Feasibility of mesenchymal stem cell culture expansion for a phase I clinical trial in multiple sclerosis.

PubMed

Planchon, Sarah M; Lingas, Karen T; Reese Koç, Jane; Hooper, Brittney M; Maitra, Basabi; Fox, Robert M; Imrey, Peter B; Drake, Kylie M; Aldred, Micheala A; Lazarus, Hillard M; Cohen, Jeffrey A

2018-01-01

Multiple sclerosis is an inflammatory, neurodegenerative disease of the central nervous system for which therapeutic mesenchymal stem cell transplantation is under study. Published experience of culture-expanding multiple sclerosis patients' mesenchymal stem cells for clinical trials is limited. To determine the feasibility of culture-expanding multiple sclerosis patients' mesenchymal stem cells for clinical use. In a phase I trial, autologous, bone marrow-derived mesenchymal stem cells were isolated from 25 trial participants with multiple sclerosis and eight matched controls, and culture-expanded to a target single dose of 1-2 × 10 6 cells/kg. Viability, cell product identity and sterility were assessed prior to infusion. Cytogenetic stability was assessed by single nucleotide polymorphism analysis of mesenchymal stem cells from 18 multiple sclerosis patients and five controls. One patient failed screening. Mesenchymal stem cell culture expansion was successful for 24 of 25 multiple sclerosis patients and six of eight controls. The target dose was achieved in 16-62 days, requiring two to three cell passages. Growth rate and culture success did not correlate with demographic or multiple sclerosis disease characteristics. Cytogenetic studies identified changes on one chromosome of one control (4.3%) after extended time in culture. Culture expansion of mesenchymal stem cells from multiple sclerosis patients as donors is feasible. However, culture time should be minimized for cell products designated for therapeutic administration.

Surgical treatment of Wolff-Parkinson-White syndrome: epicardial approach without the use of cardiopulmonary bypass.

PubMed

Graffigna, A; Pagani, F; Vigano, M

1993-03-01

Epicardial dissection without the use of cardiopulmonary bypass (CPB) was performed in 88 patients (56 males and 32 females, mean age 31.9 years). With intraoperative epicardial mapping, 101 accessory pathways were detected, with multiple pathways in 11 patients. CPB was avoided in all but one patient due to frequent onset of atrial fibrillation with rapid ventricular rate. Surgical ablation was successful in 86 patients (97.6%). Three patients required multiple surgical procedures because of persistence of conduction along a component of the original pathway. All but two patients were discharged without antiarrhythmic medication; these two patients were given quinidine therapy because of atrial fibrillation, but had normal early and late electrophysiological studies. Surgical ablation of Kent bundles by the epicardial approach for the treatment of Wolff-Parkinson-White syndrome can be achieved without the use of CPB. Optimal and steady exposure of the area are mandatory for the procedure, and dissection is eased by avoidance of heparin required for CPB.

A Teaching Hospital Medical Clinic: Secondary Rather than Primary Care.

ERIC Educational Resources Information Center

Fletcher, Suzanne; And Others

1979-01-01

A review of 287 patient visits to a teaching hospital polyclinic shows that most patients had multiple problems that required the help of subspecialists. However, the patients' needs for accessibility, comprehensiveness, coordination, and continuity are as great as those of patients receiving primary care. Implications for academic internal…

Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

PubMed

Bang, Ji Young; Wilcox, C Mel; Trevino, Jessica M; Ramesh, Jayapal; Hasan, Muhammad; Hawes, Robert H; Varadarajulu, Shyam

2014-10-01

Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts. This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8-15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success). Of 122 patients, 45 (36.9%) had 10Fr stents of which 30 patients (66.7%) had more than one stent; the remaining 77 (63.1%) patients had 7Fr stents of which 56 (72.7%) had more than one stent. The overall treatment success was 94.3%. Treatment was successful in 102 patients (83.6%) with one intervention; 13 patients (10.7%) required re-intervention for successful drainage and 7 patients (5.7%) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5%, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6%, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95% CI 0.23-10.4) and number (OR 1.15; 95% CI 0.25-5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression. There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare.

PubMed

Dolan, James G

2010-01-01

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

PubMed Central

Dolan, James G.

2010-01-01

Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers. Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine “hard data” with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings. The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP) PMID:21394218

An Expanded Theoretical Framework of Care Coordination Across Transitions in Care Settings.

PubMed

Radwin, Laurel E; Castonguay, Denise; Keenan, Carolyn B; Hermann, Cherice

2016-01-01

For many patients, high-quality, patient-centered, and cost-effective health care requires coordination among multiple clinicians and settings. Ensuring optimal care coordination requires a clear understanding of how clinician activities and continuity during transitions affect patient-centeredness and quality outcomes. This article describes an expanded theoretical framework to better understand care coordination. The framework provides clear articulation of concepts. Examples are provided of ways to measure the concepts.

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.

Reconsidering the Resources Needed for Multiple Casualty Events: Lessons Learned From the Crash of Asiana Airlines Flight 214.

PubMed

Campion, Eric M; Juillard, Catherine; Knudson, M Margaret; Dicker, Rochelle; Cohen, Mitchell J; Mackersie, Robert; Campbell, Andre R; Callcut, Rachael A

2016-06-01

To date, a substantial portion of multiple casualty incident literature has focused exclusively on prehospital and emergency department resources needed for optimal disaster response. Thus, inpatient resources required to care for individuals injured in multiple casualty events are not well described. To highlight the resources beyond initial emergency department triage needed for multiple casualty events, using one of the largest commercial aviation disasters in modern US history as a case study. Prospective case series of injured individuals treated at an urban level I trauma center following the crash of Asiana Airlines flight 214 on July 6, 2013. This analysis was conducted between June 1, 2014, and December 1, 2015. Commercial jetliner crash. Medical records, imaging data, nursing overtime, blood bank records, and trauma registry data were analyzed. Disaster logs, patient injuries, and blood product data were prospectively collected during the incident. Among 307 people aboard the flight, 192 were injured; 63 of the injured patients were initially evaluated at San Francisco General Hospital and Trauma Center (the highest number at any of the receiving medical facilities; age range, 4-74 years [23 were aged <17 years and 3 were aged >60 years]; median injury severity score of 19 admitted patients, 9 [range, 9-45]), including the highest number of critically injured patients (10 of 12). Despite the high impact of the crash, only 3 persons (<1%) died, including 1 in-hospital death. Among the 63 patients, 32 (50.8%) underwent a computed tomographic imaging study, with imaging of the abdomen and pelvis being the most common. Sixteen of the 32 patients undergoing computed tomography (50.0%) had a positive finding on at least 1 scan. Nineteen patients had major injuries and required admission, with 5 taken directly from the emergency department to the operating room. The most frequent injury was spinal fracture (13 patients). In the first 48 hours, 15 operations were performed and 117 total units of blood products were transfused. A total of 370 nursing overtime hours were required to treat the injured patients on the day of the event. Proper disaster preparedness requires attention to hospital-level needs beyond initial emergency department triage. The Asiana Airlines flight 214 crash highlights the need to plan for high use of advanced imaging, blood products, operating room availability, nursing resources, and management of inpatient hospital beds.

Bone scan as a screening test for missed fractures in severely injured patients.

PubMed

Lee, K-J; Jung, K; Kim, J; Kwon, J

2014-12-01

In many cases, patients with severe blunt trauma have multiple fractures throughout the body. These fractures are not often detectable by history or physical examination, and their diagnosis can be delayed or even missed. Thus, screening test fractures of the whole body is required after initial management. We performed this study to evaluate the reliability of bone scans for detecting missed fractures in patients with multiple severe traumas and we analyzed the causes of missed fractures by using bone scan. A bone scan is useful as a screening test for fractures of the entire body of severe trauma patients who are passed the acute phase. We reviewed the electronic medical records of severe trauma patients who underwent a bone scan from September 2009 to December 2010. Demographic and medical data were compared and statistically analyzed to determine whether missed fractures were detected after bone scan in the two groups. A total of 382 patients who had an injury severity score [ISS] greater than 16 points with multiple traumas visited the emergency room. One hundred and thirty-one patients underwent bone scan and 81 patients were identified with missed fractures by bone scan. The most frequent location for missed fractures was the rib area (55 cases, 41.98%), followed by the extremities (42 cases, 32.06%). The missed fractures that required surgery or splint were most common in extremities (11 cases). In univariate analysis, higher ISS scores and mechanism of injury were related with the probability that missed fractures would be found with a bone scan. The ISS score was statistically significant in multivariate analysis. Bone scan is an effective method of detecting missed fractures among patients with multiple severe traumas. Level IV, retrospective study. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Enhancing Continuity of Care Using an Emergency Medical Card and a Continuity of Care Report

ERIC Educational Resources Information Center

Olola, Christopher Hillary Opiyo

2010-01-01

Discontinuity of care due to poor communication of patient health information among healthcare providers (HCPs) is a major efficiency and patient safety concern. Patients often see multiple HCPs and during each visit, the patient's core health information is required for appropriate decision making. Patients with access to their electronic medical…

Anxiety Levels Are Independently Associated With Cognitive Performance in an Australian Multiple Sclerosis Patient Cohort.

PubMed

Ribbons, Karen; Lea, Rodney; Schofield, Peter W; Lechner-Scott, Jeannette

2017-01-01

Neurological and psychological symptoms in multiple sclerosis can affect cognitive function. The objective of this study was to explore the relationship between psychological measures and cognitive performance in a patient cohort. In 322 multiple sclerosis patients, psychological symptoms were measured using the Depression Anxiety and Stress Scale, and cognitive function was evaluated using Audio Recorded Cognitive Screen. Multifactor linear regression analysis, accounting for all clinical covariates, found that anxiety was the only psychological measure to remain a significant predictor of cognitive performance (p<0.001), particularly memory function (p<0.001). Further prospective studies are required to determine whether treatment of anxiety improves cognitive impairment.

3D Printing Provides a Precise Approach in the Treatment of Tetralogy of Fallot, Pulmonary Atresia with Major Aortopulmonary Collateral Arteries.

PubMed

Anwar, Shafkat; Rockefeller, Toby; Raptis, Demetrios A; Woodard, Pamela K; Eghtesady, Pirooz

2018-02-03

Patients with tetralogy of Fallot, pulmonary atresia, and multiple aortopulmonary collateral arteries (Tet PA MAPCAs) have a wide spectrum of anatomy and disease severity. Management of these patients can be challenging and often require multiple high-risk surgical and interventional catheterization procedures. These interventions are made challenging by complex anatomy that require the proceduralist to mentally reconstruct three-dimensional anatomic relationships from two-dimensional images. Three-dimensional (3D) printing is an emerging medical technology that provides added benefits in the management of patients with Tet PA MAPCAs. When used in combination with current diagnostic modalities and procedures, 3D printing provides a precise approach to the management of these challenging, high-risk patients. Specifically, 3D printing enables detailed surgical and interventional planning prior to the procedure, which may improve procedural outcomes, decrease complications, and reduce procedure-related radiation dose and contrast load.

Traumatic and non-traumatic adrenal emergencies.

PubMed

Chernyak, Victoria; Patlas, Michael N; Menias, Christine O; Soto, Jorge A; Kielar, Ania Z; Rozenblit, Alla M; Romano, Luigia; Katz, Douglas S

2015-12-01

Multiple traumatic and non-traumatic adrenal emergencies are occasionally encountered during the cross-sectional imaging of emergency department patients. Traumatic adrenal hematomas are markers of severe polytrauma, and can be easily overlooked due to multiple concomitant injuries. Patients with non-traumatic adrenal emergencies usually present to an emergency department with a non-specific clinical picture. The detection and management of adrenal emergencies is based on cross-sectional imaging. Adrenal hemorrhage, adrenal infection, or rupture of adrenal neoplasm require immediate detection to avoid dire consequences. More often however, adrenal emergencies are detected incidentally in patients being investigated for non-specific acute abdominal pain. A high index of suspicion is required for the establishment of timely diagnosis and to avert potentially life-threatening complications. We describe cross-sectional imaging findings in patients with traumatic and non-traumatic adrenal hemorrhage, adrenal infarctions, adrenal infections, and complications of adrenal masses.

[Intensive care treatment of traumatic brain injury in multiple trauma patients : Decision making for complex pathophysiology].

PubMed

Trimmel, H; Herzer, G; Schöchl, H; Voelckel, W G

2017-09-01

Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.

The role of point-of-care assessment of platelet function in predicting postoperative bleeding and transfusion requirements after coronary artery bypass grafting.

PubMed

Mishra, Pankaj Kumar; Thekkudan, Joyce; Sahajanandan, Raj; Gravenor, Mike; Lakshmanan, Suresh; Fayaz, Khazi Mohammed; Luckraz, Heyman

2015-01-01

OBJECTIVE platelet function assessment after cardiac surgery can predict postoperative blood loss, guide transfusion requirements and discriminate the need for surgical re-exploration. We conducted this study to assess the predictive value of point-of-care testing platelet function using the Multiplate® device. Patients undergoing isolated coronary artery bypass grafting were prospectively recruited ( n = 84). Group A ( n = 42) patients were on anti-platelet therapy until surgery; patients in Group B ( n = 42) stopped anti-platelet treatment at least 5 days preoperatively. Multiplate® and thromboelastography (TEG) tests were performed in the perioperative period. Primary end-point was excessive bleeding (>2.5 ml/kg/h) within first 3 h postoperative. Secondary end-points included transfusion requirements, re-exploration rates, intensive care unit and in-hospital stays. Patients in Group A had excessive bleeding (59% vs. 33%, P = 0.02), higher re-exploration rates (14% vs. 0%, P < 0.01) and higher rate of blood (41% vs. 14%, P < 0.01) and platelet (14% vs. 2%, P = 0.05) transfusions. On multivariate analysis, preoperative platelet function testing was the most significant predictor of excessive bleeding (odds ratio [OR]: 2.3, P = 0.08), need for blood (OR: 5.5, P < 0.01) and platelet transfusion (OR: 15.1, P < 0.01). Postoperative "ASPI test" best predicted the need for transfusion (sensitivity - 0.86) and excessive blood loss (sensitivity - 0.81). TEG results did not correlate well with any of these outcome measures. Peri-operative platelet functional assessment with Multiplate® was the strongest predictor for bleeding and transfusion requirements in patients on anti-platelet therapy until the time of surgery.

Development and initial outcomes of an upper gastrointestinal multidisciplinary clinic.

PubMed

Brown, Anna; Wylie, Neil; Rodgers, Michael; Casement, Jonathan; McIlree, Neil; Gray, Lindsay; Mulholland, Glen; Volkova, Vicki; van der Watt, Erna; Booth, Michael; Koea, Jonathan

2016-07-01

Patients with upper gastrointestinal cancer are often comorbid and require complex surgical treatments for their cancers, meaning that their preoperative assessment can be based around numerous outpatient assessments with multiple services. A multidisciplinary clinic (MDC) was developed for the assessment of patients with confirmed or suspected upper gastrointestinal cancers. Face-to-face meetings were held between stakeholder services at Waitemata District Health Board, and clinic resource allocated. Significant IT modification of existing clinic booking software was required. Between September 2014, and September 2015, there were a total of 165 new patient, and 710 follow-up appointments. All new patients were seen by a surgeon and then other specialties. Of the 165 new patient appointments, 146 (88%) patients had a definitive treatment plan in place and were cleared by anaesthesia and intensive care at the end of the clinic. Staff and patients report high levels of satisfaction for the clinic. A dedicated MDC has provided a single forum where complex patients can be reviewed, and a definitive treatment plan formulated in nearly 90% of patients, even when this involves multiple medical and paramedical specialties with high levels of patient and clinician satisfaction.

