histories, which raises numerous questions on the length of time and form of keeping them. Ethical and legal obligations need to be taken into account in order to identify the controversial aspects related to patients and their environment, as well as shedding light on the most appropriate behaviour in each case. We must never forget the case history is a clinical document, subjected to the medical art and medical ethics which regulate it.

Ethics in oncology: principles and responsibilities declared in the Italian Ragusa statement.

PubMed

Gori, Stefania; Pinto, Carmine; Caminiti, Caterina; Aprile, Giuseppe; Marchetti, Paolo; Perrone, Francesco; Di Maio, Massimo; Omodeo Salè, Emanuela; Mancuso, Annamaria; De Cicco, Maurizio; Di Costanzo, Francesco; Crispino, Sergio; Passalacqua, Rodolfo; Merlano, Marco; Zagonel, Vittorina; Fioretto, Luisa; Micallo, Giovanni; Labianca, Roberto; Bordonaro, Roberto; Comandone, Alessandro; Spinsanti, Sandro; Iacono, Carmelo; Nicolis, Fabrizio

2016-12-01

Cancer care involves many ethical issues. The need for more patient-centered healthcare together with the improved empowerment of every person diagnosed with cancer have been transposed by the Italian Association of Medical Oncology (AIOM) and eventually translated in the Ragusa statement. This position paper describes the philosophy that lies beneath this document and its fundamental principles.

Impaired Cognition in Rats with Cortical Dysplasia: Additional Impact of Early-Life Seizures

ERIC Educational Resources Information Center

Lucas, Marcella M.; Lenck-Santini, Pierre-Pascal; Holmes, Gregory L.; Scott, Rod C.

2011-01-01

One of the most common and serious co-morbidities in patients with epilepsy is cognitive impairment. While early-life seizures are considered a major cause for cognitive impairment, it is not known whether it is the seizures, the underlying neurological substrate or a combination that has the largest impact on eventual learning and memory. Teasing…

Otogenic Meningitis: A Comparison of Diagnostic Performance of Surgery and Radiology.

PubMed

Bruschini, Luca; Fortunato, Simona; Tascini, Carlo; Ciabotti, Annalisa; Leonildi, Alessandro; Bini, Belinda; Giuliano, Simone; Abbruzzese, Arturo; Berrettini, Stefano; Menichetti, Francesco

2017-01-01

Development of intracranial complications from middle ear infections might be difficult to diagnose. We compared radiological and surgical findings of 26 patients affected by otogenic meningitis. Results of our analysis showed that surgery is more reliable than imaging in revealing bone defects. Therefore, suggest that surgery be performed for diagnosis and eventual management of all cases of suspected otogenic meningitis.

Hypothenar hammer syndrome and basilic bypass.

PubMed

Chander, R K; Phair, J; Oza, P; Patel, M; Balar, N

2014-12-01

We report a case of hypothenar hammer syndrome. The case presents necessary diagnostic measures and discusses the etiology of this syndrome. Additionally, the case reviews treatments, which culminated in the eventual use of ulnar artery bypass with autogenous basilica vein to treat and resolve the ischemic fingers of the patient. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Determinants of compliance with nasal continuous positive airway pressure treatment applied in a community setting.

PubMed

Ball, E M.; Banks, M B.

2001-05-01

Objectives: To assess determinants of nasal continuous positive airway pressure (CPAP) compliance when applied in a community setting.Background: One-third of obstructive sleep apnea patients eventually refuse CPAP therapy. Treatment outcomes may be improved by identifying predictors of CPAP failure, including whether management by primary care physicians without sleep consultation affects results.Methods: Polysomnogram, chart review, and questionnaire results for regular CPAP users (n=123) were compared with those returning the CPAP machine (n=26).Results: Polysomnographic data and the presence of multiple sleep disorders were only modestly predictive of CPAP compliance. Striking differences in questionnaire responses separated CPAP users from non-users, who reported less satisfaction with all phases of their diagnosis and management. Rates of CPAP use were not significantly different between patients managed solely by their primary care physician or by a sleep consultant.Conclusions: Polysomnographic findings are unlikely to identify eventual CPAP non-compliers in a cost-effective fashion. Improvements in sleep apnea management may result from addressing the role of personality factors and multiple sleep disorders in determining compliance. In this practice setting, management by primary care physicians did not significantly degrade CPAP compliance.

Mody-3: novel HNF1A mutation and the utility of glucagon-like peptide (GLP)-1 receptor agonist therapy.

PubMed

Docena, Maricor K; Faiman, Charles; Stanley, Christine M; Pantalone, Kevin M

2014-02-01

An estimated 1 to 2% of cases of diabetes mellitus have a monogenic basis; however, delayed diagnosis and misdiagnosis as type 1 and 2 diabetes are common. Correctly identifying the molecular basis of an individual's diabetes may significantly alter the management approach to both the patient and his or her relatives. We describe a case of mature onset diabetes of the young (MODY) with sufficient evidence to support the classification of a novel HNF1A (hepatocyte nuclear factor-1-α) mutation as a cause of MODY-3. A 21-year-old Caucasian female presented to our office with a diagnosis of noninsulin-dependent diabetes mellitus (NIDDM) at age 10; glycemia was initially managed with oral antidiabetic (OAD) agents and insulin detemir. The patient reported a strong family history of early-onset NIDDM in both her mother and maternal grandmother, both of whom eventually required insulin therapy to control glycemia. The patient's medical and family history were highly suggestive of maturity-onset diabetes of the young (MODY), and genetic testing was performed. Genetic screening detected a mutation p. Arg200Trp in the HNF1A gene in the patient, her mother, and maternal grandmother, suggesting a diagnosis of MODY-3. This finding resulted in a change of antidiabetic therapy in all 3 patients, including the addition of once-daily liraglutide therapy, which helped improve their glycemic control. Our case report supports the classification of the p. Arg200Trp mutation as a cause of MODY-3. The findings also suggest that glucagon-like peptide-1 (GLP-1) receptor agonist therapy may be of value in managing glycemia in patients with MODY-3.

Bilateral endogenous necrotizing scleritis due to Aspergillus oryzae.

PubMed

Stenson, S; Brookner, A; Rosenthal, S

1982-01-01

A case of bilateral necrotizing scleritis due to Aspergillus oryzae is reported. The patient was a former addict of intravenous narcotics treated five years previously for meningitis due to the same organism. A seeding focus in the thoracic spine was eventually found. The patient responded well to combined local and systemic therapy with amphotericin B, flucytosine, and natamycin. This represents, to the best of our knowledge, both the first reported case of ocular disease due to this species of Aspergillus and of isolated scleral, nonintraocular involvement in endogenous oculomycosis.

Endoscopic ultrasound in pancreatic cancer: innovative applications beyond the basics.

PubMed

Yoo, Joseph; Kistler, C Andrew; Yan, Linda; Dargan, Andrew; Siddiqui, Ali A

2016-12-01

Endoscopic ultrasound (EUS) has become a mainstay in assisting in the diagnosis and staging of pancreatic cancer. In addition, EUS provides a modality to treat chronic pain through celiac plexus neurolysis. Currently, there is growing data and utilization of EUS in more diverse and innovative applications aimed at providing more sophisticated diagnostic, prognostic and therapeutic options for patients with pancreatic cancer. EUS delivery of chemotherapy, viral and biological vectors and fiducial markers may eventually revolutionize the way clinicians approach the care of a patient with pancreatic cancer.

Endoscopic ultrasound in pancreatic cancer: innovative applications beyond the basics

PubMed Central

Yoo, Joseph; Kistler, C. Andrew; Yan, Linda; Dargan, Andrew

2016-01-01

Endoscopic ultrasound (EUS) has become a mainstay in assisting in the diagnosis and staging of pancreatic cancer. In addition, EUS provides a modality to treat chronic pain through celiac plexus neurolysis. Currently, there is growing data and utilization of EUS in more diverse and innovative applications aimed at providing more sophisticated diagnostic, prognostic and therapeutic options for patients with pancreatic cancer. EUS delivery of chemotherapy, viral and biological vectors and fiducial markers may eventually revolutionize the way clinicians approach the care of a patient with pancreatic cancer. PMID:28078128

The Evolving Treatment Landscape of Advanced Renal Cell Carcinoma in Patients Progressing after VEGF Inhibition

PubMed Central

Barata, Pedro C.; Ornstein, Moshe C.

2017-01-01

Despite significant changes in the therapeutic landscape of renal cell carcinoma, the majority of patients with metastatic disease eventually progress after first-line treatment with vascular endothelial growth factor receptors (VEGFR) tyrosine kinase inhibitor (TKI) therapy. Understanding existing data on subsequent therapies is crucial to define an optimal treatment sequence following first-line failure. This review examines the data supporting currently approved agents in this setting and provides a framework for decision-making regarding treatment sequencing beyond first-line therapy with VEGFR TKIs. PMID:28725539

Postoperative conversion disorder.

PubMed

Afolabi, Kola; Ali, Sameer; Gahtan, Vivian; Gorji, Reza; Li, Fenghua; Nussmeier, Nancy A

2016-05-01

Conversion disorder is a psychiatric disorder in which psychological stress causes neurologic deficits. A 28-year-old female surgical patient had uneventful general anesthesia and emergence but developed conversion disorder 1 hour postoperatively. She reported difficulty speaking, right-hand numbness and weakness, and right-leg paralysis. Neurologic examination and imaging revealed no neuronal damage, herniation, hemorrhage, or stroke. The patient mentioned failing examinations the day before surgery and discontinuing her prescribed antidepressant medication, leading us to diagnose conversion disorder, with eventual confirmation by neuroimaging and follow-up examinations. Copyright © 2016 Elsevier Inc. All rights reserved.

Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm: a case report and literature review.

PubMed

Zhang, Shi-Huai; Zhang, Fu-Xian

2017-09-06

Aneurysm or pseudoaneurysm is the main vascular complication of Behcet's disease. Most hospitals adopt endovascular treatment. We report a case of Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm. The patient underwent two rounds of endovascular surgery, but developed new aneurysms immediately after surgery. Eventually, the patient died due to rupture of recurrent aneurysm. For vasculo-Behcet's disease, we suggest performing the operation during the stable period. At the same time, glucocorticoids could be used with immunosuppressants preoperatively and postoperatively.

A 17-Year-Old Girl With Acute Onset of Hemiparesis.

PubMed

Morrissey, Michael; Ciorciari, Anthony J; Cunningham, Sandra J

2016-06-01

The presentation of acute-onset hemiparesis in a teenager can be challenging and offers a wide differential diagnosis. We discuss the approach to the patient (which should begin with thorough history taking and physical examination) and advanced imaging as directed by the patient's signs and symptoms. We report the case of an otherwise well 17-year-old girl who presented to the pediatric emergency department with a 2-day history of left-sided weakness and difficulty ambulating. Her eventual diagnosis of Balo concentric sclerosis, a rare form of multiple sclerosis, is discussed.

Dynamics of memory-guided choice behavior in Drosophila

PubMed Central

ICHINOSE, Toshiharu; TANIMOTO, Hiromu

2016-01-01

Memory retrieval requires both accuracy and speed. Olfactory learning of the fruit fly Drosophila melanogaster serves as a powerful model system to identify molecular and neuronal substrates of memory and memory-guided behavior. The behavioral expression of olfactory memory has traditionally been tested as a conditioned odor response in a simple T-maze, which measures the result, but not the speed, of odor choice. Here, we developed multiplexed T-mazes that allow video recording of the choice behavior. Automatic fly counting in each arm of the maze visualizes choice dynamics. Using this setup, we show that the transient blockade of serotonergic neurons slows down the choice, while leaving the eventual choice intact. In contrast, activation of the same neurons impairs the eventual performance leaving the choice speed unchanged. Our new apparatus contributes to elucidating how the speed and the accuracy of memory retrieval are implemented in the fly brain. PMID:27725473

Pathologic Markers Determining Prognosis in Patients with Treated or Healing Giant Cell Arteritis.

PubMed

Sultan, Harris; Smith, Stacy V; Lee, Andrew G; Chévez-Barrios, Patricia

2018-06-08

To provide quantitative evidence linking the Cluster of Differentiation-68 (CD68)+ macrophage-marker found on temporal artery biopsies (TABs) with disease prognosis. Retrospective, cross-sectional study METHODS: We examined 42 consecutive patients who had undergone unilateral TABs at a single hospital in 2015. Clinical data, laboratory data, and histopathologic features of TABs were recorded. clinical diagnosis of giant cell arteritis (GCA) with TAB performed at the same center. CD68 immunohistochemistry was used to label macrophages in the TABs. multiple logistic regression and bivariate comparisons to measure the association between CD68+ cells per histologic section with placement on immunomodulatory therapy (IMT). Twenty seven patients were females (64%), with a mean age of 72 (standard deviation [S.D.] ±7.7). Eleven patients (26%) were placed on IMT, 17 (40%) had disease recurrence during steroid taper, and 25 (60%) were referred to rheumatology. Of 42 biopsies, 35 underwent staining with CD68 to confirm active inflammation in suspicious, but not diagnostic, specimens. Patients eventually placed on IMT had increased CD68+ cells/slice compared to those not on IMT (median 5.00 [25-75 th quartile 2.00-7.15] vs 1.21 [0.38-2.57], p=0.031, respectively). A receiver operating characteristics (ROC) curve demonstrates that 2.17 CD68+ cells/slice predicts placement on IMT with an odds ratio of 1.54 (95% C.I. 1.02-2.33, p=0.038). Patients refractory to initial steroid tapers and those eventually placed on IMT had increased CD68 cells/section. CD68+ macrophages and their location on the internal elastic lamina may predict disease severity in patients with presumed GCA. Our results suggest that this marker may expedite patient triaging to alternate treatment to the usual steroid therapy. Copyright © 2018 Elsevier Inc. All rights reserved.

Total Artificial Heart Implantation as a Bridge to Heart Transplantation in an Active Duty Service Member With Amyloid Cardiomyopathy.

PubMed

Scully, Michael S; Wessman, Dylan E; McKee, James M; Francisco, Gregory M; Nayak, Keshav R; Kobashigawa, Jon A

2017-03-01

Cardiac involvement by light-chain (AL) amyloid occurs in up to 50% of patients with primary AL amyloidosis. The prognosis of amyloid heart disease is poor with 1-year survival rates of 35 to 40%. Historically, heart transplantation was considered controversial for patients with AL amyloid cardiomyopathy (CM) given the systemic nature of the disease and poor survival. We present a case report of an active duty service member diagnosed with advanced cardiac amyloid who underwent total artificial heart transplant as a bridge to heart transplant and eventual autologous stem cell transplant. A 47-year-old active duty male initially evaluated for atypical chest pain was found to have severe concentric left ventricular hypertrophy on echocardiogram but normal voltage on electrocardiogram. Cardiac magnetic resonance imaging, laboratory studies, and bone marrow biopsy established the diagnosis of cardiac amyloidosis. At the time of diagnosis, the patient's prognosis was very poor with a median survival of 5 months on the basis of the Mayo Clinic revised prognostic staging system for amyloidosis. The patient developed rapidly progressive left ventricular dysfunction and heart failure leading to cardiac arrest. The patient received a total artificial heart as a bridge to orthotopic heart and kidney transplantation and eventual stem cell transplant. He continues to be in remission and has a fair functional capacity without restriction in activities of daily living or moderate exercise. Amyloid CM is a rare and devastating disease. The natural course of the disease has made heart transplant in these patients controversial. Modern advancements in chemotherapies and advanced heart failure treatments have improved outcomes for select patients with AL amyloid CM undergoing heart transplantation. There is ongoing research seeking improvement in treatment options and outcomes for patients with this deadly disease. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Requirements analysis, domain knowledge, and design

NASA Technical Reports Server (NTRS)

Potts, Colin

1988-01-01

Two improvements to current requirements analysis practices are suggested: domain modeling, and the systematic application of analysis heuristics. Domain modeling is the representation of relevant application knowledge prior to requirements specification. Artificial intelligence techniques may eventually be applicable for domain modeling. In the short term, however, restricted domain modeling techniques, such as that in JSD, will still be of practical benefit. Analysis heuristics are standard patterns of reasoning about the requirements. They usually generate questions of clarification or issues relating to completeness. Analysis heuristics can be represented and therefore systematically applied in an issue-based framework. This is illustrated by an issue-based analysis of JSD's domain modeling and functional specification heuristics. They are discussed in the context of the preliminary design of simple embedded systems.

Formal analysis of imprecise system requirements with Event-B.

PubMed

Le, Hong Anh; Nakajima, Shin; Truong, Ninh Thuan

2016-01-01

Formal analysis of functional properties of system requirements needs precise descriptions. However, the stakeholders sometimes describe the system with ambiguous, vague or fuzzy terms, hence formal frameworks for modeling and verifying such requirements are desirable. The Fuzzy If-Then rules have been used for imprecise requirements representation, but verifying their functional properties still needs new methods. In this paper, we propose a refinement-based modeling approach for specification and verification of such requirements. First, we introduce a representation of imprecise requirements in the set theory. Then we make use of Event-B refinement providing a set of translation rules from Fuzzy If-Then rules to Event-B notations. After that, we show how to verify both safety and eventuality properties with RODIN/Event-B. Finally, we illustrate the proposed method on the example of Crane Controller.

Gallbladder Cancer Presenting with Jaundice: Uniformly Fatal or Still Potentially Curable?

PubMed

Tran, Thuy B; Norton, Jeffrey A; Ethun, Cecilia G; Pawlik, Timothy M; Buettner, Stefan; Schmidt, Carl; Beal, Eliza W; Hawkins, William G; Fields, Ryan C; Krasnick, Bradley A; Weber, Sharon M; Salem, Ahmed; Martin, Robert C G; Scoggins, Charles R; Shen, Perry; Mogal, Harveshp D; Idrees, Kamran; Isom, Chelsea A; Hatzaras, Ioannis; Shenoy, Rivfka; Maithel, Shishir K; Poultsides, George A

2017-08-01

Jaundice as a presenting symptom of gallbladder cancer has traditionally been considered to be a sign of advanced disease, inoperability, and poor outcome. However, recent studies have demonstrated that a small subset of these patients can undergo resection with curative intent. Patients with gallbladder cancer managed surgically from 2000 to 2014 in 10 US academic institutions were stratified based on the presence of jaundice at presentation (defined as bilirubin ≥4 mg/ml or requiring preoperative biliary drainage). Perioperative morbidity, mortality, and overall survival were compared between jaundiced and non-jaundiced patients. Of 400 gallbladder cancer patients with available preoperative data, 108 (27%) presented with jaundice while 292 (73%) did not. The fraction of patients who eventually underwent curative-intent resection was much lower in the presence of jaundice (n = 33, 30%) than not (n = 218, 75%; P < 0.001). Jaundiced patients experienced higher perioperative morbidity (69 vs. 38%; P = 0.002), including a much higher need for reoperation (12 vs. 1%; P = 0.003). However, 90-day mortality (6.5 vs. 3.6%; P = 0.35) was not significantly higher. Overall survival after resection was worse in jaundiced patients (median 14 vs. 32 months; P < 0.001). Further subgroup analysis within the jaundiced patients revealed a more favorable survival after resection in the presence of low CA19-9 < 50 (median 40 vs. 12 months; P = 0.003) and in the absence of lymphovascular invasion (40 vs. 14 months; P = 0.014). Jaundice is a powerful preoperative clinical sign of inoperability and poor outcome among gallbladder cancer patients. However, some of these patients may still achieve long-term survival after resection, especially when preoperative CA19-9 levels are low and no lymphovascular invasion is noted pathologically.