Effectiveness of applying progressive muscle relaxation technique on quality of life of patients with multiple sclerosis.

PubMed

Ghafari, Somayeh; Ahmadi, Fazlolah; Nabavi, Masoud; Anoshirvan, Kazemnejad; Memarian, Robabe; Rafatbakhsh, Mohamad

2009-08-01

To identify the effects of applying Progressive Muscle Relaxation Technique on Quality of Life of patients with multiple Sclerosis. In view of the growing caring options in Multiple Sclerosis, improvement of quality of life has become increasingly relevant as a caring intervention. Complementary therapies are widely used by multiple sclerosis patients and Progressive Muscle Relaxation Technique is a form of complementary therapies. Quasi-experimental study. Multiple Sclerosis patients (n = 66) were selected with no probability sampling then assigned to experimental and control groups (33 patients in each group). Means of data collection included: Individual Information Questionnaire, SF-8 Health Survey, Self-reported checklist. PMRT performed for 63 sessions by experimental group during two months but no intervention was done for control group. Statistical analysis was done by SPSS software. Student t-test showed that there was no significant difference between two groups in mean scores of health-related quality of life before the study but this test showed a significant difference between two groups, one and two months after intervention (p < 0.05). anova test with repeated measurements showed that there is a significant difference in mean score of whole and dimensions of health-related quality of life between two groups in three times (p < 0.05). Although this study provides modest support for the effectiveness of Progressive Muscle Relaxation Technique on quality of life of multiple sclerosis patients, further research is required to determine better methods to promote quality of life of patients suffer multiple sclerosis and other chronic disease. Progressive Muscle Relaxation Technique is practically feasible and is associated with increase of life quality of multiple sclerosis patients; so that health professionals need to update their knowledge about complementary therapies.

Treatment and disease management of multiple sclerosis patients: A review for nurse practitioners.

PubMed

Roman, Cortnee; Menning, Kara

2017-10-01

This review discusses the role of the nurse practitioner (NP) in evaluating the clinical effects, potential side effects, and monitoring requirements for treatment options in multiple sclerosis (MS) and provides guidance on how to help patients understand these issues. A literature search was conducted on PubMed to identify publications on monitoring and disease management of MS patients. Additional resources included drug information web sites and package inserts. NPs play an active role in the management of MS patients via effective monitoring and communication throughout the patient's treatment regimen and disease course. In the shared decision-making model of MS treatment, NPs ensure that patients understand the implications of their disease-modifying therapies (DMTs). As patients move through treatments during the course of their disease, the importance of this role increases, and it is critical that NPs follow the guidelines in each medication's product label and take into account any potential lingering effects of prior medications. It is critical for NPs to promote patient adherence, to ensure that patients understand treatment side effects and monitoring requirements, and to take sequencing and reversibility implications of DMTs into account when making clinical decisions. ©2017 American Association of Nurse Practitioners.

The Face-Processing Network Is Resilient to Focal Resection of Human Visual Cortex

PubMed Central

Jonas, Jacques; Gomez, Jesse; Maillard, Louis; Brissart, Hélène; Hossu, Gabriela; Jacques, Corentin; Loftus, David; Colnat-Coulbois, Sophie; Stigliani, Anthony; Barnett, Michael A.; Grill-Spector, Kalanit; Rossion, Bruno

2016-01-01

Human face perception requires a network of brain regions distributed throughout the occipital and temporal lobes with a right hemisphere advantage. Present theories consider this network as either a processing hierarchy beginning with the inferior occipital gyrus (occipital face area; IOG-faces/OFA) or a multiple-route network with nonhierarchical components. The former predicts that removing IOG-faces/OFA will detrimentally affect downstream stages, whereas the latter does not. We tested this prediction in a human patient (Patient S.P.) requiring removal of the right inferior occipital cortex, including IOG-faces/OFA. We acquired multiple fMRI measurements in Patient S.P. before and after a preplanned surgery and multiple measurements in typical controls, enabling both within-subject/across-session comparisons (Patient S.P. before resection vs Patient S.P. after resection) and between-subject/across-session comparisons (Patient S.P. vs controls). We found that the spatial topology and selectivity of downstream ipsilateral face-selective regions were stable 1 and 8 month(s) after surgery. Additionally, the reliability of distributed patterns of face selectivity in Patient S.P. before versus after resection was not different from across-session reliability in controls. Nevertheless, postoperatively, representations of visual space were typical in dorsal face-selective regions but atypical in ventral face-selective regions and V1 of the resected hemisphere. Diffusion weighted imaging in Patient S.P. and controls identifies white matter tracts connecting retinotopic areas to downstream face-selective regions, which may contribute to the stable and plastic features of the face network in Patient S.P. after surgery. Together, our results support a multiple-route network of face processing with nonhierarchical components and shed light on stable and plastic features of high-level visual cortex following focal brain damage. SIGNIFICANCE STATEMENT Brain networks consist of interconnected functional regions commonly organized in processing hierarchies. Prevailing theories predict that damage to the input of the hierarchy will detrimentally affect later stages. We tested this prediction with multiple brain measurements in a rare human patient requiring surgical removal of the putative input to a network processing faces. Surprisingly, the spatial topology and selectivity of downstream face-selective regions are stable after surgery. Nevertheless, representations of visual space were typical in dorsal face-selective regions but atypical in ventral face-selective regions and V1. White matter connections from outside the face network may support these stable and plastic features. As processing hierarchies are ubiquitous in biological and nonbiological systems, our results have pervasive implications for understanding the construction of resilient networks. PMID:27511014

Renal complications in multiple myeloma and related disorders: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board.

PubMed

Faiman, Beth M; Mangan, Patricia; Spong, Jacy; Tariman, Joseph D

2011-08-01

Kidney dysfunction is a common clinical feature of symptomatic multiple myeloma. Some degree of renal insufficiency or renal failure is present at diagnosis or will occur during the course of the disease and, if not reversed, will adversely affect overall survival and quality of life. Chronic insults to the kidneys from other illnesses, treatment, or multiple myeloma itself can further damage renal function and increase the risk for additional complications, such as anemia. Patients with multiple myeloma who have light chain (Bence Jones protein) proteinuria may experience renal failure or progress to end-stage renal disease (ESRD) and require dialysis because of light chain cast nephropathy. Kidney failure in patients with presumed multiple myeloma also may result from amyloidosis, light chain deposition disease, or acute tubular necrosis caused by nephrotoxic agents; therefore, identification of patients at risk for kidney damage is essential. The International Myeloma Foundation's Nurse Leadership Board has developed practice recommendations for screening renal function, identifying positive and negative contributing risk and environmental factors, selecting appropriate therapies and supportive care measures to decrease progression to ESRD, and enacting dialysis to reduce and manage renal complications in patients with multiple myeloma.

Alemtuzumab Use in Clinical Practice: Recommendations from European Multiple Sclerosis Experts.

PubMed

Berger, Thomas; Elovaara, Irina; Fredrikson, Sten; McGuigan, Chris; Moiola, Lucia; Myhr, Kjell-Morten; Oreja-Guevara, Celia; Stoliarov, Igor; Zettl, Uwe K

2017-01-01

Alemtuzumab (Lemtrada™) is a humanized monoclonal antibody approved in more than 50 countries. Within the European Union, alemtuzumab is indicated for the treatment of adult patients with relapsing-remitting multiple sclerosis (RRMS) with active disease defined by clinical or imaging features; in the USA, the indication states that alemtuzumab should generally be reserved for the treatment of patients with relapsing forms of multiple sclerosis who have had an inadequate response to two or more disease-modifying therapies (DMTs). In clinical trials, alemtuzumab demonstrated efficacy in treatment-naïve patients with active RRMS and those relapsing on prior DMTs, with a consistent and manageable safety and tolerability profile. The European Union indication provides physicians with significant flexibility regarding treatment decisions, affording the opportunity for individualized treatment. Thus, alemtuzumab may be an appropriate treatment choice across a broad range of patients with RRMS, including, for example, treatment-naïve patients with active disease, patients with highly active disease, or for patients relapsing on prior DMTs. There are several practicalities to consider when using alemtuzumab, including the unique dosing regimen, administered via intravenous infusion on 5 consecutive days at baseline and on 3 consecutive days 12 months later, and as-needed retreatment (3 consecutive days at least 12 months after the last course) in cases of disease recurrence. Additionally, routine monthly monitoring is required for up to 48 months after the last infusion to promptly identify potentially serious autoimmune adverse events. Given these considerations, it is beneficial to gain insight into how alemtuzumab is being used in the real-world clinical setting. Here, we report recommendations from European multiple sclerosis experts regarding best practices for alemtuzumab treatment, including management of adverse events and compliance with ongoing safety monitoring requirements.

Linezolid desensitization for a patient with multiple medication hypersensitivity reactions.

PubMed

Bagwell, Autumn D; Stollings, Joanna L; White, Katie D; Fadugba, Olajumoke O; Choi, Jane J

2013-01-01

To describe a case in which a linezolid desensitization protocol was successfully used for a polymicrobial surgical wound infection in a patient with multiple drug hypersensitivity reactions. A 24-year-old woman with vocal cord dysfunction requiring tracheostomy was admitted for a surgical wound infection following a tracheostomy fistula closure procedure. The patient reported multiple antibiotic allergies including penicillins (rash), sulfonamides (rash), vancomycin (anaphylaxis), azithromycin (rash), cephalosporins (anaphylaxis), levofloxacin (unspecified), clindamycin (unspecified), and carbapenems (unspecified). Gram stain of the purulent wound drainage demonstrated mixed gram-negative and gram-positive flora, and bacterial cultures were overgrown with Proteus mirabilis, which precluded identification of other pathogens. Following failed test doses of linezolid, tigecycline, and daptomycin, all of which resulted in hypersensitivity reactions, a 16-step linezolid desensitization protocol was developed and successfully implemented without adverse reactions. The patient completed a 2-week course of antibiotic therapy that included linezolid upon finishing the desensitization protocol. Linezolid is useful in treating complicated and uncomplicated skin and soft tissue infections caused by gram-positive bacteria. With precautions, including premedication, a monitored nursing unit, and immediate availability of an emergency anaphylaxis kit, drug desensitization allows patients the ability to safely use medications to which they may have an immediate hypersensitivity reaction. Minimal data exist on linezolid desensitization protocols. Linezolid desensitization can be a viable option in patients requiring antimicrobial therapy for complicated gram-positive skin infections.

Standard and Nonstandard Craniospinal Radiotherapy Using Helical TomoTherapy

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

Parker, William, E-mail: william@medphys.mcgill.c; Brodeur, Marylene; Roberge, David

2010-07-01

Purpose: To show the advantages of planning and delivering craniospinal radiotherapy with helical TomoTherapy (TomoTherapy Inc., Madison, WI) by presenting 4 cases treated at our institution. Methods and Materials: We first present a standard case of craniospinal irradiation in a patient with recurrent myxopapillary ependymoma (MPE) and follow this with 2 cases requiring differential dosing to multiple target volumes. One of these, a patient with recurrent medulloblastoma, required a lower dose to be delivered to the posterior fossa because the patient had been previously irradiated to the full dose, and the other required concurrent boosts to leptomeningeal metastases as partmore » of his treatment for newly diagnosed MPE. The final case presented is a patient with pronounced scoliosis who required spinal irradiation for recurrent MPE. Results: The four cases presented were planned and treated successfully with Helical Tomotherapy. Conclusions: Helical TomoTherapy delivers continuous arc-based intensity-modulated radiotherapy that gives high conformality and excellent dose homogeneity for the target volumes. Increased healthy tissue sparing is achieved at higher doses albeit at the expense of larger volumes of tissue receiving lower doses. Helical TomoTherapy allows for differential dosing of multiple targets, resulting in very elegant dose distributions. Daily megavoltage computed tomography imaging allows for precision of patient positioning, permitting a reduction in planning margins and increased healthy tissue sparing in comparison with standard techniques.« less

Clinical and MRI activity as determinants of sample size for pediatric multiple sclerosis trials

PubMed Central

Verhey, Leonard H.; Signori, Alessio; Arnold, Douglas L.; Bar-Or, Amit; Sadovnick, A. Dessa; Marrie, Ruth Ann; Banwell, Brenda

2013-01-01

Objective: To estimate sample sizes for pediatric multiple sclerosis (MS) trials using new T2 lesion count, annualized relapse rate (ARR), and time to first relapse (TTFR) endpoints. Methods: Poisson and negative binomial models were fit to new T2 lesion and relapse count data, and negative binomial time-to-event and exponential models were fit to TTFR data of 42 children with MS enrolled in a national prospective cohort study. Simulations were performed by resampling from the best-fitting model of new T2 lesion count, number of relapses, or TTFR, under various assumptions of the effect size, trial duration, and model parameters. Results: Assuming a 50% reduction in new T2 lesions over 6 months, 90 patients/arm are required, whereas 165 patients/arm are required for a 40% treatment effect. Sample sizes for 2-year trials using relapse-related endpoints are lower than that for 1-year trials. For 2-year trials and a conservative assumption of overdispersion (ϑ), sample sizes range from 70 patients/arm (using ARR) to 105 patients/arm (TTFR) for a 50% reduction in relapses, and 230 patients/arm (ARR) to 365 patients/arm (TTFR) for a 30% relapse reduction. Assuming a less conservative ϑ, 2-year trials using ARR require 45 patients/arm (60 patients/arm for TTFR) for a 50% reduction in relapses and 145 patients/arm (200 patients/arm for TTFR) for a 30% reduction. Conclusion: Six-month phase II trials using new T2 lesion count as an endpoint are feasible in the pediatric MS population; however, trials powered on ARR or TTFR will need to be 2 years in duration and will require multicentered collaboration. PMID:23966255

Outcomes of reintervention after failed urethroplasty.

PubMed

Ekerhult, Teresa Olsen; Lindqvist, Klas; Peeker, Ralph; Grenabo, Lars

2017-02-01

Urethroplasty is a procedure that has a high success rate. However, there exists a small subgroup of patients who require multiple procedures to achieve an acceptable result. This study analyses the outcomes of a series of patients with failed urethroplasty. This is a retrospective review of 82 failures out of 407 patients who underwent urethroplasty due to urethral stricture during the period 1999-2013. Failure was defined as the need for an additional surgical procedure. Of the failures, 26 patients had penile strictures and 56 had bulbar strictures. Meatal strictures were not included. The redo procedures included one or multiple direct vision internal urethrotomies, dilatations or new urethroplasties, all with a long follow-up time. The patients underwent one to seven redo surgeries (mean 2.4 procedures per patient). In the present series of patients, endourological procedures cured 34% (28/82) of the patients. Ten patients underwent multiple redo urethroplasties until a satisfactory outcome was achieved; the penile strictures were the most difficult to cure. In patients with bulbar strictures, excision with anastomosis and substitution urethroplasty were equally successful. Nevertheless, 18 patients were defined as treatment failures. Of these patients, nine ended up with clean intermittent self-dilatation as a final solution, five had perineal urethrostomy and four are awaiting a new reintervention. Complicated cases need centralized professional care. Despite the possibility of needing multiple reinterventions, the majority of patients undergoing urethroplasty have a good chance of successful treatment.