Long-Term Outcomes Among Patients Who Achieve Complete or Near-Complete Responses After the Induction Phase of Bladder-Preserving Combined-Modality Therapy for Muscle-Invasive Bladder Cancer: A Pooled Analysis of NRG Oncology/RTOG 9906 and 0233

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

Mitin, Timur, E-mail: mitin@ohsu.edu; George, Asha; Zietman, Anthony L.

Purpose: To investigate the differences in outcomes among patients with muscle-invasive bladder cancer on NRG Oncology Radiation Therapy Oncology Group protocols 9906 and 0233 who achieved complete response and near-complete response after induction chemoradiation and then completed bladder-preserving therapy with chemoradiation therapy (chemo-RT) to full dose (60-64 Gy). Patients and Methods: A pooled analysis was performed on 119 eligible patients with muscle-invasive bladder cancer enrolled on NRG Oncology Radiation Therapy Oncology Group trials 9906 and 0233, who were classified as having a complete (T0) or near-complete (Ta or Tis) response after induction chemo-RT and completed consolidation with a total RT dose ofmore » at least 60 Gy. Bladder recurrence, salvage cystectomy rates, and disease-specific survival were estimated by the cumulative incidence method and bladder-intact and overall survivals by the Kaplan-Meier method. Results: Among the 119 eligible patients, 101 (85%) achieved T0, and 18 (15%) achieved Ta or Tis after induction chemo-RT and proceeded to consolidation. After a median follow-up of 5.9 years, 36 of 101 T0 patients (36%) versus 5 of 18 Ta or Tis patients (28%) experienced bladder recurrence (P=.52). Thirteen patients among complete responders eventually required late salvage cystectomy for tumor recurrence, compared with 1 patient among near-complete responders (P=.63). Disease-specific, bladder-intact, and overall survivals were not significantly different between T0 and Ta/Tis cases. Conclusions: The bladder recurrence and salvage cystectomy rates of the complete and the near-complete responders were similar. Therefore it is reasonable to recommend that patients with Ta or Tis after induction chemo-RT continue with bladder-sparing therapy with consolidation chemo-RT to full dose (60-64 Gy).« less

Is non-operative management still justified in the treatment of adhesive small bowel obstruction in children?

PubMed

Nasir, Abdulrasheed A; Abdur-Rahman, Lukman O; Bamigbola, Kayode T; Oyinloye, Adewale O; Abdulraheem, Nurudeen T; Adeniran, James O

2013-01-01

Adhesive small bowel obstruction (ASBO) is a feared complication after abdominal operations in both children and adults. The optimal management of ASBO in the pediatric population is debated. The aim of the present study was to examine the safety and effectiveness of non-operative management in ASBO. A retrospective review of 33 patients who were admitted for ASBO over a 5-year period was carried out. Follow-up data were available for 29 patients. Demographic, clinical, and operative details and outcomes were collected for these patients. Data analysis was done with SPSS version 15.0. P ≤ 0.05 was regarded as significant. Out of 618 abdominal surgeries within the 5-year period, 34 admissions were recorded from 29 patients at the follow-up period of 1-28 months. There were 19 boys (65.5%). The median age of patients was 4.5 years. Typhoid intestinal perforation (n = 7), intussusception (n = 6), intestinal malrotation (n = 5), and appendicitis (n = 4) were the major indications for a prior abdominal surgery leading to ASBO. Twenty-five patients (73.5%) developed SBO due to adhesions within the first year of the primary procedure. Of the 34 patients admitted with ASBO, 18 (53%) underwent operative intervention and 16 (47%) were successfully managed non-operatively. There were no differences in sex (P = 0.24), initial procedure (P = 0.12), age, duration of symptoms, and time to re-admission between the patients who responded to non-operative management and those who underwent operative intervention. However, the length of hospital stay was significantly shorter in the non-operative group (P < 0.0001). Five (14.7%) patients had small bowel resection. A 43-day-old child who initially underwent Ladd's procedure died within 15 h of re-admission while being prepared for surgery, accounting for the only mortality (3.4%). Non-operative management is still a safe and preferred approach in selected patients with ASBO. However, 53% eventually required surgery.

Does previous open renal surgery or percutaneous nephrolithotomy affect the outcomes and complications of percutaneous nephrolithotomy.

PubMed

Ozgor, Faruk; Kucuktopcu, Onur; Sarılar, Omer; Toptas, Mehmet; Simsek, Abdulmuttalip; Gurbuz, Zafer Gokhan; Akbulut, Mehmet Fatih; Muslumanoglu, Ahmet Yaser; Binbay, Murat

2015-11-01

In this study, we aim to evaluate the effectiveness and safety of PNL in patients with a history of open renal surgery or PNL by comparing with primary patients and to compare impact of previous open renal surgery and PNL on the success and complications of subsequent PNL. Charts of patients, who underwent PNL at our institute, were analyzed retrospectively. Patients were divided into three groups according to history of renal stone surgery. Patients without history of renal surgery were enrolled into Group 1. Other patients with previous PNL and previous open surgery were categorized as Group 2 and Group 3. Preoperative characteristic, perioperative data, stone-free status, and complication rates were compared between the groups. Stone-free status was accepted as completing clearance of stone and residual fragment smaller than 4 mm. Eventually, 2070 patients were enrolled into the study. Open renal surgery and PNL had been done in 410 (Group 2) and 131 (Group 3) patients, retrospectively. The mean operation time was longer (71.3 ± 33.5 min) in Group 2 and the mean fluoroscopy time was longer (8.6 ± 5.0) in Group 3 but there was no statistically significant difference between the groups. Highest stone clearance was achieved in primary PNL patients (81.62%) compared to the other groups (77.10% in Group 2 and 75.61% in Group 3). Stone-free rate was not significantly different between Group 2 and Group 3. Fever, pulmonary complications, and blood transfusion requirement were not statically different between groups but angioembolization was significantly higher in Group 2. Percutaneous nephrolithotomy is a safe and effective treatment modality for patients with renal stones regardless history of previous PNL or open renal surgery. However, history of open renal surgery but not PNL significantly reduced PNL success.

Do surgeons and patients discuss what they document on consent forms?

PubMed

Hall, Daniel E; Hanusa, Barbara H; Fine, Michael J; Arnold, Robert M

2015-07-01

Previous studies of surgeon behavior report that surgeons rarely meet basic standards of informed consent, raising concerns that current practice requires urgent remediation. We wondered if the Veterans Affairs Healthcare System's recent implementation of standardized, procedure-specific consent forms might produce a better practice of informed consent than has been reported previously. Our goal was to determine how the discussions shared between surgeons and patients correspond to the VA's standardized consent forms. We enrolled a prospective cohort of patients presenting for possible cholecystectomy or inguinal herniorrhaphy and the surgical providers for those patients. Audio recordings captured the clinical encounter(s) culminating in a decision to have surgery. Each patient's informed consent was documented using a standardized, computer-generated form. We abstracted and compared the information documented with the information discussed. Of 75 consecutively enrolled patients, 37 eventually decided to have surgery and signed the standardized consent form. Patients and providers discussed 37% (95% confidence interval, 0.07-0.67) and 33% (95% confidence interval, 0.21-0.43) of the information found on the cholecystectomy and herniorrhaphy consent forms, respectively. However, the patient-provider discussions frequently included relevant details nowhere documented on the standardized forms, culminating in discussions that included a median 27.5 information items for cholecystectomy and 20 items for herniorrhaphy. Fully, 80% of cholecystectomy discussions and 76% of herniorrhaphy discussions mentioned at least one risk, benefit or alternative, indication for, and description of the procedure. The patients and providers observed here collaborated in a detailed process of informed consent that challenges the initial reports suggesting the need to remediate surgeon's practice of informed consent. However, because the discrepancy between the information documented and discussed exposes legal and ethical liability, there is an opportunity to improve the iMed system so that it better reflects what surgeons discuss and more frequently includes all the information patients need. Published by Elsevier Inc.

Design and Development of a Miniaturized Percutaneously Deployable Wireless Left Ventricular Assist Device: Early Prototypes and Feasibility Testing.

PubMed

Letzen, Brian; Park, Jiheum; Tuzun, Zeynep; Bonde, Pramod

The current left ventricular assist devices (LVADs) are limited by a highly invasive implantation procedure in a severely unstable group of advanced heart failure patients. Additionally, the current transcutaneous power drive line acts as a nidus for infection resulting in significant morbidity and mortality. In an effort to decrease this invasiveness and eliminate drive line complications, we have conceived a wireless miniaturized percutaneous LVAD, capable of being delivered endovascularly with a tether-free operation. The system obviates the need for a transcutaneous fluid purge line required in existing temporary devices by utilizing an incorporated magnetically coupled impeller for a complete seal. The objective of this article was to demonstrate early development and proof-of-concept feasibility testing to serve as the groundwork for future formalized device development. Five early prototypes were designed and constructed to iteratively minimize the pump size and improve fluid dynamic performance. Various magnetic coupling configurations were tested. Using SolidWorks and ANSYS software for modeling and simulation, several geometric parameters were varied. HQ curves were constructed from preliminary in vitro testing to characterize the pump performance. Bench top tests showed no-slip magnetic coupling of the impeller to the driveshaft up to the current limit of the motor. The pump power requirements were tested in vitro and were within the appropriate range for powering via a wireless energy transfer system. Our results demonstrate the proof-of-concept feasibility of a novel endovascular cardiac assist device with the potential to eventually offer patients an untethered, minimally invasive support.