The effect of increased number of cesarean on maternal and fetal outcomes.

PubMed

Çintesun, Ersin; Al, Ragıp Atakan

2017-01-01

The aim of this study was to evaluate the effects of multiple cesarean deliveries (CDs) on maternal-fetal mor-bidity and mortality rates. This retrospective study included a total of 1,506 patients who underwent multiple CDs between January 2006 and May 2014. The patients were divided into two groups. One group consisted of patients with four or more CDs (n = 444) and a control group of patients with three CDs (n=1,062). Both groups were analyzed for demographics, complications from multiple cesarean deliveries and perinatal outcomes. The mean age was higher in the study group (p < 0.001). Dense adhesion (p < 0.001), demand for tubal ligation (p < 0.001), the requirement of pelvic drainage (p < 0.001), duration of hospitalization (p < 0.001) and the requirement for blood transfusion (p=0.03) was also significantly higher in the study group. Hemoglobin levels (p = 0.002) were signifi-cantly higher in the control group on the second postoperative day. Regarding perinatal morbidity; umbilical artery pH results (p = 0.003) were significantly lower in the study group. There was no significant difference in the maternal and fetal mortality rates between both groups. According to our study results, an increase in the number of cesarean sections increases maternal and fetal morbidity rates significantly. Therefore, we recommend decreasing the rate of primary cesarean deliveries by encouraging vaginal birth after CD. We also advocate the use of permanent contraceptive methods in patients with a high number of CD's. Further large-scale prospective results are required to establish a definitive conclusion.

Population pharmacokinetics of pomalidomide in patients with relapsed or refractory multiple myeloma with various degrees of impaired renal function.

PubMed

Li, Yan; Wang, Xiaomin; O'Mara, Edward; Dimopoulos, Meletios A; Sonneveld, Pieter; Weisel, Katja C; Matous, Jeffrey; Siegel, David S; Shah, Jatin J; Kueenburg, Elisabeth; Sternas, Lars; Cavanaugh, Chloe; Zaki, Mohamed; Palmisano, Maria; Zhou, Simon

2017-01-01

Pomalidomide is an immunomodulatory drug for treatment of relapsed or refractory multiple myeloma (rrMM) in patients who often have comorbid renal conditions. To assess the impact of renal impairment on pomalidomide exposure, a population pharmacokinetics (PPK) model of pomalidomide in rrMM patients with various degrees of impaired renal function was developed. Intensive and sparse pomalidomide concentration data collected from two clinical studies in rrMM patients with normal renal function, moderately impaired renal function, severely impaired renal function not requiring dialysis, and with severely impaired renal function requiring dialysis were pooled over the dose range of 2 to 4 mg, to assess specifically the influence of the impaired renal function as a categorical variable and a continuous variable on pomalidomide clearance and plasma exposure. In addition, pomalidomide concentration data collected on dialysis days from both the withdrawal (arterial) side and from the returning (venous) side of the dialyzer, from rrMM patients with severely impaired renal function requiring dialysis, were used to assess the extent to which dialysis contributes to the removal of pomalidomide from blood circulation. PPK analyses demonstrated that moderate to severe renal impairment not requiring dialysis has no influence on pomalidomide clearance or plasma exposure, as compared to those patients with normal renal function, while pomalidomide exposure increased approximately 35% in patients with severe renal impairment requiring dialysis on nondialysis days. In addition, dialysis increased total body pomalidomide clearance from 5 L/h to 12 L/h, indicating that dialysis will significantly remove pomalidomide from the blood circulation. Thus, pomalidomide should be administered post-dialysis on the days of dialysis.

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.

Multiple Intravenous Infusions Phase 1b

PubMed Central

Cassano-Piché, A; Fan, M; Sabovitch, S; Masino, C; Easty, AC

2012-01-01

Background Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medical Practices Canada and United States Food and Drug Administration MAUDE) found that a high percentage of incidents associated with the administration of multiple IV infusions resulted in patient harm. Objectives The primary objectives of Phase 1b of this study were to identify safety issues with the potential to cause patient harm stemming from the administration of multiple IV infusions; and to identify how nurses are being educated on key principles required to safely administer multiple IV infusions. Data Sources and Review Methods A field study was conducted at 12 hospital clinical units (sites) across Ontario, and telephone interviews were conducted with program coordinators or instructors from both the Ontario baccalaureate nursing degree programs and the Ontario postgraduate Critical Care Nursing Certificate programs. Data were analyzed using Rasmussen’s 1997 Risk Management Framework and a Health Care Failure Modes and Effects Analysis. Results Twenty-two primary patient safety issues were identified with the potential to directly cause patient harm. Seventeen of these (critical issues) were categorized into 6 themes. A cause-consequence tree was established to outline all possible contributing factors for each critical issue. Clinical recommendations were identified for immediate distribution to, and implementation by, Ontario hospitals. Future investigation efforts were planned for Phase 2 of the study. Limitations This exploratory field study identifies the potential for errors, but does not describe the direct observation of such errors, except in a few cases where errors were observed. Not all issues are known in advance, and the frequency of errors is too low to be observed in the time allotted and with the limited sample of observations. Conclusions The administration of multiple IV infusions to a single patient is a complex task with many potential associated patient safety risks. Improvements to infusion and infusion-related technology, education standards, clinical best practice guidelines, hospital policies, and unit work practices are required to reduce the risk potential. This report makes several recommendations to Ontario hospitals so that they can develop an awareness of the issues highlighted in this report and minimize some of the risks. Further investigation of mitigating strategies is required and will be undertaken in Phase 2 of this research. Plain Language Summary Patients, particularly in critical care environments, often require multiple intravenous (IV) medications via large volumetric or syringe infusion pumps. The infusion of multiple IV medications is not without risk; unintended errors during these complex procedures have resulted in patient harm. However, the range of associated risks and the factors contributing to these risks are not well understood. Health Quality Ontario’s Ontario Health Technology Advisory Committee commissioned the Health Technology Safety Research Team at the University Health Network to conduct a multi-phase study to identify and mitigate the risks associated with multiple IV infusions. Some of the questions addressed by the team were as follows: What is needed to reduce the risk of errors for individuals who are receiving a lot of medications? What strategies work best? The initial report, Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report, summarizes the interim findings based on a literature review, an incident database review, and a technology scan. The Health Technology Safety Research Team worked in close collaboration with the Institute for Safe Medication Practices Canada on an exploratory study to understand the risks associated with multiple IV infusions and the degree to which nurses are educated to help mitigate them. The current report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan, presents the findings of a field study of 12 hospital clinical units across Ontario, as well as 13 interviews with educators from baccalaureate-level nursing degree programs and postgraduate Critical Care Nursing Certificate programs. It makes 9 recommendations that emphasize best practices for the administration of multiple IV infusions and pertain to secondary infusions, line identification, line set-up and removal, and administering IV bolus medications. The Health Technology Safety Research Team has also produced an associated report for hospitals entitled Mitigating the Risks Associated With Multiple IV Infusions: Recommendations Based on a Field Study of Twelve Ontario Hospitals, which highlights the 9 interim recommendations and provides a brief rationale for each one. PMID:23074426

Peptidomic analysis of endogenous plasma peptides from patients with pancreatic neuroendocrine tumours.

PubMed

Kay, Richard G; Challis, Benjamin G; Casey, Ruth T; Roberts, Geoffrey P; Meek, Claire L; Reimann, Frank; Gribble, Fiona M

2018-06-01

Diagnosis of pancreatic neuroendocrine tumours requires the study of patient plasma with multiple immunoassays, using multiple aliquots of plasma. The application of mass spectrometry based techniques could reduce the cost and amount of plasma required for diagnosis. Plasma samples from two patients with pancreatic neuroendocrine tumours were extracted using an established acetonitrile based plasma peptide enrichment strategy. The circulating peptidome was characterised using nano and high flow rate LC/MS analyses. To assess the diagnostic potential of the analytical approach, a large sample batch (68 plasmas) from control subjects, and aliquots from subjects harbouring two different types of pancreatic neuroendocrine tumour (insulinoma and glucagonoma) were analysed using a 10-minute LC/MS peptide screen. The untargeted plasma peptidomics approach identified peptides derived from the glucagon prohormone, chromogranin A, chromogranin B and other peptide hormones and proteins related to control of peptide secretion. The glucagon prohormone derived peptides that were detected were compared against putative peptides that were identified using multiple antibody pairs against glucagon peptides. Comparison of the plasma samples for relative levels of selected peptides showed clear separation between the glucagonoma and the insulinoma and control samples. The combination of the organic solvent extraction methodology with high flow rate analysis could potentially be used to aid diagnosis and monitor treatment of patients with functioning pancreatic neuroendocrine tumours. However, significant validation will be required before this approach can be clinically applied. This article is protected by copyright. All rights reserved.

Distinct roles of dopamine and subthalamic nucleus in learning and probabilistic decision making.

PubMed

Coulthard, Elizabeth J; Bogacz, Rafal; Javed, Shazia; Mooney, Lucy K; Murphy, Gillian; Keeley, Sophie; Whone, Alan L

2012-12-01

Even simple behaviour requires us to make decisions based on combining multiple pieces of learned and new information. Making such decisions requires both learning the optimal response to each given stimulus as well as combining probabilistic information from multiple stimuli before selecting a response. Computational theories of decision making predict that learning individual stimulus-response associations and rapid combination of information from multiple stimuli are dependent on different components of basal ganglia circuitry. In particular, learning and retention of memory, required for optimal response choice, are significantly reliant on dopamine, whereas integrating information probabilistically is critically dependent upon functioning of the glutamatergic subthalamic nucleus (computing the 'normalization term' in Bayes' theorem). Here, we test these theories by investigating 22 patients with Parkinson's disease either treated with deep brain stimulation to the subthalamic nucleus and dopaminergic therapy or managed with dopaminergic therapy alone. We use computerized tasks that probe three cognitive functions-information acquisition (learning), memory over a delay and information integration when multiple pieces of sequentially presented information have to be combined. Patients performed the tasks ON or OFF deep brain stimulation and/or ON or OFF dopaminergic therapy. Consistent with the computational theories, we show that stopping dopaminergic therapy impairs memory for probabilistic information over a delay, whereas deep brain stimulation to the region of the subthalamic nucleus disrupts decision making when multiple pieces of acquired information must be combined. Furthermore, we found that when participants needed to update their decision on the basis of the last piece of information presented in the decision-making task, patients with deep brain stimulation of the subthalamic nucleus region did not slow down appropriately to revise their plan, a pattern of behaviour that mirrors the impulsivity described clinically in some patients with subthalamic nucleus deep brain stimulation. Thus, we demonstrate distinct mechanisms for two important facets of human decision making: first, a role for dopamine in memory consolidation, and second, the critical importance of the subthalamic nucleus in successful decision making when multiple pieces of information must be combined.

Gamified Design for Health Workshop.

PubMed

Giunti, Guido

2016-01-01

Increasing lifespans for chronic disease sufferers means a population of young patients who require lifestyle intervention from an early age. For multiple sclerosis (MS) patients, social problems begin with the decline of cognitive skills and their quality of life is affected. In this workshop, organizers will propose participants to work on different gamification design approachs to solve MS patients' engagement problem. Participants will obtain skills that can be extrapolated to other conditions that require patients change to adopt a different behavior. At the end, participants will present their proposed gamification design and discuss and comment each solution, assessing potential unintended outcomes and advantages.

Return to the Primary Acute Care Service Among Patients With Multiple Myeloma on an Acute Inpatient Rehabilitation Unit.

PubMed

Fu, Jack B; Lee, Jay; Shin, Ben C; Silver, Julie K; Smith, Dennis W; Shah, Jatin J; Bruera, Eduardo

2017-06-01

Pancytopenia, immunosuppression, and other factors may place patients with multiple myeloma at risk for medical complications. These patients often require inpatient rehabilitation. No previous studies have looked at risk factors for return to the primary acute care service of this patient population. To determine the percentage of and factors associated with return to the primary acute care service of multiple myeloma rehabilitation inpatients. Retrospective review. Acute inpatient rehabilitation unit within a National Cancer Institute Comprehensive Cancer Center. All patients with multiple myeloma admitted to the inpatient rehabilitation unit between March 1, 2004, and February 28, 2015. Return to the primary acute care service was analyzed with demographic information, multiple myeloma characteristics, medications, laboratory values, and hospital admission characteristics. One hundred forty-three inpatient rehabilitation admissions were found during the study period. After we removed multiple admissions of the same patients and planned transfers to the primary acute care service, 122 admissions were analyzed. Thirty-two (26%) patients transferred back to the primary acute care service for unplanned reasons. Multivariate analysis revealed male gender and thrombocytopenia as significantly associated with return to the primary acute care service. The median survival of patients who transferred back to the inpatient primary acute care service was 180 days versus 550 days for those who did not (P < .001). Because of their medical fragility, clinicians caring for rehabilitation inpatients with multiple myeloma should maintain close contact with the primary oncology service. Factors associated with an increased risk of transfer back to the primary acute care service include male gender and thrombocytopenia. IV. Copyright © 2017 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

Surgical Management of Carney Complex-Associated Pituitary Pathology.

PubMed

Lonser, Russell R; Mehta, Gautam U; Kindzelski, Bogdan A; Ray-Chaudhury, Abhik; Vortmeyer, Alexander O; Dickerman, Robert; Oldfield, Edward H

2017-05-01

Carney complex (CNC) is a familial neoplasia syndrome that is associated with pituitary-associated hypersecretion of growth hormone (GH) (acromegaly). The underlying cause of pituitary GH hypersecretion and its management have been incompletely defined. To provide biological insight into CNC-associated pituitary pathology and improve management, we analyzed findings in CNC patients who underwent transsphenoidal surgery. Consecutive CNC patients at the National Institutes of Health with acromegaly and imaging evidence of a pituitary adenoma(s) who underwent transsphenoidal resection of tumor(s) were included. Prospectively acquired magnetic resonance imaging and biochemical, surgical, and histological data were analyzed. Seven acromegalic CNC patients (2 male, 5 female) were included. The mean age at surgery was 29.7 years (range, 18-44 years). The mean follow-up was 4.7 years (range, 0.2-129 months). Magnetic resonance imaging revealed a single pituitary adenoma in 4 patients and multiple pituitary adenomas in 3 patients. Whereas patients with single discrete pituitary adenomas underwent selective adenomectomy, patients with multiple adenomas underwent selective adenomectomy of multiple tumors, as well as partial or total hypophysectomy. All adenomas were either GH and prolactin positive or exclusively prolactin positive. Pituitary tissue surrounding the adenomas in patients with multiple adenomas revealed hyperplastic GH- and prolactin-positive tissue. CNC-associated acromegaly results from variable pituitary pathology, including a single GH-secreting adenoma or multiple GH-secreting adenomas and/or GH hypersecretion of the pituitary gland surrounding multiple adenomas. Although selective adenomectomy is the preferred treatment for cases of GH-secreting adenomas, multiple adenomas with associated pituitary gland GH hypersecretion may require partial or complete hypophysectomy to achieve biochemical remission. Copyright © 2017 by the Congress of Neurological Surgeons

Surgical Management of Carney Complex–Associated Pituitary Pathology

PubMed Central

Mehta, Gautam U.; Kindzelski, Bogdan A.; Ray-Chaudhury, Abhik; Vortmeyer, Alexander O.; Dickerman, Robert; Oldfield, Edward H.

2017-01-01

Abstract BACKGROUND: Carney complex (CNC) is a familial neoplasia syndrome that is associated with pituitary-associated hypersecretion of growth hormone (GH) (acromegaly). The underlying cause of pituitary GH hypersecretion and its management have been incompletely defined. OBJECTIVE: To provide biological insight into CNC-associated pituitary pathology and improve management, we analyzed findings in CNC patients who underwent transsphenoidal surgery. METHODS: Consecutive CNC patients at the National Institutes of Health with acromegaly and imaging evidence of a pituitary adenoma(s) who underwent transsphenoidal resection of tumor(s) were included. Prospectively acquired magnetic resonance imaging and biochemical, surgical, and histological data were analyzed. RESULTS: Seven acromegalic CNC patients (2 male, 5 female) were included. The mean age at surgery was 29.7 years (range, 18-44 years). The mean follow-up was 4.7 years (range, 0.2-129 months). Magnetic resonance imaging revealed a single pituitary adenoma in 4 patients and multiple pituitary adenomas in 3 patients. Whereas patients with single discrete pituitary adenomas underwent selective adenomectomy, patients with multiple adenomas underwent selective adenomectomy of multiple tumors, as well as partial or total hypophysectomy. All adenomas were either GH and prolactin positive or exclusively prolactin positive. Pituitary tissue surrounding the adenomas in patients with multiple adenomas revealed hyperplastic GH- and prolactin-positive tissue. CONCLUSION: CNC-associated acromegaly results from variable pituitary pathology, including a single GH-secreting adenoma or multiple GH-secreting adenomas and/or GH hypersecretion of the pituitary gland surrounding multiple adenomas. Although selective adenomectomy is the preferred treatment for cases of GH-secreting adenomas, multiple adenomas with associated pituitary gland GH hypersecretion may require partial or complete hypophysectomy to achieve biochemical remission. PMID:27509071

Intracranial aneurysms: optimized diagnostic tools call for thorough interdisciplinary treatment strategies.

PubMed

Mueller, Oliver M; Schlamann, Marc; Mueller, Daniela; Sandalcioglu, I Erol; Forsting, Michael; Sure, Ulrich

2011-09-01

Intracranial aneurysms (IAs) require deliberately selected treatment strategies as they are incrementally found prior to rupture and deleterious subarachnoid haemorrhage (SAH). Multiple and recurrent aneurysms necessitate both neurointerventionalists and neurosurgeons to optimize aneurysmal occlusion in an interdisciplinary effort. The present study was conducted to condense essential strategies from a single neurovascular centre with regard to the lessons learned. Medical charts of 321 consecutive patients treated for IAs at our centre from September 2008 until December 2010 were retrospectively analysed for clinical presentation of the aneurysms, multiplicity and treatment pathways. In addition, a selective Medline search was performed. A total of 321 patients with 492 aneurysms underwent occlusion of their symptomatic aneurysm: 132 (41.1%) individuals were treated surgically, 189 (58.2%) interventionally; 138 patients presented with a SAH, of these 44.2% were clipped and 55.8% were coiled. Aneurysms of the middle cerebral artery were primarily occluded surgically (88), whereas most of the aneurysms of the internal carotid artery and anterior communicating artery (114) were treated endovascularly. Multiple aneurysms (range 2-5 aneurysms/individual) were diagnosed in 98 patients (30.2%). During the study period 12 patients with recurrent aneurysms were allocated to another treatment modality (previously clip to coil and vice versa). Our data show that successful interdisciplinary occlusion of IAs is based on both neurosurgical and neurointerventional therapy. In particular, multiple and recurrent aneurysms require tailored individual approaches to aneurysmal occlusion. This is achieved by a consequent interdisciplinary pondering of the optimal strategy to occlude IAs in order to prevent SAH.

Prevalence, clinical features and management of pediatric magnetic foreign body ingestions.

PubMed

Tavarez, Melissa M; Saladino, Richard A; Gaines, Barbara A; Manole, Mioara D

2013-01-01

Foreign body (FB) ingestions are frequent in children. Whereas the majority of FBs pass spontaneously through the gastrointestinal tract, ingestion of magnetic FBs pose a particular risk for obstruction due to proximate attraction through the intestinal wall. We aimed to identify the prevalence, clinical presentation, and management of magnetic FB ingestions at our tertiary care institution. We performed a retrospective chart review of medical records of patients presenting to the pediatric Emergency Department (ED) or admitted to the hospital with FB ingestions from June 2003-July 2009. From those cases, patients with magnetic FB ingestions were identified. During the study period, 337,839 patients presented to the ED; 38 cases of magnetic FB ingestion were identified (prevalence 0.01%). Abdominal radiography was obtained in all cases. Ingestion of a single magnet occurred in 30 of 38 cases (79%). Of those, 4 patients underwent endoscopic removal due to signs of FB impaction in the esophagus or pylorus; no complications were noted. Ingestion of multiple magnets (range 2-6) occurred in 8 of 38 cases. Four of the 8 patients with multiple magnetic FBs (50%) presented with signs of peritonitis and required operative repair of multiple intestinal perforations. No deaths were identified. Although ingestion of a single magnetic FB may, in most cases, be managed as a simple FB ingestion, the ingestion of multiple magnetic FB is associated with a high risk of complication and requires aggressive management. We propose an algorithm for management of children with magnetic FB ingestions. Copyright © 2013 Elsevier Inc. All rights reserved.

Oxidative stress in severe pulmonary trauma in critical ill patients. Antioxidant therapy in patients with multiple trauma--a review.

PubMed

Bedreag, Ovidiu Horea; Rogobete, Alexandru Florin; Sarandan, Mirela; Cradigati, Alina Carmen; Papurica, Marius; Dumbuleu, Maria Corina; Chira, Alexandru Mihai; Rosu, Oana Maria; Sandesc, Dorel

2015-01-01

Multiple trauma patients require extremely good management and thus, the trauma team needs to be prepared and to be up to date with the new standards of intensive therapy. Oxidative stress and free radicals represent an extremely aggressive factor to cells, having a direct consequence upon the severity of lung inflammation. Pulmonary tissue is damaged by oxidative stress, leading to biosynthesis of mediators that exacerbate inflammation modulators. The subsequent inflammation spreads throughout the body, leading most of the time to multiple organ dysfunction and death. In this paper, we briefly present an update of biochemical effects of oxidative stress and free radical damage to the pulmonary tissue in patients in critical condition in the intensive care unit. Also, we would like to present a series of active substances that substantially reduce the aggressiveness of free radicals, increasing the chances of survival.

Assessment of Neutrophil Function in Patients with Septic Shock: Comparison of Methods

PubMed Central

Wenisch, C.; Fladerer, P.; Patruta, S.; Krause, R.; Hörl, W.

2001-01-01

Patients with septic shock are shown to have decreased neutrophil phagocytic function by multiple assays, and their assessment by whole-blood assays (fluorescence-activated cell sorter analysis) correlates with assays requiring isolated neutrophils (microscopic and spectrophotometric assays). For patients with similar underlying conditions but without septic shock, this correlation does not occur. PMID:11139215

Cyclodiode photocoagulation for refractory glaucoma after penetrating keratoplasty.

PubMed

Shah, P; Lee, G A; Kirwan, J K; Bunce, C; Bloom, P A; Ficker, L A; Khaw, P T

2001-11-01

This study analyzes the results of intraocular pressure (IOP) reduction by contact diode cycloablation (cyclodiode) in cases of refractory glaucoma after penetrating keratoplasty. Retrospective noncomparative, interventional case series. Twenty-eight eyes in 28 patients attending the Moorfields Eye Hospital. Cyclodiode (40 applications x 1.5 W x 1.5 seconds over 270-300 degrees ) was used to control the IOP in refractory glaucoma after penetrating keratoplasty. Postoperative IOP, graft status, visual acuity, and number of antiglaucoma medications were recorded after cyclodiode treatment. Cyclodiode resulted in a reduction of IOP from a median of 33 mmHg (interquartile range [28, 40.5]) to a median of 15 mmHg (interquartile range [12, 20.5]). Most patients had a significant lowering in IOP with a median reduction of 16 mmHg (interquartile range [12, 25]; P < 0.0001). IOPs of 6 to 21 mmHg were achieved in 22 patients (79%). Sixteen patients (57%) required more than one treatment with cyclodiode to control the IOP, with three patients (11%) requiring three treatments and two patients (7%) requiring four treatments. Visual acuity improved (> two Snellen lines of acuity) in three patients (11%) and remained the same (+/- one Snellen line) in 17 patients (61%). The mean number of antiglaucoma medications before cycloablation was 2.6 and was 1.8 after treatment (P < 0.001). Of the 19 patients (68%) with originally clear grafts, three grafts (16%) developed opacification. One patient (4%), with a history of nanophthalmos and recurrent uveal effusion, had delayed hypotony (IOP < 6 mmHg) occurring 46 months after the diode treatment. All patients had at least 6 months follow-up. These patients have often undergone multiple previous complicated ocular interventions and are often not suitable for filtration surgery. Reduction of IOP with maintenance of visual acuity and a good safety profile was achieved in most patients in this study but may require multiple treatments. We propose cyclodiode as an effective treatment for many patients in the management of refractory glaucoma after penetrating keratoplasty.

Anesthetic Challenges in Robotic-assisted Urologic Surgery

PubMed Central

Hsu, Richard L; Kaye, Alan D; Urman, Richard D

2013-01-01

Robotic-assisted surgery has evolved over the past two decades with constantly improving technology, assisting surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and limited access to the patient, all present anesthetic management challenges in urologic surgery. Patient positioning requirements can cause significant physiologic effects and may result in many complications. Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce surgical and anesthetic complications. PMID:24659914

21 CFR 1311.120 - Electronic prescription application requirements.

Code of Federal Regulations, 2011 CFR

2011-04-01

... the practitioner to sign multiple prescriptions for a single patient at one time using a single... practitioners, a practitioner authorized to sign controlled substance prescriptions must approve logical access... application must require the practitioner or his agent to select the DEA registration number to be included on...

Risks and burden of viral respiratory tract infections in patients with multiple myeloma in the era of immunomodulatory drugs and bortezomib: experience at an Australian Cancer Hospital.

PubMed

Teh, Benjamin W; Worth, Leon J; Harrison, Simon J; Thursky, Karin A; Slavin, Monica A

2015-07-01

Infections are a leading cause of morbidity and mortality in patients with multiple myeloma. The epidemiology, risk factors and outcomes of viral respiratory tract infections (vRTI) are not well described in patients with multiple myeloma managed with novel agents, the current standard of care. Patients with myeloma from 2009 to 2012 who tested positive on respiratory virus multiplex polymerase chain reaction had clinical, radiological and microbiological records reviewed. The Fourth European Conference on Infections in Leukaemia (ECIL-4) definitions of RTI were applied. Univariate and multivariate regression analysis of risk factors was performed using vRTI as the evaluable outcome. Of 330 patients, 75 (22.7%) tested positive for a total of 100 vRTI episodes. All patients received thalidomide, lenalidomide or bortezomib in combination with myeloma therapies (median of three treatment regimens). vRTI occurred most commonly in patients with progressive disease, and receipt of more than three lines of myeloma therapy was associated with an increased risk of vRTI (p < 0.01). Amongst key respiratory pathogens, influenza was associated with the highest hospital admission rate (66.7%), ICU admission rate (41.6%) and mortality (33.3%) whilst RSV was associated with prolonged hospital stay. Patients with multiple myeloma and advanced disease managed with multiple lines of therapy are at risk for vRTI, and targeted interventions for prevention/treatment are required.

Potential Benefits of Rib Fracture Fixation in Patients with Flail Chest and Multiple Non-flail Rib Fractures.

PubMed

Qiu, Meiguang; Shi, Zhanjun; Xiao, Jun; Zhang, Xuming; Ling, Shishui; Ling, Hao

2016-12-01

The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest ( n  = 38) and multiple non-flail rib fracture groups ( n  = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.

Healthcare resource utilisation associated with skeletal-related events in European patients with multiple myeloma: Results from a prospective, multinational, observational study.

PubMed

Ashcroft, John; Duran, Ignacio; Hoefeler, Herbert; Lorusso, Vito; Lueftner, Diana; Campioni, Marco; Intorcia, Michele; Bahl, Amit

2018-05-01

Patients with multiple myeloma (MM) often experience debilitating skeletal-related events (SREs: pathologic fracture, radiation to bone [RB], surgery to bone [SB] or spinal cord compression [SCC]). This is the first comprehensive, prospective, observational analysis of healthcare resource utilisation (HRU), independently attributed to SREs by investigators, in patients with MM. Eligible patients had lytic bone lesions, life expectancy ≥6 months, Eastern Cooperative Oncology Group performance status ≤2 and ≥1 SRE in the 97 days before enrolment. Data were collected retrospectively for 97 days before enrolment and prospectively for 18-21 months. Altogether, 153 patients were enrolled from Germany, Italy, Spain and the United Kingdom. Of the 281 observed SREs, 36.7% required inpatient stays (mean duration: 20.6 days per SRE [standard deviation (SD): 22.9]). SB and SCC were the SREs most likely to require stays (72.3% and 50.0% of SREs, respectively); SCC required the longest mean (SD) stay per event (40.5 [40.8] days). Overall, 179 SREs required outpatient visits; this was most likely for RB (74.8%) and least likely for non-vertebral fracture (50.0%). All SREs were associated with substantial HRU; therefore, preventing SREs in MM will reduce the economic and resource burden on healthcare systems. © 2018 The Authors. European Journal of Haematology Published by John Wiley & Sons Ltd.

The Face-Processing Network Is Resilient to Focal Resection of Human Visual Cortex.