Surgical tips and tricks during urethroplasty for bulbar urethral strictures focusing on accurate localisation of the stricture: results from a tertiary centre.

PubMed

Kuo, Tricia L C; Venugopal, Suresh; Inman, Richard D; Chapple, Christopher R

2015-04-01

There are several techniques for characterising and localising an anterior urethral stricture, such as preoperative retrograde urethrography, ultrasonography, and endoscopy. However, these techniques have some limitations. The final determinant is intraoperative assessment, as this yields the most information and defines what surgical procedure is undertaken. We present our intraoperative approach for localising and operating on a urethral stricture, with assessment of outcomes. A retrospective review of urethral strictures operated was carried out. All patients had a bulbar or bulbomembranous urethroplasty. All patients were referred to a tertiary centre and operated on by two urethral reconstructive surgeons. Intraoperative identification of the stricture was performed by cystoscopy. The location of the stricture is demonstrated externally on the urethra by external transillumination of the urethra and comparison with the endoscopic picture. This is combined with accurate placement of a suture through the urethra, at the distal extremity of the stricture, verified precisely by endoscopy. Clinical data were collected in a dedicated database. Intraoperative details and postoperative follow-up data for each patient were recorded and analysed. A descriptive data analysis was performed. A representative group of 35 male patients who had surgery for bulbar stricture was randomly selected from January 2010 to December 2013. Mean follow-up was 13.8 mo (range 2-43 mo). Mean age was 46.5 yr (range 17-70 yr). Three patients had undergone previous urethroplasty and 26 patients had previous urethrotomy or dilatation. All patients had preoperative retrograde urethrography and most (85.7%) had endoscopic assessment. The majority of patients (48.6%) had a stricture length of >2-7 cm and 45.7% of patients required a buccal mucosa graft. There were no intraoperative complications. Postoperatively, two patients had a urinary tract infection. All patients were assessed postoperatively via flexible cystoscopy. Only one patient required subsequent optical urethrotomy for recurrence. Our intraoperative strategy for anterior urethral stricture assessment provides a clear stepwise approach, regardless of the type of urethroplasty eventually chosen (anastomotic disconnected or Heineke-Mikulicz) or augmentation (dorsal, ventral, or augmented roof strip). It is useful in all cases by allowing precise localisation of the incision in the urethra, whether the stricture is simple or complex. We studied the treatment of bulbar urethral strictures with different types of urethroplasty, using a specific technique to identify and characterise the length of the stricture. This technique is effective, precise, and applicable to all patients undergoing urethroplasty for bulbar urethral stricture. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

[Intrathecal baclofen therapy for spastic paraparesis due to aortic dissecting aneurysm; recent progress in treatment strategy].

PubMed

Nakajima, T; Akagawa, H; Ochiai, T; Hayashi, M; Goto, S; Taira, T; Okada, Y

2009-11-01

A 48-year-old man suffered from acute dissection of thoracic aortic aneurysm which eventually led to replacement of the ascending aorta with a tube graft. During this clinical course, circulatory failure in intercostal artery resulted in spinal cord infarction followed by moto-sensory disturbance below Th7 dermatomic area. Seven months later, spasticity with pain in both lower extremities became conspicuous that was uncontrollable by any oral medication. Eventually the patient underwent the implantation of continuous infusion pump for intrathecal baclofen therapy (ITB). The clinical condition was remarkably improved and now has been well controlled. ITB, authorized by Japanese Ministry of Health Labour and Welfare in 2006, has notable therapeutic effects on spasticity derived from any sort of central nervous disorder. More promotive enlightenment if ITB is indispensable for enhancement of its medical benefit in Japan.

Everolimus affects vasculogenic mimicry in renal carcinoma resistant to sunitinib

PubMed Central

Serova, Maria; Tijeras-Raballand, Annemilaï; Santos, Celia Dos; Martinet, Matthieu; Neuzillet, Cindy; Lopez, Alfred; Mitchell, Dianne C.; Bryan, Brad A.; Gapihan, Guillaume; Janin, Anne; Bousquet, Guilhem; Riveiro, Maria Eugenia; Bieche, Ivan; Faivre, Sandrine

2016-01-01

Angiogenesis is hallmark of clear cell renal cell carcinogenesis. Anti-angiogenic therapies have been successful in improving disease outcome; however, most patients treated with anti-angiogenic agents will eventually progress. In this study we report that clear cell renal cell carcinoma was associated with vasculogenic mimicry in both mice and human with tumor cells expressing endothelial markers in the vicinity of tumor vessels. We show that vasculogenic mimicry was efficiently targeted by sunitinib but eventually associated with tumor resistance and a more aggressive phenotype both in vitro and in vivo. Re-challenging these resistant tumors in mice, we showed that second-line treatment with everolimus particularly affected vasculogenic mimicry and tumor cell differentiation compared to sorafenib and axitinib. Finally, our results highlighted the phenotypic and genotypic changes at the tumor cell and microenvironment levels during sunitinib response and progression and the subsequent improvement second-line therapies bring to the current renal cell carcinoma treatment paradigm. PMID:27509260

1981 Image II Conference Proceedings.

DTIC Science & Technology

1981-11-01

rapid motion of terrain detail across the display requires fast display processors. Other difficulties are perceptual: the visual displays must convey...has been a continuing effort by Vought in the last decade. Early systems were restricted by the unavailability of video bulk storage with fast random...each photograph. The calculations aided in the proper sequencing of the scanned scenes on the tape recorder and eventually facilitated fast random

The Anniversary of the First Public Announcement of the Successful Test of Fission Proceedings (50th) Held in Washington, DC on 17 January 1989

DTIC Science & Technology

1989-01-17

Sigmund Freud but eventually broke with him and established his own school and pattern of work. When studying the behavioral patterns of children and...conform in most cases to U matters related to sexual activities so strongly emphasized by Freud . Instead, they required much more general analysis and

Developing teamwork skills in capstone design courses.

PubMed

Goldberg, Jay

2010-01-01

The majority of our biomedical engineering graduates will eventually work in an industry where they will be part of multidisciplinary teams that use the collective skills, expertise, experience, and training of each team member. Diversity within these teams provides different perspectives, opinions, and ways of viewing problems, leading to a larger set of potential solutions. Successful careers require engineers to be able to function on multidisciplinary teams.

New-onset neonatal pulmonary hypertension associated with a rhinovirus infection

PubMed Central

Patel, Nishit; The, Tiong G

2012-01-01

A 3.5-week-old male neonate who developed an upper and lower respiratory tract rhinovirus infection that was temporally associated with the development of severe pulmonary hypertension is described. Rhinovirus has not previously been associated with pulmonary hypertension. This child developed severe pulmonary hypertension with right ventricular failure, requiring mechanical ventilation, nitric oxide inhalation and, eventually, extracorporeal membrane oxygenation. PMID:22332130

Texas High School Seniors: The Path of Students Who Fail the First Administration of End of Course Exams and Eventually Meet Standard and Graduate

ERIC Educational Resources Information Center

Nanez, Lilia G.

2015-01-01

This qualitative phenomenological research study investigated Texas high school seniors who failed the initial administration of the End of Course (EOC) exams required for graduation but succeeded upon subsequent test administration. The four questions that guided the research explored the experienced regarding the EOC exams by identifying which…

Isolated Major Aortopulmonary Collateral as the Sole Pulmonary Blood Supply to an Entire Lung Segment.

PubMed

Kim, Hannah S; Grady, R Mark; Shahanavaz, Shabana

2017-01-01

Congenital systemic-to-pulmonary collateral arteries or major aortopulmonary collaterals are associated with cyanotic congenital heart disease with decreased pulmonary blood flow. Though it is usually associated with congenital heart diseases, there is an increased incidence of isolated acquired aortopulmonary collaterals in premature infants with chronic lung disease. Interestingly, isolated congenital aortopulmonary collaterals can occur without any lung disease, which may cause congestive heart failure and require closure. We present a neonate with an echocardiogram that showed only left-sided heart dilation. Further workup with a CT angiogram demonstrated an anomalous systemic artery from the descending thoracic aorta supplying the left lower lobe. He eventually developed heart failure symptoms and was taken to the catheterization laboratory for closure of the collateral. However, with the collateral being the only source of blood flow to the entire left lower lobe, he required surgical unifocalization. Isolated aortopulmonary collaterals without any other congenital heart disease or lung disease are rare. Our patient is the first reported case to have an isolated aortopulmonary collateral being the sole pulmonary blood supply to an entire lung segment. Due to its rarity, there is still much to learn about the origin and development of these collaterals that possibly developed prenatally.

Is Repeat PTA of a Failing Hemodialysis Fistula Durable?

PubMed Central

Zdanowski, Zbigniew

2014-01-01

Purpose. Our objective was to evaluate the outcome of percutaneous transluminal angioplasty (PTA) and particularly rePTA in a failing arteriovenous fistula (AV-fistula). Are multiple redilations worthwhile? Patients and Methods. All 159 stenoses of AV fistulas that were treated with PTA, with or without stenting, during 2008 and 2009, were included. Occluded fistulas that were dilated after successful thrombolysis were also included. Median age was 68 (interquartile range 61.5–78.5) years and 75% were male. Results. Seventy-nine (50%) of the primary PTAs required no further reintervention. The primary patency was 61% at 6 months and 42% at 12 months. Eighty (50%) of the stenoses needed at least one reintervention. Primary assisted patency (defined as patency after subsequent reinterventions) was 89% at 6 months and 85% at 12 months. The durability of repeated PTAs was similar to the durability of the primary PTA. However, an early primary PTA carried a higher risk for subsequent reinterventions. Successful dialysis was achieved after 98% of treatments. Nine percent of the stenoses eventually required surgical revision and 13% of the fistulas failed permanently. Conclusion. The present study suggests that most failing AV-fistulas can be salvaged endovascularly. Repeated PTA seems similarly durable as the primary PTA. PMID:24587906

Sunitinib dose escalation overcomes transient resistance in clear cell renal cell carcinoma and is associated with epigenetic modifications.

PubMed

Adelaiye, Remi; Ciamporcero, Eric; Miles, Kiersten Marie; Sotomayor, Paula; Bard, Jonathan; Tsompana, Maria; Conroy, Dylan; Shen, Li; Ramakrishnan, Swathi; Ku, Sheng-Yu; Orillion, Ashley; Prey, Joshua; Fetterly, Gerald; Buck, Michael; Chintala, Sreenivasulu; Bjarnason, Georg A; Pili, Roberto

2015-02-01

Sunitinib is considered a first-line therapeutic option for patients with advanced clear cell renal cell carcinoma (ccRCC). Despite sunitinib's clinical efficacy, patients eventually develop drug resistance and disease progression. Herein, we tested the hypothesis whether initial sunitinib resistance may be transient and could be overcome by dose increase. In selected patients initially treated with 50 mg sunitinib and presenting with minimal toxicities, sunitinib dose was escalated to 62.5 mg and/or 75 mg at the time of tumor progression. Mice bearing two different patient-derived ccRCC xenografts (PDX) were treated 5 days per week with a dose-escalation schema (40-60-80 mg/kg sunitinib). Tumor tissues were collected before dose increments for immunohistochemistry analyses and drug levels. Selected intrapatient sunitinib dose escalation was safe and several patients had added progression-free survival. In parallel, our preclinical results showed that PDXs, although initially responsive to sunitinib at 40 mg/kg, eventually developed resistance. When the dose was incrementally increased, again we observed tumor response to sunitinib. A resistant phenotype was associated with transient increase of tumor vasculature despite intratumor sunitinib accumulation at higher dose. In addition, we observed associated changes in the expression of the methyltransferase EZH2 and histone marks at the time of resistance. Furthermore, specific EZH2 inhibition resulted in increased in vitro antitumor effect of sunitinib. Overall, our results suggest that initial sunitinib-induced resistance may be overcome, in part, by increasing the dose, and highlight the potential role of epigenetic changes associated with sunitinib resistance that can represent new targets for therapeutic intervention. ©2014 American Association for Cancer Research.

Heart transplantation for adults with congenital heart disease: current status and future prospects.

PubMed

Matsuda, Hikaru; Ichikawa, Hajime; Ueno, Takayoshi; Sawa, Yoshiki

2017-06-01

Increased survival rates after corrective or palliative surgery for complex congenital heart disease (CHD) in infancy and childhood are now being coupled with increased numbers of patients who survive to adulthood with various residual lesions or sequelae. These patients are likely to deteriorate in cardiac function or end-organ function, eventually requiring lifesaving treatment including heart transplantation. Although early and late outcomes of heart transplantation have been improving for adult survivors of CHD, outcomes and pretransplant management could still be improved. Survivors of Fontan procedures are a vulnerable cohort, particularly when single ventricle physiology fails, mostly with protein-losing enteropathy and hepatic dysfunction. Therefore, we reviewed single-institution and larger database analyses of adults who underwent heart transplantation for CHD, to enable risk stratification by identifying the indications and outcomes. As the results, despite relatively high early mortality, long-term results were encouraging after heart transplantation. However, further investigations are needed to improve the indication criteria for complex CHD, especially for failed Fontan. In addition, the current system of status criteria and donor heart allocation system in heart transplantation should be arranged as suitable for adults with complex CHD. Furthermore, there is a strong need to develop ventricular assist devices as a bridge to transplantation or destination therapy, especially where right-sided circulatory support is needed.

Bilateral cataract formation via acute spontaneous fracture of the lens following treatment of hyperglycemic hyperosmolar syndrome.

PubMed

Sychev, Yevgeniy V; Zepeda, Emily M; Lam, Deborah L

2017-09-01

Acute development of cataracts that may be transient is known to occur during correction of diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Nettleship in 1885 was the first to describe the presence of a transient cataract in three diabetic patients that grew worse and eventually cleared with treatment. 1 We present a case of irreversible cataracts formed by nuclear fracture of the crystalline lens after hyperglycemia correction, an entity that has not yet been described. A 67 year-old Caucasian man presented with sudden bilateral vision loss one week after a week-long hospitalization in the intensive care unit for correction of hyperglycemia in the setting of hyperglycemic hyperosmolar syndrome requiring an insulin drip. This was caused by spontaneous fractures of the lens nuclei causing bilateral irreversible cataracts. The patient underwent uncomplicated bilateral cataract extraction resulting in restoration of normal vision. Acute transient cataracts that develop during correction of hyperglycemic hyperosmolar syndrome are thought to result from osmotic lens swelling. In this case report, internal fracture of the lens was produced by mechanical forces generated in the process of lens swelling occurring as a consequence of initial hyperglycemia and its subsequent correction. This case represents a rare ocular complication of hyperglycemia correction, and provides new evidence that mechanical forces can be part of diabetic cataractogenesis.

Wound outcome in combat injuries is associated with a unique set of protein biomarkers

PubMed Central

2013-01-01

Background The ability to forecast whether a wound will heal after closure without further debridement(s), would provide substantial benefits to patients with severe extremity trauma. Methods Wound effluent is a readily available material which can be collected without disturbing healthy tissue. For analysis of potential host response biomarkers, forty four serial combat wound effluent samples from 19 patients with either healing or failing traumatic- and other combat-related wounds were examined by 2-D DIGE. Spot map patterns were correlated to eventual wound outcome (healed or wound failure) and analyzed using DeCyder 7.0 and differential proteins identified via LC-MS/MS. Results This approach identified 52 protein spots that were differentially expressed and thus represent candidate biomarkers for this clinical application. Many of these proteins are intimately involved in inflammatory and immune responses. Furthermore, discriminate analysis further refined the 52 differential protein spots to a smaller subset of which successfully differentiate between wounds that will heal and those that will fail and require further surgical intervention with greater than 83% accuracy. Conclusion These results suggest candidates for a panel of protein biomarkers that may aid traumatic wound care prognosis and treatment. We recommend that this strategy be refined, and then externally validated, in future studies of traumatic wounds. PMID:24192341

Management of hyperuricemia in gout: focus on febuxostat

PubMed Central

Reinders, Mattheus K; Jansen, Tim L Th A

2010-01-01

Gout is the most common inflammatory arthritis in an elderly population, and can be diagnosed with absolute certainty by polarization microscopy. However, diagnosis may be challenging because atypical presentations are more common in the elderly. Management of hyperuricemia in the elderly with gout requires special consideration because of co-medication, contra-indications, and risk of adverse reactions. Urate-lowering agents include allopurinol and uricosuric agents. These also must be used sensibly in the elderly, especially when renal function impairment is present. However, if used at the lowest dose that maintains the serum urate level below 5.0 to 6.0 mg/dL (0.30 to 0.36 mmol/L), the excess urate in the body will eventually be eliminated, acute flares will no longer occur, and tophi will resolve. Febuxostat, a new xanthine oxidase inhibitor, is welcomed, as few alternatives for allopurinol are available. Its pharmacokinetics and pharmacodynamics are not significantly altered in patients with moderate renal function or hepatic impairment. Its antihyperuricemic efficacy at 80 to 120 mg/day is better than “standard dosage” allopurinol (300 mg/day). Long-term safety data and efficacy data on tophus diminishment and reduction of gout flares have recently become available. Febuxostat may provide an important option in patients unable to use allopurinol, or refractory to allopurinol. PMID:20169038

Telerehabilitation for patients with heart failure.

PubMed

Tousignant, Michel; Mampuya, Warner Mbuila

2015-02-01

Heart failure is a chronic and progressive condition that is associated with high morbidity and mortality rates. Even though cardiac rehabilitation (CR) has been shown to be beneficial to heart failure patients, only a very small proportion of them will actually be referred and eventually participate. The low participation rate is due in part to accessibility and travel difficulties. Telerehabilitation is a new approach in the rehabilitation field that allows patients to receive a complete rehabilitation program at home in a safe manner and under adequate supervision. We believe that by increasing accessibility to CR, telerehabilitation programs will significantly improve heart failure patients' functional capacity and quality of life. However, it is crucial to provide policy makers with evidence-based data on cardiac telerehabilitation if we want to see its successful implementation in heart failure patients.

Extracorporeal shock wave lithotripsy for obstructing pancreatic duct calculi.

PubMed

Matthews, K; Correa, R J; Gibbons, R P; Weissman, R M; Kozarek, R A

1997-08-01

A review was done to determine the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in the treatment of impacted pancreatic duct calculi. A total of 19 patients, who were potential candidates for radical pancreatic surgery after unsuccessful endoscopic retrograde cholangiopancreatography, sphincterotomy and attempted stone extraction from the pancreatic ducts, underwent ESWL of the calculi. Followup ranged from 6 months to 6 years. Of the 19 patients 14 avoided a major operation and 6 have remained pain-free for the long term. Two patients died of causes not related to ESWL or endoscopic retrograde cholangiopancreatography. Five patients eventually underwent a Whipple or Puestow procedure for relief of symptoms or persistent obstruction. Complications were minimal. ESWL is a valuable adjunct in patients with impacted pancreatic duct calculi unretrievable by primary endoscopic retrograde cholangiopancreatography.

Characteristics of Cervical Spine Injury in Pediatric Patients With Facial Fractures.