PubMed

Weiner, Kevin S; Jonas, Jacques; Gomez, Jesse; Maillard, Louis; Brissart, Hélène; Hossu, Gabriela; Jacques, Corentin; Loftus, David; Colnat-Coulbois, Sophie; Stigliani, Anthony; Barnett, Michael A; Grill-Spector, Kalanit; Rossion, Bruno

2016-08-10

Human face perception requires a network of brain regions distributed throughout the occipital and temporal lobes with a right hemisphere advantage. Present theories consider this network as either a processing hierarchy beginning with the inferior occipital gyrus (occipital face area; IOG-faces/OFA) or a multiple-route network with nonhierarchical components. The former predicts that removing IOG-faces/OFA will detrimentally affect downstream stages, whereas the latter does not. We tested this prediction in a human patient (Patient S.P.) requiring removal of the right inferior occipital cortex, including IOG-faces/OFA. We acquired multiple fMRI measurements in Patient S.P. before and after a preplanned surgery and multiple measurements in typical controls, enabling both within-subject/across-session comparisons (Patient S.P. before resection vs Patient S.P. after resection) and between-subject/across-session comparisons (Patient S.P. vs controls). We found that the spatial topology and selectivity of downstream ipsilateral face-selective regions were stable 1 and 8 month(s) after surgery. Additionally, the reliability of distributed patterns of face selectivity in Patient S.P. before versus after resection was not different from across-session reliability in controls. Nevertheless, postoperatively, representations of visual space were typical in dorsal face-selective regions but atypical in ventral face-selective regions and V1 of the resected hemisphere. Diffusion weighted imaging in Patient S.P. and controls identifies white matter tracts connecting retinotopic areas to downstream face-selective regions, which may contribute to the stable and plastic features of the face network in Patient S.P. after surgery. Together, our results support a multiple-route network of face processing with nonhierarchical components and shed light on stable and plastic features of high-level visual cortex following focal brain damage. Brain networks consist of interconnected functional regions commonly organized in processing hierarchies. Prevailing theories predict that damage to the input of the hierarchy will detrimentally affect later stages. We tested this prediction with multiple brain measurements in a rare human patient requiring surgical removal of the putative input to a network processing faces. Surprisingly, the spatial topology and selectivity of downstream face-selective regions are stable after surgery. Nevertheless, representations of visual space were typical in dorsal face-selective regions but atypical in ventral face-selective regions and V1. White matter connections from outside the face network may support these stable and plastic features. As processing hierarchies are ubiquitous in biological and nonbiological systems, our results have pervasive implications for understanding the construction of resilient networks. Copyright © 2016 the authors 0270-6474/16/368426-16$15.00/0.

Community-acquired respiratory infections are common in patients with non-Hodgkin lymphoma and multiple myeloma.

PubMed

Lavi, Noa; Avivi, Irit; Kra-Oz, Zipora; Oren, Ilana; Hardak, Emilia

2018-07-01

Available data suggest that respiratory infections are associated with increased morbidity and mortality in patients hospitalized due to acute leukemia and allogeneic stem cell transplantation (allo-SCT). However, the precise incidence, risk factors, and severity of respiratory infection, mainly community-acquired, in patients with lymphoma and multiple myeloma (MM) are not fully determined. The current study aimed to investigate risk factors for respiratory infections and their clinical significance in patients with B cell non-Hodgkin lymphoma (NHL) and multiple myeloma (MM) in the first year of diagnosis. Data of consecutive patients diagnosed with NHL or MM and treated at the Rambam Hematology Inpatient and Outpatient Units between 01/2011 and 03/2012 were evaluated. Information regarding anticancer treatment, incidence and course of respiratory infections, and infection-related outcomes was analyzed. One hundred and sixty episodes of respiratory infections were recorded in 103 (49%) of 211 (73-MM, 138-NHL) patients; 126 (79%) episodes were community-acquired, 47 (29%) of them required hospitalization. In univariate analysis, age < 60 years, MM diagnosis, and autologous SCT increased the respiratory infection risk (P = 0.058, 0.038, and 0.001, respectively). Ninety episodes (56% of all respiratory episodes) were examined for viral pathogens. Viral infections were documented in 25/90 (28%) episodes, 21 (84%) of them were community-acquired, requiring hospitalization in 5 (24%) cases. Anti-flu vaccination was performed in 119 (56%) patients. Two of the six patients diagnosed with influenza were vaccinated. Respiratory infections, including viral ones, are common in NHL and MM. Most infections are community-acquired and have a favorable outcome. Rapid identification of viral pathogens allows avoiding antibiotic overuse in this patient population.

Improving bed turnover time with a bed management system.

PubMed

Tortorella, Frank; Ukanowicz, Donna; Douglas-Ntagha, Pamela; Ray, Robert; Triller, Maureen

2013-01-01

Efficient patient throughput requires a high degree of coordination and communication. Opportunities abound to improve the patient experience by eliminating waste from the process and improving communication among the multiple disciplines involved in facilitating patient flow. In this article, we demonstrate how an interdisciplinary team at a large tertiary cancer center implemented an electronic bed management system to improve the bed turnover component of the patient throughput process.

Smoldering multiple myeloma requiring treatment: time for a new definition?

PubMed Central

Stewart, A. Keith; Chanan-Khan, Asher; Rajkumar, S. Vincent; Kyle, Robert A.; Fonseca, Rafael; Kapoor, Prashant; Bergsagel, P. Leif; McCurdy, Arleigh; Gertz, Morie A.; Lacy, Martha Q.; Lust, John A.; Russell, Stephen J.; Zeldenrust, Steven R.; Reeder, Craig; Roy, Vivek; Buadi, Francis; Dingli, David; Hayman, Suzanne R.; Leung, Nelson; Lin, Yi; Mikhael, Joseph; Kumar, Shaji K.

2013-01-01

Smoldering multiple myeloma (SMM) bridges the gap between monoclonal gammopathy of undetermined significance (a mostly premalignant disorder) and active multiple myeloma (MM). Until recently, no interventional study in patients with SMM showed improved overall survival (OS) with therapy as compared with observation. A report from the PETHEMA-GEM (Programa Español de Tratamientos en Hematologica) group described both fewer myeloma-related events and better OS among patients with high-risk SMM who were treated with lenalidomide and dexamethasone. This unique study prompted us to review current knowledge about SMM and address the following questions: (1) Are there patients currently defined as SMM who should be treated routinely? (2) Should the definitions of SMM and MM be reconsidered? (3) Has the time come when not treating is more dangerous than treating? (4) Could unintended medical harm result from overzealous intervention? Our conclusion is that those patients with the highest-risk SMM (extreme bone marrow plasmacytosis, extremely abnormal serum immunoglobulin free light chain ratio, and multiple bone lesions detected only by modern imaging) should be reclassified as active MM so that they can receive MM-appropriate therapy and the paradigm of careful observation for patients with SMM can be preserved. PMID:24144641

Robotic partial nephrectomy for complex renal tumors: surgical technique.

PubMed

Rogers, Craig G; Singh, Amar; Blatt, Adam M; Linehan, W Marston; Pinto, Peter A

2008-03-01

Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.

Estimation of energy requirements for mechanically ventilated, critically ill patients using nutritional status

PubMed Central

Kan, Mee-Nin; Chang, Han-Hsin; Sheu, Woei-Fen; Cheng, Chien-Hsiang; Lee, Bor-Jen; Huang, Yi-Chia

2003-01-01

Background There is very little information on what is considered an adequate energy intake for mechanically ventilated, critically ill patients. The purpose of the present study was to determine this energy requirement by making use of patients' nutritional status. Methods The study was conducted in a multidisciplinary intensive care unit of Taichung Veterans General Hospital, Taiwan. Patients were hemodynamically stable and not comatose, and were requiring at least 7 days of mechanical ventilation. Fifty-four patients successfully completed this study. The resting energy expenditure was measured using indirect calorimetry. The total energy requirement was considered 120% of the measured energy expenditure. The daily nutrient intake was recorded. Nutritional status was assessed using single and multiple parameters, nitrogen balance, and medical records, and was performed within 24 hours of admission and after 7 days in the intensive care unit. Results Fifteen patients were being underfed (<90% of total energy requirement), 20 patients were in the appropriate feeding (AF) group (within ± 10% of total energy requirement), and 19 patients received overfeeding (>110% of total energy requirement). Patients in the underfeeding group received only 68.3% of their energy requirement, while the overfeeding group patients received up to 136.5% of their required calories. Only patients in the AF group had a positive nitrogen balance (0.04 ± 5.1) on day 7. AF group patients had a significantly higher Nutritional Risk Index value at day 7 than at day 1. Conclusion AF patients had more improvement in nutritional status than patients in the other feeding groups. To provide at least 120% of the resting energy expenditure seemed adequate to meet the caloric energy needs of hemodynamically stable, mechanically ventilated, critically ill patients. PMID:12974978

Multiple neoplasms among cervical cancer patients in the material of the lower Silesian cancer registry.

PubMed

Izmajłowicz, Barbara; Kornafel, Jan; Błaszczyk, Jerzy

2014-01-01

According to the definition by the International Agency for Research on Cancer (IARC), primary multiple neoplasms are two or more neoplasms of different histopathological build in one organ, or two or more tumors occurring in one patient, regardless of the time of their occurrence (synchronic - up to 6 months, metachronous - after 6 months), coming from an organ or a tissue and not being an infiltration from another neoplasm, a relapse or a metastasis. It was the aim of the study to analyze the frequency of the occurrence of multiple neoplasms among patients suffering from uterine cervix cancer, with a special interest in coexistent neoplasms, the time of their occurrence and total 5-year survivals. The data from the Lower Silesian Cancer Registry concerning the years 1984-2009 formed the material of the present study. 5.3% of all cervix neoplasms occurred as multiple cancers. Cervix neoplasms were 13.4% of multiple neoplasms. On average, cervical cancer occurred as a subsequent cancer in 6 patients yearly (60.7% of the occurrences of cervical cancer were in the period of 5 years following treatment for the first neoplasm). 5-year survival in patients suffering from primarily multiple cervix neoplasms constituted 57% and was convergent with the results for all patients suffering from cervical cancer. Cervical cancer as the first neoplasm occurred in 287 patients, on average in 11 patients annually. In the period of the first 5 years after the treatment of cervical cancer, there were 42.8% occurrences of other cancers. Cervical neoplasms most frequently coexisted with cancers of the breast, lung and large intestine. The frequency of the occurrence of multiple neoplasm among cervical cancer patients is increasing. Most frequently they coexist with other tobacco-related neoplasms, those related to HPV infections and with secondary post-radiation neoplasms. These facts should be taken into consideration during post-treatment observation and when directing diagnostic and prophylactic tests. Synchronic neoplasms require detailed diagnostics and planning of treatment by a team of specialists. The occurrence of primary multiple cervical neoplasms does not worsen the prognosis as compared to patients suffering exclusively from cervical cancer.

Results of multiple drilling compared with those of conventional methods of core decompression.

PubMed

Song, Won Seok; Yoo, Jeong Joon; Kim, Young-Min; Kim, Hee Joong

2007-01-01

We performed multiple drilling as a femoral head-preserving procedure for osteonecrosis of the femoral head thinking the therapeutic effects of core decompression could be achieved by this simpler procedure than core decompression. We retrospectively reviewed 136 patients (163 hips) who had multiple drilling using 9/64-inch Steinmann pins for treatment of nontraumatic osteonecrosis of the femoral head. The mean followup for patients who did not require additional surgery (113 hips) was 87 months (range, 60-134 months). We defined failure as the need for additional surgery or a Harris hip score less than 75. After a minimum 5-year followup, 79% (31/39) of patients with Stage I disease and 77% (62/81) of patients with Stage II disease had no additional surgery. All (15/15) small lesions (<25% involvement) and 84% (37/44) of medium-sized lesions (25-50% involvement) were considered successful. Survival rates of patients with Ficat Stages I or II lesions were greater than survival rates for patients with Stage III lesions. Hips with a large necrotic area had poor results. We had one instance of subtrochanteric fracture through drill entry holes. Multiple drilling is straightforward with few complications and produces results comparable to results of other core decompression techniques.

Recent developments in the surgical management of perianal fistula for Crohn’s disease

PubMed Central

Geltzeiler, Cristina B.; Wieghard, Nicole; Tsikitis, Vassiliki L.

2014-01-01

Perianal manifestations of Crohn’s disease (CD) are common and, of them, fistulas are the most common. Perianal fistulas can be extremely debilitating for patients and are often very challenging for clinicians to treat. CD perianal fistulas usually require multidisciplinary and multimodality treatment, including both medical and surgical approaches. The majority of patients require multiple surgical interventions. CD patients with perianal fistulas have a high rate of primary non-healing, surgical morbidity, and high recurrence rates. This has led to constant efforts to improve surgical management of this disease process. PMID:25331917

[Multiple sclerosis, loss of functionality and gender].

PubMed

Bravo-González, Félix; Álvarez-Roldán, Arturo

2017-12-01

To identify the type of support and assistance that patients with multiple sclerosis need in order to cope with the loss of functionality, and to show how gender affects the perception of these needs. Interpretative-phenomenological qualitative study. Granada (Spain). Year: 2014. Intentional sample: 30 patients and 20 family caregivers. Data were gathered from 26 interviews and 4 focus groups. The data were coded and analysed with the NVivo programme. The multiple sclerosis patients and family caregivers had different perceptions of the loss of capacity to undertake activities of daily living. Being able to self care was considered the last vestige of autonomy. The women with multiple sclerosis tried to take on the responsibility of housework, but the male caregivers became gradually involved in these tasks. Gender roles were redefined with respect to housekeeping. The multiple sclerosis patients showed a need for emotional support. Some of the men had abandoned the stereotype of the strong male as a result of the decline in their health. Adaptations in the home took place without planning them in advance. The use of mobility devices started on an occasional basis. A fear of stigma was an obstacle for regular use of assistive technology. Health care for people with multiple sclerosis should include family caregivers. Gender influences the perception that caregivers and patients have of the assistance they require to maximise their quality of life. This flags up several intervention areas for the follow-up and long-term care of these patients by the healthcare system. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

Disconnection mechanism and regional cortical atrophy contribute to impaired processing of facial expressions and theory of mind in multiple sclerosis: a structural MRI study.

PubMed

Mike, Andrea; Strammer, Erzsebet; Aradi, Mihaly; Orsi, Gergely; Perlaki, Gabor; Hajnal, Andras; Sandor, Janos; Banati, Miklos; Illes, Eniko; Zaitsev, Alexander; Herold, Robert; Guttmann, Charles R G; Illes, Zsolt

2013-01-01

Successful socialization requires the ability of understanding of others' mental states. This ability called as mentalization (Theory of Mind) may become deficient and contribute to everyday life difficulties in multiple sclerosis. We aimed to explore the impact of brain pathology on mentalization performance in multiple sclerosis. Mentalization performance of 49 patients with multiple sclerosis was compared to 24 age- and gender matched healthy controls. T1- and T2-weighted three-dimensional brain MRI images were acquired at 3Tesla from patients with multiple sclerosis and 18 gender- and age matched healthy controls. We assessed overall brain cortical thickness in patients with multiple sclerosis and the scanned healthy controls, and measured the total and regional T1 and T2 white matter lesion volumes in patients with multiple sclerosis. Performances in tests of recognition of mental states and emotions from facial expressions and eye gazes correlated with both total T1-lesion load and regional T1-lesion load of association fiber tracts interconnecting cortical regions related to visual and emotion processing (genu and splenium of corpus callosum, right inferior longitudinal fasciculus, right inferior fronto-occipital fasciculus, uncinate fasciculus). Both of these tests showed correlations with specific cortical areas involved in emotion recognition from facial expressions (right and left fusiform face area, frontal eye filed), processing of emotions (right entorhinal cortex) and socially relevant information (left temporal pole). Thus, both disconnection mechanism due to white matter lesions and cortical thinning of specific brain areas may result in cognitive deficit in multiple sclerosis affecting emotion and mental state processing from facial expressions and contributing to everyday and social life difficulties of these patients.

Multiple Fentanyl Overdoses - New Haven, Connecticut, June 23, 2016.

PubMed

Tomassoni, Anthony J; Hawk, Kathryn F; Jubanyik, Karen; Nogee, Daniel P; Durant, Thomas; Lynch, Kara L; Patel, Rushaben; Dinh, David; Ulrich, Andrew; D'Onofrio, Gail

2017-02-03

On the evening of June 23, 2016, a white powder advertised as cocaine was purchased off the streets from multiple sources and used by an unknown number of persons in New Haven, Connecticut. During a period of less than 8 hours, 12 patients were brought to the emergency department (ED) at Yale New Haven Hospital, experiencing signs and symptoms consistent with opioid overdose. The route of intoxication was not known, but presumed to be insufflation ("snorting") in most cases. Some patients required doses of the opioid antidote naloxone exceeding 4 mg (usual initial dose = 0.1-0.2 mg intravenously), and several patients who were alert after receiving naloxone subsequently developed respiratory failure. Nine patients were admitted to the hospital, including four to the intensive care unit (ICU); three required endotracheal intubation, and one required continuous naloxone infusion. Three patients died. The white powder was determined to be fentanyl, a drug 50 times more potent than heroin, and it included trace amounts of cocaine. The episode triggered rapid notification of public health and law enforcement agencies, interviews of patients and their family members to trace and limit further use or distribution of the fentanyl, immediate naloxone resupply and augmentation for emergency medical services (EMS) crews, public health alerts, and plans to accelerate naloxone distribution to opioid users and their friends and families. Effective communication and timely, coordinated, collaborative actions of community partners reduced the harm caused by this event and prevented potential subsequent episodes.

Using a modification of the Clavien-Dindo system accounting for readmissions and multiple interventions: defining quality for pancreaticoduodenectomy.

PubMed

Baker, Marshall S; Sherman, Karen L; Stocker, Susan J; Hayman, Amanda V; Bentrem, David J; Prinz, Richard A; Talamonti, Mark S

2014-09-01

The Clavien-Dindo system (CD) does not change the grade assigned a complication when multiple readmissions or interventions are required to manage a complication. We apply a modification of CD accounting for readmissions and interventions to pancreaticoduodenectomy (PD). PDs done between 1999 and 2009 were reviewed. CD grade IIIa complications requiring more than one intervention and II and IIIa complications requiring significantly prolonged lengths of stay including all 90-day readmissions were classified severe-adverse-postoperative-outcomes (SAPO). CD IIIb, IV, and V complications were also classified SAPOs. All other complications were considered minor-adverse-postoperative-outcomes (MAPO). Four-hundred forty three of 490 PD patients (90.4%) had either no complication or a complication of low to moderate CD grade (I, II, IIIa). When reclassified by the new metric, 92 patient-outcomes (19%) were upgraded from CD II or IIIa to SAPO. One-hundred thirty nine patients (28.4%) had a SAPO. Multivariable regression identified age >75 years, pylorus preservation and operative blood loss >1,500 ml as predictors of SAPO. Age was not associated with poor outcome using the unmodified CD system. Established systems may under-grade the severity of some complications following PD. We define a procedure-specific modification of CD accounting for readmissions and multiple interventions. Using this modification, advanced age, pylorus preservation, and significant blood loss are associated with poor outcome. © 2014 Wiley Periodicals, Inc.

Pain medication management processes used by oncology outpatients and family caregivers part I: health systems contexts.

PubMed

Schumacher, Karen L; Plano Clark, Vicki L; West, Claudia M; Dodd, Marylin J; Rabow, Michael W; Miaskowski, Christine

2014-11-01

Oncology patients with persistent pain treated in outpatient settings and their family caregivers have significant responsibility for managing pain medications. However, little is known about their practical day-to-day experiences with pain medication management. The aim was to describe day-to-day pain medication management from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psychoeducational intervention called the Pro-Self(©) Plus Pain Control Program. In this article, we focus on pain medication management by patients and family caregivers in the context of multiple complex health systems. We qualitatively analyzed audio-recorded intervention sessions that included extensive dialogue between patients, family caregivers, and nurses about pain medication management during the 10-week intervention. The health systems context for pain medication management included multiple complex systems for clinical care, reimbursement, and regulation of analgesic prescriptions. Pain medication management processes particularly relevant to this context were getting prescriptions and obtaining medications. Responsibilities that fell primarily to patients and family caregivers included facilitating communication and coordination among multiple clinicians, overcoming barriers to access, and serving as a final safety checkpoint. Significant effort was required of patients and family caregivers to insure safe and effective pain medication management. Health systems issues related to access to needed analgesics, medication safety in outpatient settings, and the effort expended by oncology patients and their family caregivers require more attention in future research and health-care reform initiatives. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Second-site prosthetic joint infection in patients with multiple prosthetic joints.

PubMed

Clesham, Kevin; Hughes, Andrew J; O' hEireamhoin, Sven; Fleming, Catherine; Murphy, Colin G

2018-04-10

Prosthetic joint infections (PJIs) are among the most serious complications in arthroplasty. A second-site PJI in patients with multiple prosthetic joints increases morbidity, with many requiring further revision procedures. We aimed to establish why some patients with multiple joints develop second-site infections. Our institution's arthroplasty database was reviewed from 2004 to 2017. All PJIs were identified, and all patients with more than one prosthetic joint in situ were included. We recorded risk factors, causative organisms, number of procedures and length of stay. Forty-four patients meeting the criteria were identified. Four patients (9.1%) developed second-site infection. Eight patients (18.2%) developed re-infection of the primary PJI. Positive MRSA carrier status and PJI of a total knee replacement were associated with an increased risk of a second episode of infection. Patients who developed further infection had more frequent admission and longer lengths of stay than isolated PJIs. Higher morbidity and use of hospital resources are associated with this cohort of patients. PJIs in total knee replacements and positive MRSA status are associated with higher rates of second infection. Identifying this vulnerable cohort of patients at an early stage is critical to ensure measures are taken to reduce the risks of further infection.

Treatment of candidosis in severely injured adults with short-course, low-dose amphotericin B.

PubMed

Rosemurgy, A S; Drost, T F; Murphy, C G; Kearney, R E; Albrink, M H

1990-12-01

Thirty-three (0.7%) of 4,818 trauma patients admitted between January 1, 1987, and July 1, 1989, developed invasive candidosis requiring IV antifungal therapy. All patients were seriously traumatized. Before developing candidosis, all patients had documented bacterial infections. These infections were generally polymicrobial and were treated with multiple broad-spectrum antibiotics (an average of 5.4 antibiotics for 17.2 days). Twenty-eight (85%) of 33 patients received enteral feedings for an average of 11 days +/- 1.5 (SEM) before developing candidosis and 24 (73%) received NG/oral nystatin for an average of 7.6 days +/- 0.9 before developing candidosis. All patients with candidosis were treated with intravenous amphotericin B: cumulative dose of 157.3 mg +/- 31.3 mg given over 10 days +/- 1.1. One patient developed recurrent candidosis despite NG/oral prophylaxis and enteral feedings. Six patients (18%) died due to sepsis and multiple organ failure. The patients who died did not objectively differ from the survivors. Candidosis is an infrequent infection in severely injured patients. Candidosis was invariably preceded by treatment with multiple broad-spectrum antibiotics for a variety of polymicrobial bacterial infections. NG/oral nystatin and enteral feedings did not prevent candidosis, in contrast to widely accepted beliefs. Amphotericin B therapy was safe. Recurrent candidosis was unusual. Candida infections had a high mortality rate associated with multiple blood transfusions and prolonged hospitalization. Candidosis represents a sign of severe injury and illness but can be amenable to prompt, aggressive treatment.

SUMMIT (Serially Unified Multicenter Multiple Sclerosis Investigation): creating a repository of deeply phenotyped contemporary multiple sclerosis cohorts.

PubMed

Bove, Riley; Chitnis, Tanuja; Cree, Bruce Ac; Tintoré, Mar; Naegelin, Yvonne; Uitdehaag, Bernard Mj; Kappos, Ludwig; Khoury, Samia J; Montalban, Xavier; Hauser, Stephen L; Weiner, Howard L

2017-08-01

There is a pressing need for robust longitudinal cohort studies in the modern treatment era of multiple sclerosis. Build a multiple sclerosis (MS) cohort repository to capture the variability of disability accumulation, as well as provide the depth of characterization (clinical, radiologic, genetic, biospecimens) required to adequately model and ultimately predict a patient's course. Serially Unified Multicenter Multiple Sclerosis Investigation (SUMMIT) is an international multi-center, prospectively enrolled cohort with over a decade of comprehensive follow-up on more than 1000 patients from two large North American academic MS Centers (Brigham and Women's Hospital (Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women's Hospital (CLIMB; BWH)) and University of California, San Francisco (Expression/genomics, Proteomics, Imaging, and Clinical (EPIC))). It is bringing online more than 2500 patients from additional international MS Centers (Basel (Universitätsspital Basel (UHB)), VU University Medical Center MS Center Amsterdam (MSCA), Multiple Sclerosis Center of Catalonia-Vall d'Hebron Hospital (Barcelona clinically isolated syndrome (CIS) cohort), and American University of Beirut Medical Center (AUBMC-Multiple Sclerosis Interdisciplinary Research (AMIR)). We provide evidence for harmonization of two of the initial cohorts in terms of the characterization of demographics, disease, and treatment-related variables; demonstrate several proof-of-principle analyses examining genetic and radiologic predictors of disease progression; and discuss the steps involved in expanding SUMMIT into a repository accessible to the broader scientific community.

Outlook with conservative treatment of peptic oesophageal stricture.

PubMed Central

Ogilvie, A L; Ferguson, R; Atkinson, M

1980-01-01

In order to assess the outlook for patients with peptic oesophageal strictures treated by Eder Puestow dilatation at fibreoptic endoscopy, 50 patients were followed up for periods ranging from nine months to four years. Twenty patients (40%) required only a single dilatation, and the remaining 30 (60%) required multiple dilatations. The frequency of dilatation tended to decrease with time. There was one death attributable to the procedure. Two patients developed an adenocarcinoma at the site of the stricture. We conclude that conservative management of peptic oesophageal stricture combining the use of dilatation at fibreoptic endoscopy with medical measures to control gastro-oesophageal reflux offers a relatively safe means of providing symptomatic relief, maintaining nutrition, and allowing the patient an acceptable quality of life. PMID:7364314

Digital health technology and diabetes management.

PubMed

Cahn, Avivit; Akirov, Amit; Raz, Itamar

2018-01-01

Diabetes care is largely dependent on patient self-management and empowerment, given that patients with diabetes must make numerous daily decisions as to what to eat, when to exercise, and determine their insulin dose and timing if required. In addition, patients and providers are generating vast amounts of data from many sources, including electronic medical records, insulin pumps, sensors, glucometers, and other wearables, as well as evolving genomic, proteomic, metabolomics, and microbiomic data. Multiple digital tools and apps have been developed to assist patients to choose wisely, and to enhance their compliance by using motivational tools and incorporating incentives from social media and gaming techniques. Healthcare teams (HCTs) and health administrators benefit from digital developments that sift through the enormous amounts of patient-generated data. Data are acquired, integrated, analyzed, and presented in a self-explanatory manner, highlighting important trends and items that require attention. The use of decision support systems may propose data-driven actions that, for the most, require final approval by the patient or physician before execution and, once implemented, may improve patient outcomes. The digital diabetes clinic aims to incorporate all digital patient data and provide individually tailored virtual or face-to-face visits to those persons who need them most. Digital diabetes care has demonstrated only modest HbA1c reduction in multiple studies and borderline cost-effectiveness, although patient satisfaction appears to be increased. Better understanding of the barriers to digital diabetes care and identification of unmet needs may yield improved utilization of this evolving technology in a safe, effective, and cost-saving manner. © 2017 Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.

Spasticity management in multiple sclerosis.

PubMed

Hughes, Christina; Howard, Ileana M

2013-11-01

Spasticity is a prevalent and potentially disabling symptom common in individuals with multiple sclerosis. Adequate evaluation and management of spasticity requires a careful assessment of the patient's history to determine functional impact of spasticity and potential exacerbating factors, and physical examination to determine the extent of the condition and culpable muscles. A host of options for spasticity management are available: therapeutic exercise, physical modalities, complementary/alternative medicine interventions, oral medications, chemodenervation, and implantation of an intrathecal baclofen pump. Choice of treatment hinges on a combination of the extent of symptoms, patient preference, and availability of services. Copyright © 2013 Elsevier Inc. All rights reserved.

The impact of self-transcendence on physical health status promotion in multiple sclerosis patients attending peer support groups.

PubMed

JadidMilani, Maryam; Ashktorab, Tahereh; AbedSaeedi, Zhila; AlaviMajd, Hamid

2015-12-01

This study aimed to investigate the effect of self-transcendence on the physical health of multiple sclerosis (MS) patients attending peer support groups. This study was a quasi-experimental before-and-after design including 33 MS patients in three groups: 10 men in the men-only group, 11 women in the women-only group, and 12 men and women in the mixed group. Participants were required to attend eight weekly sessions of 2 h each. Instruments included the physical health section of the Multiple Sclerosis Quality of Life Inventory and Reed's Self-Transcendence Scale. Peer support group attendance was found to have a significant positive effect on the physical health and self-transcendence of MS patients when comparing average scores before and after attendance. Regression analysis showed that improvement in self-transcendence predicted improvement in physical health. Results show the positive effects of peer support groups on self-transcendence and physical health in MS patients, and suggest that improvement in well-being can be gained by promoting self-transcendence and physical health. © 2015 Wiley Publishing Asia Pty Ltd.

Free 'mini' groin flap for digital resurfacing.

PubMed

Tare, M; Ramakrishnan, V

2009-06-01

Ten cases of post-traumatic skin and soft tissue loss over the digits were resurfaced by free 'mini' groin flap. Five patients had defects of the dorsum of the digit, three had proximal palmar defects, one patient had circumferential skin loss and one had multiple digital injuries. The flap was harvested from the contralateral groin using a two-team approach. The average size of the flap was 5.5 x 4.75 cm and the mean operating time was 2.45 hrs. All patients had physiotherapy within 48-72 hrs. There were no flap losses. Six patients were happy with the cosmetic result and did not require any further debulking. We recommend free tissue transfer for digital resurfacing specifically in moderate to large dorsal defects, proximal volar defects, circumferential skin loss and multiple digit injuries.

Experience with recurrent respiratory papillomatosis in a developing country: impact of tracheostomy.