PubMed

Halsey, Jordan N; Hoppe, Ian C; Marano, Andrew A; Kordahi, Anthony M; Lee, Edward S; Granick, Mark S

2016-01-01

Cervical spine injury may present with pediatric patients having sustained fractures of the craniofacial skeleton. Management considerations of the cervical spine often take priority to the fractures of the facial skeleton. The goal of this study was to examine this subset of patients with a focus on initial presentation and need for intervention. A retrospective review from 2000 to 2012 of all facial fractures in patients ≤ 18 years at a level 1 trauma center was performed. Patient demographics, location of fractures, and the presence of a cervical spine injury were collected. During this time period, 285 patients met inclusion criteria. Ten patients were found to have a cervical spine injury. Fractures of the zygoma and orbit were significantly associated with a cervical spine injury. Patients with a cervical spine injury had a Glasgow Coma Scale of 11.2 compared with 13.8 in those without (P < 0.05). C1 was injured in 4 patients, C2 in 2 patients, and C3 to C7 in 4 patients. A surgical airway was required in 1 patient, and 6 were intubated in the trauma bay. Fractures of the mandible were significantly associated with injury to C2. Le Fort fractures and palate fractures approached significance with injury to C1. Only 1 patient had neurologic impairment at presentation, manifested as upper extremity parasthesias, and underwent decompression and fusion in the operating room. Those patients admitted (90%) were all admitted for reasons other than management of the cervical spine injury. The majority of patients (70%) were treated with collar immobilization. One patient expired. No patients had a neurologic deficit at the time of discharge. In this study only 1 cervical spine injury necessitated intervention, with an eventual full recovery. Cervical spine injuries presenting with fractures of the facial skeleton appear to be relatively benign in this series; however, care must be taken to identify all such injuries to avoid exacerbation during maneuvers commonly used for facial fracture treatment. Special caution should be used when examining patients with a depressed Glasgow Coma Scale or in those with upper midface fractures.

A medical oncologist's approach to immunotherapy for advanced renal tumors: is nephrectomy indicated?

PubMed

Cooney, Matthew M; Remick, Scot C; Vogelzang, Nicholas J

2004-02-01

Metastatic renal cell carcinoma is highly resistant to systemic therapy. Although interleukin-2 and interferon remain the most active agents for this disease, long-term survival rates remain poor. Two phase 3 trials, European Organization Research and Treatment of Cancer 30947 and Southwest Oncology Group 8949, have demonstrated a survival benefit of nephrectomy followed by interferon versus interferon alone in patients having an excellent performance status (PS 0 and 1). Removal of the primary tumor followed by interferon is not recommended for patients with a moderate or poor PS (PS 2-4). Even with this aggressive approach, most patients eventually will die from their kidney cancer; therefore, every patient with metastatic disease should be considered for enrollment into clinical trials.

Retaining customers in a managed care market. Hospitals must understand the connection between patient satisfaction, loyalty, retention, and revenue.

PubMed

Gemme, E M

1997-01-01

Traditionally, health care patients have been treated by health care professionals as people with needs rather than as customers with options. Although managed care has restricted patient choice, choice has not been eliminated. The premise of this article is that patients are primary health care consumers. Adopting such a premise and developing an active customer retention program can help health care organizations change their culture for the better, which may lead to higher customer retention levels and increased revenues. Customer retention programs based on service excellence that empower employees to provide excellent care can eventually lead to a larger market share for health care organizations trying to survive this era of intense competition.

Does a normalizing electroencephalogram in benign childhood epilepsy with centrotemporal spikes abort attention deficit hyperactivity disorder?

PubMed

Schneebaum-Sender, Nira; Goldberg-Stern, Hadassa; Fattal-Valevski, Aviva; Kramer, Uri

2012-10-01

This retrospective study delineated the efficacy of antiepileptic drugs in preventing the need for methylphenidate in patients with benign childhood epilepsy with centrotemporal spikes and attention deficit hyperactivity disorder. Seventeen patients were identified. A reduction of electroencephalogram pathologic activity by more than 50% was achieved in some patients with the antiepileptic drugs levetiracetam, sulthiame, lamotrigine, clobazam, and valproic acid. Complete normalization was achieved in two patients with sulthiame. Improvement in attention along with the reduction of pathologic electroencephalogram activity was observed in four patients, two with sulthiame, and one each with lamotrigine and levetiracetam (which was ceased because of suicidal tendencies). However, this improvement in attention was either temporary or not significant enough to discontinue methylphenidate. Methylphenidate was eventually prescribed to all patients. Copyright © 2012 Elsevier Inc. All rights reserved.

Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study.

PubMed

Contou, Damien; Roux, Damien; Jochmans, Sébastien; Coudroy, Rémi; Guérot, Emmanuel; Grimaldi, David; Ricome, Sylvie; Maury, Eric; Plantefève, Gaëtan; Mayaux, Julien; Mekontso Dessap, Armand; Brun-Buisson, Christian; de Prost, Nicolas

2016-11-06

The lack of a patent source of infection after 24 hours of management of shock considered septic is a common and disturbing scenario. We aimed to determine the prevalence and the causes of shock with no diagnosis 24 hours after its onset, and to compare the outcomes of patients with early-confirmed septic shock to those of others. We conducted a pragmatic, prospective, multicenter observational cohort study in ten intensive care units (ICU) in France. We included all consecutive patients admitted to the ICU with suspected septic shock defined by clinical suspicion of infection leading to antibiotic prescription plus acute circulatory failure requiring vasopressor support. A total of 508 patients were admitted with suspected septic shock. Among them, 374 (74 %) had early-confirmed septic shock, while the 134 others (26 %) had no source of infection identified nor microbiological documentation retrieved 24 hours after shock onset. Among these, 37/134 (28 %) had late-confirmed septic shock diagnosed after 24 hours, 59/134 (44 %) had a condition mimicking septic (septic shock mimicker, mainly related to adverse drug reactions, acute mesenteric ischemia and malignancies) and 38/134 (28 %) had shock of unknown origin by the end of the ICU stay. There were no differences between patients with early-confirmed septic shock and the remainder in ICU mortality and the median duration of ICU stay, of tracheal intubation and of vasopressor support. The multivariable Cox model showed that the risk of day-60 mortality did not differ between patients with or without early-confirmed septic shock. A sensitivity analysis was performed in the subgroup (n = 369/508) of patients meeting the Sepsis-3 definition criteria and displayed consistent results. One quarter of the patients admitted in the ICU with suspected septic shock had no infection identified 24 hours after its onset and almost half of them were eventually diagnosed with a septic shock mimicker. Outcome did not differ between patients with early-confirmed septic shock and other patients.

Spot Weight Adaptation for Moving Target in Spot Scanning Proton Therapy.

PubMed

Morel, Paul; Wu, Xiaodong; Blin, Guillaume; Vialette, Stéphane; Flynn, Ryan; Hyer, Daniel; Wang, Dongxu

2015-01-01

This study describes a real-time spot weight adaptation method in spot-scanning proton therapy for moving target or moving patient, so that the resultant dose distribution closely matches the planned dose distribution. The method proposed in this study adapts the weight (MU) of the delivering pencil beam to that of the target spot; it will actually hit during patient/target motion. The target spot that a certain delivering pencil beam may hit relies on patient monitoring and/or motion modeling using four-dimensional (4D) CT. After the adapted delivery, the required total weight [Monitor Unit (MU)] for this target spot is then subtracted from the planned value. With continuous patient motion and continuous spot scanning, the planned doses to all target spots will eventually be all fulfilled. In a proof-of-principle test, a lung case was presented with realistic temporal and motion parameters; the resultant dose distribution using spot weight adaptation was compared to that without using this method. The impact of the real-time patient/target position tracking or prediction was also investigated. For moderate motion (i.e., mean amplitude 0.5 cm), D95% to the planning target volume (PTV) was only 81.5% of the prescription (RX) dose; with spot weight adaptation PTV D95% achieves 97.7% RX. For large motion amplitude (i.e., 1.5 cm), without spot weight adaptation PTV D95% is only 42.9% of RX; with spot weight adaptation, PTV D95% achieves 97.7% RX. Larger errors in patient/target position tracking or prediction led to worse final target coverage; an error of 3 mm or smaller in patient/target position tracking is preferred. The proposed spot weight adaptation method was able to deliver the planned dose distribution and maintain target coverage when patient motion was involved. The successful implementation of this method would rely on accurate monitoring or prediction of patient/target motion.

Infantile spasms with periventricular nodular heterotopia, unbalanced chromosomal translocation 3p26.2 -10p15.1 and 6q22.31 duplication.

PubMed

Jones, Kevin; Weiss, Shelly K; Minassian, Berge

2016-07-01

Patients presenting with infantile spasms, dysmorphic features, and periventricular nodular heterotopia may benefit from genetic copy number variation microarray, or whole-exome sequencing to identify candidate genes. This will allow personalized diagnosis and prognostication and the eventual understanding of single and combined gene functions in brain health and disease.

Percutaneous tricuspid valvotomy for pacemaker lead-induced tricuspid stenosis

PubMed Central

Patil, Devendra V.; Nabar, Ashish A.; Sabnis, Girish R.; Phadke, Milind S.; Lanjewar, Charan P.; Kerkar, Prafulla G.

2015-01-01

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India. PMID:26995417

Diagnostic Value of Isolated Mentalis Versus Mentalis Plus Upper Limb Electromyography in Idiopathic REM Sleep Behavior Disorder Patients Eventually Developing a Neurodegenerative Syndrome.