PubMed

Orji, Foster Tochukwu; Okorafor, Ijeoma A; Akpeh, James O

2013-02-01

The frequent relapses of recurrent respiratory papillomatosis (RRP) sometimes demand repeated surgical excision with tracheostomy. This situation plays a vital role in the management of RRP in developing countries such as ours because of late presentation. This study was conducted to evaluate our experience with RRP and to determine the incidence and impact of tracheostomy in the overall management and outcomes of our patients. The records of 59 patients with histologically confirmed RRP treated between 1994 and 2008 at our tertiary institution were reviewed. We collected data such as age at onset, tracheostomy frequency and duration, number of required surgical excisions, papilloma spread to the lower airways. Patients' characteristics and the course of the disease were compared between a juvenile-onset papillomatosis (JoRRP) group and an adult-onset group (AdRRP). Overall, 68 % of our patients were in the JoRRP group (ages 2-11 years, mean 6 years). The other 32 % were 22-58 years of age (AdRRP group). Two cases of JoRRP continued into adult life. Multiple RRP dominated in the JoRRP group (93 %), whereas solitary papillomas predominated in the AdRRP group (63 %). Tracheostomy was performed because of upper airway obstruction in 42 % of our patients, with children accounting for 72 %. The mean duration of tracheostomy was 3.5 months, with 80 % lasting <4 months. Significantly more JoRRP patients had severe upper airway obstruction, required tracheostomy, and underwent multiple surgical excisions (p = 0.04, 0.02, and 0.009, respectively). Tracheobronchial spread occurred in a patient with prolonged tracheostomy. Multiple laryngeal papillomatosis clearly followed a more severe and less predictable course than the solitary type in both groups. Although there was a high incidence of tracheostomy in this study, short-duration tracheostomies accounted for the low incidence of extralaryngeal spread.

Management of a high risk epileptic patient under conscious sedation: A multidisciplinary approach

PubMed Central

Chellathurai, Burnice Nalina Kumari; Thiagarajan, Ramakrishnan; Jayakumaran, SelvaKumar; Devadoss, Pradeep; Elavazhagan

2016-01-01

Epilepsy, characterized by the risk of recurrent seizures, is a chronic disease that afflicts about 5% of the world's population. The main dental problems associated with epileptic patients include gingival hyperplasia, minor oral injuries, tooth trauma, and prosthodontic problems, which require the dental treatment. Stress and fear are the most common triggering factors for the epilepsy in dental chair. Therefore, a more appropriate method of treating such epileptic patients may be warranted. Conscious sedation is a technique of providing good anesthesia and analgesia to patients, the main advantage of which is the patient's rapid return to presentation levels. Midazolam used as a sedative agent has anticonvulsant properties. This case report highlights a case requiring multiple dental procedures carried out in a high risk epileptic patient under conscious sedation. PMID:27041847

Comparing two methods of thoracoscopic sympathectomy for palmar hyperhidrosis.

PubMed

Ibrahim, Magdi; Allam, Abdulla

2014-09-01

Hyperhidrosis can cause significant professional and social handicaps. Thoracic endoscopic sympathectomy has become the surgical technique of choice for treating intractable palmar hyperhidrosis and can be performed through multiple ports or a single port. This prospective study compares outcomes between the two methods. The study followed 71 consecutive patients who underwent video-assisted sympathectomy for palmar hyperhidrosis between January 2008 and June 2012. In all patients, the procedure was bilateral and performed in one stage. The multiple-port method was used in 35 patients (group A) and the single-port method in 36 patients (group B). Preoperative, intraoperative, and postoperative variables; morbidity, recurrence; and survival were compared in both groups. The procedure was successful in 100% of the patients; none experienced a recurrence of palmar hyperhidrosis, Horner syndrome (oculosympathetic palsy), or serious postoperative complications, and none died. No patients required conversion to an open procedure. Residual minimal pneumothorax occurred in two patients (5.7%) in group A and in one patient (2.8%) in group B. Minimal hemothorax occurred in one patient (2.9%) in group A and in three patients (8.3%) in group B. Compensatory hyperhidrosis occurred in seven patients (20%) in group A and in eight patients (22.2%) in group B. No difference was found between the multiple- and single-port methods. Both are effective, safe minimally invasive procedures that permanently improve quality of life in patients with palmar hyperhidrosis.

Need for tissue plasminogen activator for central venous catheter dysfunction is significantly associated with thrombosis in pediatric cancer patients.

PubMed

MacLean, Jessica; MacDonald, Tamara; Digout, Carol; Smith, Nadine; Rigby, Krista; Kulkarni, Ketan

2018-06-01

Central venous catheter (CVC) dysfunction is a common complication among pediatric cancer patients. Tissue plasminogen activator (tPA) is administered to resolve CVC dysfunction. The present study was designed to determine risk factors associated with requirement of tPA for CVC dysfunction and to assess the clinical impact of CVC dysfunction in terms of CVC loss and venous thrombotic events (VTE). Case records of all pediatric patients with cancer from the Maritimes, Canada were reviewed following ethics approval. Data regarding demographics, clinical diagnosis, CVC dysfunction, characteristics of CVCs, and VTE were pooled from multiple data sources. Seven hundred and forty-one patients required ≥1 CVC. 26.3% of patients required tPA for ≥1 episodes of CVC dysfunction. Requirement of one or more doses of tPA for episodes of CVC dysfunction increased the odds of VTE by two times (95% confidence interval, 1.1-3.6). Patients that required ≥1 doses of tPA required significantly more CVCs (2.05 ± 1.29 per individual patient, 55% of the patients needed >1 CVCs) as compared to the remainder (1.52 ± 0.95 per individual patient, 32% needed >1 CVCs) (P = 0.0001). Multivariate analysis revealed age > 10 years, diagnosis of sarcoma, and tunneled line were independently associated with tPA requirement. We determined independent risk factors associated with requirement of tPA for CVC dysfunction. Requirement of tPA for CVC dysfunction was associated with significantly increased risk of VTE and requirement of more CVCs. These observations can assist in identification of patients at increased risk of CVC dysfunction and inform approaches to reduce CVC loss and VTE. © 2018 Wiley Periodicals, Inc.

Quantification of Circulating Clonal Plasma Cells via Multiparametric Flow Cytometry Identifies Patients with Smoldering Multiple Myeloma at High Risk of Progression

PubMed Central

Gonsalves, Wilson I.; Rajkumar, S. Vincent; Dispenzieri, Angela; Dingli, David; Timm, Michael M.; Morice, William G.; Lacy, Martha Q.; Buadi, Francis K.; Go, Ronald S.; Leung, Nelson; Kapoor, Prashant; Hayman, Suzanne R.; Lust, John A.; Russell, Stephen J.; Zeldenrust, Steven R.; Hwa, Lisa; Kourelis, Taxiarchis V.; Kyle, Robert A.; Gertz, Morie A.; Kumar, Shaji K.

2017-01-01

The presence of high numbers of circulating clonal plasma cells (cPCs) in patients with smoldering multiple myeloma (SMM), detected by a slide-based immunofluorescence assay, has been associated with a shorter time to progression (TTP) to multiple myeloma (MM). The significance of quantifying cPCs via multiparameter flow cytometry, a much more readily available diagnostic modality, in patients with SMM has not been evaluated. This study evaluated 100 patients with a known or new diagnosis of SMM who were seen at the Mayo Clinic, Rochester from January 2008 until December 2013. Patients with ≥ 150 cPCs (N = 9) were considered to have high number of cPCs based on the 97% specificity and 78% PPV of progression to MM within 2 years of cPC assessment. The median TTP of patients with ≥ 150 cPCs was 9 months compared to not reached for patients with < 150 cPCs (P < 0.001). Thus, quantification of cPCs via multiparametric flow cytometry identifies patients with SMM at very high risk of progression to MM within 2 years and warrants confirmation in larger studies. In the future, this may allow reclassification of such patients as having MM requiring therapy prior to them enduring end-organ damage. PMID:27457702

Postinflammatory hyperpigmentation in patients with skin of color.

PubMed

Shokeen, Divya

2016-01-01

Postinflammatory hyperpigmentation (PIH) has posed a substantial challenge for patients with higher Fitzpatrick skin types, specifically types III to VI. Treatment modalities pose a number of limitations due to the number of treatments required, potential side effects, and overall efficacy. Fortunately, multiple therapies have been delineated that can be moderately to highly efficacious in treating PIH in patients with skin of color. This article will review some of these modalities and procedures for this common patient concern.

21 CFR 320.31 - Applicability of requirements regarding an “Investigational New Drug Application.”

Code of Federal Regulations, 2010 CFR

2010-04-01

... patients where either the maximum single or total daily dose exceeds that specified in the labeling of the... application. (2) A multiple-dose study in normal subjects or patients where either the single or total daily... conducting the study, including any contract research organization, shall retain reserve samples of any test...

Effects on Cognition of Stereotactic Lesional Surgery For the Treatment of Tremor in Multiple Sclerosis

PubMed Central

Jahanshahi, Marjan; Pieter, Socorro; Alusi, Sundus H.; Jones, Catherine R. G.; Glickman, Scott; Stein, John; Aziz, Tipu; Bain, Peter G.

2008-01-01

Objective: To assess the effect of stereotactic lesional surgery for treatment of tremor in multiple sclerosis on cognition. Methods: Eleven patients (3 males, 8 females) with multiple sclerosis participated in the study. Six subjects comprised the surgical group and five the matched control group. All patients were assessed at baseline and three months using a neuropsychological test battery that included measures of intellectual ability, memory, language, perception and executive function. Results: There were no significant differences between the surgical and control groups and no change from pre to post testing except for a decline in scores on the Mini-Mental State Examination (MMSE), WAIS-R Digit Span and Verbal Fluency in the surgical group. Conclusions: The results indicate that stereotactic lesional surgery does not result in major cognitive impairment in multiple sclerosis. However, the decline in MMSE scores, digit span and verbal fluency require further investigation in a larger sample. PMID:19491469

Anesthetic Considerations in Robotic-Assisted Gynecologic Surgery

PubMed Central

Kaye, Alan D.; Vadivelu, Nalini; Ahuja, Nitin; Mitra, Sukanya; Silasi, Dan; Urman, Richard D.

2013-01-01

Background Robotic-assisted surgery has evolved over the past 2 decades with constantly improving technology that assists surgeons in multiple subspecialty disciplines. The surgical requirements of lithotomy and steep Trendelenburg positions, along with the creation of a pneumoperitoneum and lack of direct access to the patient all present management challenges in gynecologic surgery. Patient positioning requirements can have significant physiologic effects and can result in many complications. Methods This review focuses on the anesthetic and surgical implications of robot-assisted technology in gynecologic surgery. Conclusion Good communication among team members and knowledge of the nuances of robotic surgery have the potential to improve patient outcomes, increase efficiency, and reduce complications. PMID:24358000

Comparison of CT and MRI in diagnosis of cerebrospinal leak induced by multiple fractures of skull base

PubMed Central

Wang, Xuhui; Xu, Minhui; Liang, Hong; Xu, Lunshan

2011-01-01

Background Multiple basilar skull fracture and cerebrospinal leak are common complications of traumatic brain injury, which required a surgical repair. But due to the complexity of basilar skull fracture after severe trauma, preoperatively an exact radiological location is always difficult. Multi-row spiral CT and MRI are currently widely applied in the clinical diagnosis. The present study was performed to compare the accuracy of cisternography by multi-row spiral CT and MRI in the diagnosis of cerebrospinal leak. Methods A total of 23 patients with multiple basilar skull fracture after traumatic brain injury were included. The radiological and surgical data were retrospectively analyzed. 64-row CT (mm/row) scan and three-dimensional reconstruction were performed in 12 patients, while MR plain scan and cisternography were performed in another 11 patients. The location of cerebrospinal leak was diagnosed by 2 experienced physicians majoring neurological radiology. Surgery was performed in all patients. The cerebrospinal leak location was confirmed and repaired during surgery. The result was considered as accurate when cerebrospinal leak was absent after surgery. Results According to the surgical exploration, the preoperative diagnosis of the active cerebrospinal leak location was accurate in 9 out of 12 patients with CT scan. The location could not be confirmed by CT because of multiple fractures in 2 patients and the missed diagnosis occurred in 1 patient. The preoperative diagnosis was accurate in 10 out of 11 patients with MRI examination. Conclusions MRI cisternography is more advanced than multi-row CT scan in multiple basilar skull fracture. The combination of the two examinations may increase the diagnostic ratio of active cerebrospinal leak. PMID:22933941

Factors related to difficulties with employment in patients with multiple sclerosis: a review of 2002-2011 literature.

PubMed

Schiavolin, Silvia; Leonardi, Matilde; Giovannetti, Ambra M; Antozzi, Carlo; Brambilla, Laura; Confalonieri, Paolo; Mantegazza, Renato; Raggi, Alberto

2013-06-01

We assess the knowledge available on the difficulties experienced by multiple sclerosis (MS) patients in work-related activities. A literature review was carried out using the keywords 'multiple sclerosis' and 'employment' or 'work' through PubMed and EMBASE. Papers reporting patient-derived data on difficulties at work as primary or secondary outcome measures and published in the period 2002-December 2011 were searched. A total of 26 papers were selected, for a total of 32 507 patients (mean age 46.2 years; 42.1% with relapsing-remitting MS). Most papers reported observational studies or cross-sectional surveys focused on health-related quality of life and MS costs. Symptoms more frequently addressed are fatigue, mobility and cognitive impairments. Limited research has been carried out on the working environment. We found a relatively small number of papers published in the last 10 years on the difficulties that patients with MS can experience at work, and this kind of information always appeared as a secondary outcome. In general, it is possible to affirm that MS has a strong impact on patients' employment status, as the mean unemployment rate was 59%. Research on factors promoting maintenance of remunerative employment is required.

Prevalence of autoimmune hemolytic anemia in multiple myeloma: A prospective study.

PubMed

Kashyap, Rajesh; Singh, Abhay; Kumar, Pradeep

2016-06-01

Autoimmune hemolytic anemia (AIHA) is frequently associated with B-cell lymphoproliferative disorders, and patients rarely develop overt clinical manifestations of AIHA. AIHA is rare in patients with multiple myeloma (MM). We conducted a prospective study to detect the presence of AIHA in MM patients and its impact on clinical presentation and outcome of the disease. Sixty-six patients were diagnosed to have MM. Seventeen of these patients who had severe anemia (hemoglobin < 6 g/dL) requiring frequent blood transfusions with or without features of hemolysis were screened for AIHA by performing direct and indirect antiglobulin (Coombs') test. Seven (10.6%) of these 17 patients were found to be complicated with AIHA and carried autoantibodies in their sera. Five patients had de novo MM and two had relapsed MM. Six patients (85.7%) had stage IIIA disease and one (14.3%) had stage IIIB disease. The IgG subclass of the antibody binding to red cell membrane was compared with that of M-protein and these findings showed full correlation in all the seven patients. All of these patients were positive for subtypes of IgG and one patient had simultaneous positivity for IgA and IgG2, with presence of cold antibodies in the serum. Patients with primary disease showed remission of AIHA with therapy, whereas both the patients with relapsed disease showed no response to treatment and remained positive for antiglobulin test. AIHA should be suspected in MM patients with severe anemia requiring frequent blood transfusions. © 2014 Wiley Publishing Asia Pty Ltd.

Can discrete event simulation be of use in modelling major depression?