PubMed

Fernández-Arcos, Ana; Iranzo, Alex; Serradell, Mónica; Gaig, Carles; Guaita, Marc; Salamero, Manel; Santamaria, Joan

2017-04-01

To compare two electromyographic (EMG) montages, isolated mentalis muscle versus mentalis in combination with upper limb muscles in the baseline diagnostic video-polysomnography (V-PSG) of patients with idiopathic REM sleep behaviors disorder (IRBD) who eventually were diagnosed with a clinically defined neurodegenerative syndrome. Forty-nine patients were included. At baseline, diagnosis of RBD was based on a typical history of dream enactment behaviors plus V-PSG showing REM sleep with qualitative increased EMG activity and/or abnormal behaviors. Quantification of EMG activity (tonic, phasic and "any") in the mentalis and upper limb muscles (biceps brachii-BB, n = 36 or flexor digitorum superficialis-FDS, n = 13) was performed manually and compared with published cut-offs. Nine (18.4%) patients had either tonic or phasic EMG below the cut-offs for the isolated mentalis and four of them (11.1 %) also had values below the cut-off for the mentalis combined with BB. All 13 patients recorded with the FDS were above the mentalis combined with FDS cut-off. For the diagnosis of IRBD, sensitivity of isolated mentalis was 81.6% and of the combination of mentalis plus upper limb muscles was 91.8% (p = .03). Audiovisual analysis showed abnormal REM sleep behaviors in all nine patients with values below the cut-offs. Quantification of EMG activity in the upper limbs combined with the mentalis increases the ability to diagnose IRBD when compared with the isolated measurement of the mentalis. Detection of typical abnormal behaviors during REM sleep with audiovisual analysis is essential for the diagnosis of IRBD in patients with EMG values below the published cut-offs. © Sleep Research Society 2017. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.

Exoplanet habitability.

PubMed

Seager, Sara

2013-05-03

The search for exoplanets includes the promise to eventually find and identify habitable worlds. The thousands of known exoplanets and planet candidates are extremely diverse in terms of their masses or sizes, orbits, and host star type. The diversity extends to new kinds of planets, which are very common yet have no solar system counterparts. Even with the requirement that a planet's surface temperature must be compatible with liquid water (because all life on Earth requires liquid water), a new emerging view is that planets very different from Earth may have the right conditions for life. The broadened possibilities will increase the future chances of discovering an inhabited world.

Follicular cyst of the jaw developing into a keratocyst in a patient with unrecognized Gorlin-Goltz syndrome.

PubMed

Longobardi, Gianluigi; Diana, Giovanni; Poddi, Valentina; Pagano, Immacolata

2010-05-01

Gorlin-Goltz (GG) syndrome is an inherited autosomal dominant condition. Its diagnosis may be clinically confirmed by checking either major or minor signs that define the diagnostic criteria. It may occur that, although GG syndrome is a well-known condition, only the specific symptom could be observed by different specialists. Therefore, the patient cannot be placed into an always complex clinical panel. We introduce an example in this report. Throughout a 20-year clinical history characterized by the lack of proper diagnosis and missed follow-up operations, a patient with GG syndrome underwent partial amputation of the jaw after severe complications. A 52-year-old man required an implant-prosthetic rehabilitation since becoming edentulous after a partial resection of the jaw due to a keratocyst, which was later reconstructed through a free fibula flap. The observation of a typical phenotype and various symptoms that succeeded for longer than 20 years, with anamnestic evaluation and clinical examination, led us to suspect a complex pathologic condition such as GG syndrome, which was not previously considered, although the patient had undergone several polyspecialistic evaluations. Diagnosis has been eventually confirmed by a genetic study, which was always mandatory. The simultaneous presence of muscular and skeletal malformations, basocellular nevi, and multiple cysts of the jaw can represent signs linking to a condition such as GG syndrome. There are many syndromes involving the head and neck region, and specialists are supposed to be alerted when faced with similar typical expressions associated with a characteristic soma so as to avoid delays in diagnosing the syndrome.

Nuclear Thermal Rocket Element Environmental Simulator (NTREES)

NASA Technical Reports Server (NTRS)

Emrich, William J., Jr.

2008-01-01

To support the eventual development of a nuclear thermal rocket engine, a state-of-the-art experimental test setup has been constructed to evaluate the performance characteristics of candidate fuel element materials and geometries in representative environments. The test device simulates the environmental conditions (minus the radiation) to which nuclear rocket fuel components will be subjected during reactor operation. Test articles mounted in the simulator are inductively heated in such a manner as to accurately reproduce the temperatures and heat fluxes normally expected to occur as a result of nuclear fission while at the same time being exposed to flowing hydrogen. This project is referred to as the Nuclear Thermal Rocket Element Environment Simulator or NTREES. The NTREES device is located at the Marshall Space flight Center in a laboratory which has been modified to accommodate the high powers required to heat the test articles to the required temperatures and to handle the gaseous hydrogen flow required for the tests. Other modifications to the laboratory include the installation of a nitrogen gas supply system and a cooling water supply system. During the design and construction of the facility, every effort was made to comply with all pertinent regulations to provide assurance that the facility could be operated in a safe and efficient manner. The NTREES system can currently supply up to 50 kW of inductive heating to the fuel test articles, although the facility has been sized to eventually allow test article heating levels of up to several megawatts.

Hypersonic Research Vehicle (HRV) real-time flight test support feasibility and requirements study. Part 2: Remote computation support for flight systems functions

NASA Technical Reports Server (NTRS)

Rediess, Herman A.; Hewett, M. D.

1991-01-01

The requirements are assessed for the use of remote computation to support HRV flight testing. First, remote computational requirements were developed to support functions that will eventually be performed onboard operational vehicles of this type. These functions which either cannot be performed onboard in the time frame of initial HRV flight test programs because the technology of airborne computers will not be sufficiently advanced to support the computational loads required, or it is not desirable to perform the functions onboard in the flight test program for other reasons. Second, remote computational support either required or highly desirable to conduct flight testing itself was addressed. The use is proposed of an Automated Flight Management System which is described in conceptual detail. Third, autonomous operations is discussed and finally, unmanned operations.

Medical and legal problems in intermediate intensive units.

PubMed

Gherson, G

1994-12-01

Due to a lack of legislation on the subject (the only data concerns the standard of hospital personnel in the Ministerial Decree (DM) of 13th September 1988), the medical and legal problems are concerned, in the first instance, with defining the type of unit, the context within which it can be placed and the eventual access to essential services and minimum equipment. With regard to responsibility, bearing in mind that the medical team of the intermediary unit (as with all other hospital teams) is employed by the public National Health Service, medical malpractice can be associated with lack of equipment and an inadequate public health service, which is often the cause. If penal responsibility is strictly personal (art. 27 of the Constitution) the civil relationship is, on the one hand, a relationship between the administration and the patient (the physician as employee must give his services within the Health Service and does not have an official personal relationship with the patient) so the Hospital organisation has a contractual type of civil responsibility whereas the employed doctors have an extra-contractual responsibility with different obligations. These responsibilities, which are also determined by the functions of the physician within the USL Health Service (DPR n. 761/1979), can also include control of non-medical staff, control of the equipment, specific training of personnel, etc. Problems concerning the admission of patients to the intermediate unit must also be taken into account (precise evaluation of the indications and of the type of patient to be admitted, refusal of patients in such a condition as to require intensive care or invasive techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

Watchful waiting and factors predictive of secondary treatment of localized prostate cancer.

PubMed

Wu, Hongyan; Sun, Leon; Moul, Judd W; Wu, Hong Yu; McLeod, David G; Amling, Christopher; Lance, Raymond; Kusuda, Leo; Donahue, Timothy; Foley, John; Chung, Andrew; Sexton, Wade; Soderdahl, Douglas

2004-03-01

Watchful waiting remains an important treatment option for some patients with localized prostate cancer. We defined the demographic, clinical and outcome features of men selecting watchful waiting as an initial treatment strategy, and determined factors predictive of eventual progression to secondary treatment. Of 8390 patients diagnosed with prostate cancer from 1990 to 2001 in the Department of Defense Center for Prostate Disease Research Database, 1158 patients chose watchful waiting as initial treatment. The demographic and clinical differences between patients on watchful waiting and those choosing other initial treatments were compared using the chi-square test. Secondary treatment-free survival according to various prognostic factors was plotted using the Kaplan-Meier method and differences were tested using the log rank test. A multivariate Cox proportional hazards regression analysis was performed to determine which factors were independent predictors of secondary treatment. Compared to other patients, those selecting watchful waiting were older, had lower prostate specific antigen (PSA) at diagnosis, and were more likely to have lower stage (cT1) and lower grade (Gleason sum 7 or less) cancers. Age, PSA and clinical stage were all significant and independent predictors of secondary treatment. The relative risk of secondary treatment can be expressed as EXP (-0.034 x age at diagnosis + 0.284 x LOG (diagnostic PSA) + 0.271 x clinical stage T2 + 0.264 x clinical stage T3). Men who elect watchful waiting as initial management for prostate cancer are older with lower Gleason sums and serum PSA. In these men, age at diagnosis, serum PSA and clinical stage are the most significant predictors of requiring or selecting secondary treatment.

Herpes simplex type 1 pneumonitis and acute respiratory distress syndrome in a patient with chronic lymphatic leukemia: a case report.

PubMed

Luginbuehl, Miriam; Imhof, Alexander; Klarer, Alexander

2017-11-23

Pulmonary pathogenicity of herpes simplex virus type 1 in patients in intensive care without classic immunosuppression as well as the necessity of antiviral treatment in the case of herpes simplex virus detection in respiratory specimens in these patients is controversial. We present a case of acute respiratory distress syndrome in a patient with stable chronic lymphatic leukemia not requiring treatment, in whom we diagnosed herpes simplex virus type 1 bronchopneumonitis based on herpes simplex virus type 1 detection in bronchoalveolar lavage fluid and clinical response to antiviral treatment. A 72-year-old white man presented with symptoms of lower respiratory tract infection. His medical history was significant for chronic lymphatic leukemia, which had been stable without treatment, arterial hypertension, multiple squamous cell carcinomas of the scalp, and alcohol overuse. Community-acquired pneumonia was suspected and appropriate broad-spectrum antibacterial treatment was initiated. Within a few hours, rapid respiratory deterioration led to cardiac arrest. He was successfully resuscitated, but developed acute respiratory distress syndrome. Furthermore, he remained febrile and inflammation markers remained elevated despite antibacterial treatment. Polymerase chain reaction from bronchoalveolar lavage fluid and viral culture from tracheobronchial secretions tested positive for herpes simplex virus type 1. We initiated antiviral treatment with acyclovir. Concomitantly we further escalated the antibacterial treatment, although no bacterial pathogen had been isolated at any point. Defervescence occurred rapidly and his C-reactive protein and leukocyte levels decreased. He was successfully weaned from mechanical ventilation, transferred to the ward, and eventually discharged to home. Herpes simplex virus should be considered a cause for lower respiratory tract infection in critically ill patients, especially in the setting of an underlying disease.

Percutaneous sclerotherapy of pediatric lymphatic malformations: experience and outcomes according to the agent used.

PubMed

Gallego Herrero, C; Navarro Cutillas, V

Analyze statistically the success, number of sessions required and complete duration of treatment of agents used in pediatric percutaneous sclerotherapy of lymphatic malformations, to determine the most suitable. Retrospective study based on outcomes from percutaneous sclerotherapy performed on lymphatic malformations of 56 patients conducted by pediatric interventional radiologist for 14 years. As first approach, the procedure consists of ultrasound-guided introduction of sclerosing agent. Sessions were repeated until clinical resolution. Success, number of sessions and the duration of treatment were recorded and statistical treatment of the data was performed to obtain further conclusions. Lost patients in follow up and other minority agents used were excluded from the data. Eventually, 52 patients treated with OK432 (n=29), Ethibloc (n=5) and combination therapy (n=18) were included. The average number of sessions and duration in months of treatment was respectively 2.38 and 8.6 for OK432, 1.4 and 5.6 for Ethibloc, and 1.83 and 2.30 for dual therapy. The results were statistically significant for the difference in duration between OK432 and dual therapy. Also, 60-80% of patients reached proper results related to success, but the difference was no significant among the agents. Other demographic and anatomical variables were analyzed, not showing any difference, which supports the homogeneity of the sample. Despite of no significant difference in success and number of sessions among agents, longer duration of treatment with OK432 than dual therapy could mean greater health costs and probably greater disturb for patient and family. Copyright © 2017 SERAM. Publicado por Elsevier España, S.L.U. All rights reserved.

Nucleus accumbens surgery for addiction.

PubMed

Li, Nan; Wang, Jing; Wang, Xue-lian; Chang, Chong-wang; Ge, Shun-nan; Gao, Li; Wu, He-ming; Zhao, Hai-kang; Geng, Ning; Gao, Guo-dong

2013-01-01

Opiate addiction remains intractable in a large percentage of patients, and relapse is the biggest hurdle to recovery because of psychological dependence. Multiple studies identify a central role of the nucleus accumbens (NAc) in addiction; several studies note decreased addictive behavior after interventions in this area. Based on animal experiments, our institute started the clinical trial for the treatment of drug addicts' psychological dependence by making lesions in the bilateral NAc with stereotactic surgery from July 2000. The short-term outcomes were encouraging and triggered rapid application of this treatment in China from 2003 to 2004. However, lack of long-term outcomes and controversy eventually led to halting the surgery for addiction by the Ministry of Health of China in November 2004 and a nationwide survey about it later. Our institute had performed this surgery in 272 patients with severe heroin addiction. The follow-up study showed that the 5-year nonrelapse rate was 58% and the quality of life was significantly improved. Patients had several kinds of side effects, but the incidence rate was relatively low. The patients gradually recovered more than 5 years after the surgery. The side effects did not severely influence an individual's life or work. Nationwide surgery showed that the nonrelapse rate was 50% in the sample of 150 cases, from 1167 patients overall who underwent stereotactic surgery in China. Although sometimes accompanied by neuropsychological adverse events, stereotactic ablation of NAc may effectively treat opiate addiction. Lesion location has a significant impact on treatment efficacy and requires further study. Because ablation is irreversible, the NAc surgery for addiction should be performed with cautiousness, and deep brain stimulation (DBS) is an ideal alternative. Copyright © 2013 Elsevier Inc. All rights reserved.

Café-au-lait Macules and Neurofibromatosis Type 1: A Review of the Literature.

PubMed

Bernier, Anne; Larbrisseau, Albert; Perreault, Sebastien

2016-07-01

The first sign of neurofibromatosis type 1 (NF1) in a child is often the presence of multiple café-au-lait macules. Although previous studies reported that almost individuals with multiple café-au-lait macules will eventually develop NF1 based on clinical criteria, recent studies and clinical observations suggest that a significant percentage of them do not have NF1. We conducted the first systematic review of the literature on the prevalence of definitive NF1 among patients referred for isolated café-au-lait macules, searching more precisely for the proportion of those patients who do not have NF1. Because we now know that the presence of café-au-lait macules and freckling might not distinguish between NF1 and other conditions such as Legius syndrome, definitive NF1 was defined as the presence of café-au-lait macules with or without freckling plus one of the following: Lisch nodules, neurofibroma, plexiform neurofibroma, bone dysplasia, optic pathway glioma, or familial history of NF1. Six articles reported sufficient data to meet our inclusion criteria. Grouping all studies together, we found that 19.5% to 57.1% of all patients with isolated café-au-lait macules did not have a diagnosis of NF1 after follow-up or genetic testing. A significant portion of the patients presenting with isolated café-au-lait macules at initial consultation might not have NF1. Genetic testing could help guide the follow-up of those patients, but further evidence is required to make recommendations. Copyright © 2016 Elsevier Inc. All rights reserved.

Does delayed esophagectomy after endoscopic resection affect outcomes in patients with stage T1 esophageal cancer? A propensity score-based analysis.

PubMed

Wang, Shengfei; Huang, Yangle; Xie, Juntao; Zhuge, Lingdun; Shao, Longlong; Xiang, Jiaqing; Zhang, Yawei; Sun, Yihua; Hu, Hong; Chen, Sufeng; Lerut, Toni; Luketich, James D; Zhang, Jie; Chen, Haiquan

2018-03-01

Although endoscopic resection (ER) may be sufficient treatment for early-stage esophageal cancer, additional treatment is recommended when there is a high risk of cancer recurrence. It is unclear whether delaying esophagectomy by performing and assessing the success of ER affects outcomes as compared with immediate esophagectomy without ER. Additionally, long-term survival after sequential ER and esophagectomy required further investigation. Between 2011 and 2015, 48 patients with stage T1 esophageal cancer underwent esophagectomy after ER with curative intent at our institution. Two-to-one propensity score methods were used to identify 96 matched-control patients who were treated with esophagectomy only using baseline patient, tumor characteristics and surgical approach. Time from initial evaluation to esophagectomy, relapse-free survival, overall survival, and postoperative complications were compared between the propensity-matched groups. In the ER + esophagectomy group, the time from initial evaluation to esophagectomy was significantly longer than in the esophagectomy only group (114 vs. 8 days, p < 0.001). The incidence of dense adhesion (p = 0.347), operative time (p = 0.867), postoperative surgical complications (p = 0.966), and postoperative length of hospital stay (p = 0.125) were not significantly different between the groups. Moreover, recurrence-free survival and overall survival were also similar between the two groups (p = 0.411 and p = 0.817, respectively). Treatment of stage T1 esophageal cancer with ER prior to esophagectomy did not increase the difficulty of performing esophagectomy or the incidence of postoperative complications and did not affect survival after esophagectomy. These results suggest that ER can be recommended for patients with stage T1 cancer even if esophagectomy is warranted eventually.

Acute Kawasaki disease with emphasis on the echocardiographic profile: A single center experience

PubMed Central

Hamza, Hala S.; Zaher, Asmaa Z.; Agha, Hala M.

Background: Echocardiographic features of acute Kawasaki disease (KD) have not been well characterized in Egyptian children. This study aimed to provide insight into the pattern of cardiac involvement in Egyptian children with Kawasaki disease, focusing on echocardiographic coronary abnormalities and their associated risk predictors. Methods and Results: Medical records of 64 KD patients from 2012 to 2016 were retrospectively analyzed with recalculation of coronary artery z-scores during the first eight weeks after fever onset. All patients received intravenous immunoglobulin (IVIG) and 57.8% were treated within 10 days of illness onset. Coronary abnormalities were found in 53.1% of all patients, and in 43.2% of those who received IVIG within 10 days. Giant aneurysms (z-score>10) comprised 23.5% of all coronary abnormalities. Coronary thrombosis occurred in two patients (5%), both of whom developed myocardial infarction, and one succumbed to heart failure with eventual in-hospital death. Overall, 7% of patients had mitral regurgitation (n = 5), 1.5% had aortic regurgitation (n = 1), and 7.8% had pericardial effusion (n = 5). Among a number of laboratory and clinical predictors, platelet count had the strongest association with coronary abnormalities (Area under Receiver-operating characteristic (ROC) curve: 0.794; 95% confidence interval 0.678–0.910; P < 0.001). Conclusion: Coronary abnormalities occur in a substantial percentage of KD in Egypt, with associated evidence of severe inflammation. Further efforts are required to increase awareness of the disease and to emphasize the importance of early IVIG administration. Future studies should also be undertaken to characterize the long term progression profile of the disease as well as the possible genetic background of the disease in Egypt. PMID:29564348