PubMed Central

Le Lay, Agathe; Despiegel, Nicolas; François, Clément; Duru, Gérard

2006-01-01

Background Depression is among the major contributors to worldwide disease burden and adequate modelling requires a framework designed to depict real world disease progression as well as its economic implications as closely as possible. Objectives In light of the specific characteristics associated with depression (multiple episodes at varying intervals, impact of disease history on course of illness, sociodemographic factors), our aim was to clarify to what extent "Discrete Event Simulation" (DES) models provide methodological benefits in depicting disease evolution. Methods We conducted a comprehensive review of published Markov models in depression and identified potential limits to their methodology. A model based on DES principles was developed to investigate the benefits and drawbacks of this simulation method compared with Markov modelling techniques. Results The major drawback to Markov models is that they may not be suitable to tracking patients' disease history properly, unless the analyst defines multiple health states, which may lead to intractable situations. They are also too rigid to take into consideration multiple patient-specific sociodemographic characteristics in a single model. To do so would also require defining multiple health states which would render the analysis entirely too complex. We show that DES resolve these weaknesses and that its flexibility allow patients with differing attributes to move from one event to another in sequential order while simultaneously taking into account important risk factors such as age, gender, disease history and patients attitude towards treatment, together with any disease-related events (adverse events, suicide attempt etc.). Conclusion DES modelling appears to be an accurate, flexible and comprehensive means of depicting disease progression compared with conventional simulation methodologies. Its use in analysing recurrent and chronic diseases appears particularly useful compared with Markov processes. PMID:17147790

Can discrete event simulation be of use in modelling major depression?

PubMed

Le Lay, Agathe; Despiegel, Nicolas; François, Clément; Duru, Gérard

2006-12-05

Depression is among the major contributors to worldwide disease burden and adequate modelling requires a framework designed to depict real world disease progression as well as its economic implications as closely as possible. In light of the specific characteristics associated with depression (multiple episodes at varying intervals, impact of disease history on course of illness, sociodemographic factors), our aim was to clarify to what extent "Discrete Event Simulation" (DES) models provide methodological benefits in depicting disease evolution. We conducted a comprehensive review of published Markov models in depression and identified potential limits to their methodology. A model based on DES principles was developed to investigate the benefits and drawbacks of this simulation method compared with Markov modelling techniques. The major drawback to Markov models is that they may not be suitable to tracking patients' disease history properly, unless the analyst defines multiple health states, which may lead to intractable situations. They are also too rigid to take into consideration multiple patient-specific sociodemographic characteristics in a single model. To do so would also require defining multiple health states which would render the analysis entirely too complex. We show that DES resolve these weaknesses and that its flexibility allow patients with differing attributes to move from one event to another in sequential order while simultaneously taking into account important risk factors such as age, gender, disease history and patients attitude towards treatment, together with any disease-related events (adverse events, suicide attempt etc.). DES modelling appears to be an accurate, flexible and comprehensive means of depicting disease progression compared with conventional simulation methodologies. Its use in analysing recurrent and chronic diseases appears particularly useful compared with Markov processes.

Simultaneous assay of multiple antibiotics in human plasma by LC-MS/MS: importance of optimizing formic acid concentration.

PubMed

Chen, Feng; Hu, Zhe-Yi; Laizure, S Casey; Hudson, Joanna Q

2017-03-01

Optimal dosing of antibiotics in critically ill patients is complicated by the development of resistant organisms requiring treatment with multiple antibiotics and alterations in systemic exposure due to diseases and extracorporeal drug removal. Developing guidelines for optimal antibiotic dosing is an important therapeutic goal requiring robust analytical methods to simultaneously measure multiple antibiotics. An LC-MS/MS assay using protein precipitation for cleanup followed by a 6-min gradient separation was developed to simultaneously determine five antibiotics in human plasma. The precision and accuracy were within the 15% acceptance range. The formic acid concentration was an important determinant of signal intensity, peak shape and matrix effects. The method was designed to be simple and successfully applied to a clinical pharmacokinetic study.

Progression and prognosis in multiple system atrophy: an analysis of 230 Japanese patients.

PubMed

Watanabe, Hirohisa; Saito, Yufuko; Terao, Shinichi; Ando, Tetsuo; Kachi, Teruhiko; Mukai, Eiichiro; Aiba, Ikuko; Abe, Yuji; Tamakoshi, Akiko; Doyu, Manabu; Hirayama, Masaaki; Sobue, Gen

2002-05-01

We investigated the disease progression and survival in 230 Japanese patients with multiple system atrophy (MSA; 131 men, 99 women; 208 probable MSA, 22 definite; mean age at onset, 55.4 years). Cerebellar dysfunction (multiple system atrophy-cerebellar; MSA-C) predominated in 155 patients, and parkinsonism (multiple system atrophy-parkinsonian; MSA-P) in 75. The median time from initial symptom to combined motor and autonomic dysfunction was 2 years (range 1-10). Median intervals from onset to aid-requiring walking, confinement to a wheelchair, a bedridden state and death were 3, 5, 8 and 9 years, respectively. Patients manifesting combined motor and autonomic involvement within 3 years of onset had a significantly increased risk of not only developing advanced disease stage but also shorter survival (P < 0.01). MSA-P patients had more rapid functional deterioration than MSA-C patients (aid-requiring walking, P = 0.03; confinement to a wheelchair, P < 0.01; bedridden state, P < 0.01), but showed similar survival. Onset in older individuals showed increased risk of confinement to a wheelchair (P < 0.05), bedridden state (P = 0.03) and death (P < 0.01). Patients initially complaining of motor symptoms had accelerated risk of aid-requiring walking (P < 0.01) and confinement to a wheelchair (P < 0.01) compared with those initially complaining of autonomic symptoms, while the time until confinement to a bedridden state and survival were no worse. Gender was not associated with differences in worsening of function or survival. On MRI, a hyperintense rim at the lateral edge of the dorsolateral putamen was seen in 34.5% of cases, and a 'hot cross bun' sign in the pontine basis (PB) in 63.3%. These putaminal and pontine abnormalities became more prominent as MSA-P and MSA-C features advanced. The atrophy of the cerebellar vermis and PB showed a significant correlation particularly with the interval following the appearance of cerebellar symptoms in MSA-C (r = 0.71, P < 0.01, r = 0.76 and P < 0.01, respectively), but the relationship between atrophy and functional status was highly variable among the individuals, suggesting that other factors influenced the functional deterioration. Atrophy of the corpus callosum was seen in a subpopulation of MSA, suggesting hemispheric involvement in a subgroup of MSA patients. The present study suggested that many factors are involved in the progression of MSA but, most importantly, the interval from initial symptom to combined motor and autonomic dysfunction can predict functional deterioration and survival in MSA.

Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis

PubMed Central

Veeratterapillay, R; Shaw, MBK; Williams, R; Haslam, P; Lall, A; De la Hunt, M; Hasan, ST; Thomas, DJ

2012-01-01

INTRODUCTION Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years. METHODS All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications. RESULTS PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5–40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion. CONCLUSIONS Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance. PMID:23131231

Safety and efficacy of percutaneous nephrolithotomy for the treatment of paediatric urolithiasis.

PubMed

Veeratterapillay, R; Shaw, M B K; Williams, R; Haslam, P; Lall, A; De la Hunt, M; Hasan, S T; Thomas, D J

2012-11-01

Paediatric percutaneous nephrolithotomy (PCNL) has revolutionised the treatment of paediatric nephrolithiasis. Paediatric PCNL has been performed using both adult and paediatric instruments. Stone clearance rates and complications vary according to the technique used and surgeon experience. We present our experience with PCNL using adult instruments and a 28Fr access tract for large renal calculi in children under 18 years. All patients undergoing PCNL at our institution between 2000 and 2009 were reviewed. Demographics, surgical details and post-operative follow-up information were obtained to identify stone clearance rates and complications. PCNL was performed in 32 renal units in 31 patients (mean age: 10.8 years). The mean stone diameter was 19mm (range: 5-40mm). Twenty-six cases required single puncture and six required multiple tracts. Overall, 11 staghorn stones, 10 multiple calyceal stones and 11 single stones were treated. Twenty-seven patients (84%) were completely stone free following initial PCNL. Two cases had extracorporeal shock wave lithotripsy for residual fragments, giving an overall stone free rate of 91% following treatment. There was no significant bleeding or sepsis encountered either during the operation or in the post-operative setting. No patient required or received a blood transfusion. Paediatric PCNL can be performed safely with minimal morbidity using adult instruments for large stone burden, enabling rapid and complete stone clearance.

Use of Fetal Magnetic Resonance Image Analysis and Machine Learning to Predict the Need for Postnatal Cerebrospinal Fluid Diversion in Fetal Ventriculomegaly.

PubMed

Pisapia, Jared M; Akbari, Hamed; Rozycki, Martin; Goldstein, Hannah; Bakas, Spyridon; Rathore, Saima; Moldenhauer, Julie S; Storm, Phillip B; Zarnow, Deborah M; Anderson, Richard C E; Heuer, Gregory G; Davatzikos, Christos

2018-02-01

Which children with fetal ventriculomegaly, or enlargement of the cerebral ventricles in utero, will develop hydrocephalus requiring treatment after birth is unclear. To determine whether extraction of multiple imaging features from fetal magnetic resonance imaging (MRI) and integration using machine learning techniques can predict which patients require postnatal cerebrospinal fluid (CSF) diversion after birth. This retrospective case-control study used an institutional database of 253 patients with fetal ventriculomegaly from January 1, 2008, through December 31, 2014, to generate a predictive model. Data were analyzed from January 1, 2008, through December 31, 2015. All 25 patients who required postnatal CSF diversion were selected and matched by gestational age with 25 patients with fetal ventriculomegaly who did not require CSF diversion (discovery cohort). The model was applied to a sample of 24 consecutive patients with fetal ventriculomegaly who underwent evaluation at a separate institution (replication cohort) from January 1, 1998, through December 31, 2007. Data were analyzed from January 1, 1998, through December 31, 2009. To generate the model, linear measurements, area, volume, and morphologic features were extracted from the fetal MRI, and a machine learning algorithm analyzed multiple features simultaneously to find the combination that was most predictive of the need for postnatal CSF diversion. Accuracy, sensitivity, and specificity of the model in correctly classifying patients requiring postnatal CSF diversion. A total of 74 patients (41 girls [55%] and 33 boys [45%]; mean [SD] gestational age, 27.0 [5.6] months) were included from both cohorts. In the discovery cohort, median time to CSF diversion was 6 days (interquartile range [IQR], 2-51 days), and patients with fetal ventriculomegaly who did not develop symptoms were followed up for a median of 29 months (IQR, 9-46 months). The model correctly classified patients who required CSF diversion with 82% accuracy, 80% sensitivity, and 84% specificity. In the replication cohort, the model achieved 91% accuracy, 75% sensitivity, and 95% specificity. Image analysis and machine learning can be applied to fetal MRI findings to predict the need for postnatal CSF diversion. The model provides prognostic information that may guide clinical management and select candidates for potential fetal surgical intervention.

Fatal thalamic abscess secondary to dental infection.

PubMed

Basyuni, Shadi; Sharma, Valmiki; Santhanam, Vijay; Ferro, Ashley

2015-12-17

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later. 2015 BMJ Publishing Group Ltd.

Long-term management of patients with multiple sclerosis.

PubMed

Weightman, Cherie

2006-07-01

This article explores the challenges of long-term case management for patients who have multiple sclerosis (MS). Currently there is scant research into district nursing input into long-term management of patients who have MS. Until now the role of the community nurses has been confined to palliation or terminal care, focusing on the more physical manifestations of MS. The contemporary role of district nurse is going to evolve to include proactive approaches. Governmental initiatives demand proactive services, and place emphasis on self-care for patients with MS. Themes that emerge from this article relate to the pre-existing skills--such as managing patients with complex needs and the advanced assessment skills--that will be required to achieve this. What is clear is that community nurses already possess many of the prerequisite skills needed for long-term management, and they should not be daunted by this prospect.

The role of insulin pump therapy for type 2 diabetes mellitus.

PubMed

Landau, Zohar; Raz, Itamar; Wainstein, Julio; Bar-Dayan, Yosefa; Cahn, Avivit

2017-01-01

Many patients with type 2 diabetes fail to achieve adequate glucose control despite escalation of treatment and combinations of multiple therapies including insulin. Patients with long-standing type 2 diabetes often suffer from the combination of severe insulin deficiency in addition to insulin resistance, thereby requiring high doses of insulin delivered in multiple injections to attain adequate glycemic control. Insulin-pump therapy was first introduced in the 1970s as an approach to mimic physiological insulin delivery and attain normal glucose in patients with type 1 diabetes. The recent years have seen an increase in the use of this technology for patients with type 2 diabetes. This article summarizes the clinical studies evaluating insulin pump use in patients with type 2 diabetes and discusses the benefits and shortcomings of pump therapy in this population. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Gunshot wounds and blast injuries to the face are associated with significant morbidity and mortality: results of an 11-year multi-institutional study of 720 patients.

PubMed

Shackford, Steven R; Kahl, Jessica E; Calvo, Richard Y; Kozar, Rosemary A; Haugen, Christine E; Kaups, Krista L; Willey, Marybeth; Tibbs, Brian M; Mutto, Susan M; Rizzo, Anne G; Lormel, Christy S; Shackford, Meghan C; Burlew, Clay Cothren; Moore, Ernest E; Cogbill, Thomas H; Kallies, Kara J; Haan, James M; Ward, Jeanette

2014-02-01

Gunshot wounds and blast injuries to the face (GSWBIFs) produce complex wounds requiring management by multiple surgical specialties. Previous work is limited to single institution reports with little information on processes of care or outcome. We sought to determine those factors associated with hospital complications and mortality. We performed an 11-year multicenter retrospective cohort analysis of patients sustaining GSWBIF. The face, defined as the area anterior to the external auditory meatuses from the top of the forehead to the chin, was categorized into three zones: I, the chin to the base of the nose; II, the base of the nose to the eyebrows; III, above the brows. We analyzed the effect of multiple factors on outcome. From January 1, 2000, to December 31, 2010, we treated 720 patients with GSWBIF (539 males, 75%), with a median age of 29 years. The wounding agent was handgun in 41%, explosive (shotgun and blast) in 20%, rifle in 6%, and unknown in 33%. Prehospital or resuscitative phase airway was required in 236 patients (33%). Definitive care was rendered by multiple specialties in 271 patients (38%). Overall, 185 patients died (26%), 146 (79%) within 48 hours. Of the 481 patients hospitalized greater than 48 hours, 184 had at least one complication (38%). Factors significantly associated with any of a total of 207 complications were total number of operations (p < 0.001), Revised Trauma Score (RTS, p < 0.001), and head Abbreviated Injury Scale (AIS) score (p < 0.05). Factors significantly associated with mortality were RTS (p < 0.001), head AIS score (p < 0.001), total number of operations (p < 0.001), and age (p < 0.05). An injury located in Zone III was independently associated with mortality (p < 0.001). GSWBIFs have high mortality and are associated with significant morbidity. The multispecialty involvement required for definitive care necessitates triage to a trauma center and underscores the need for an organized approach and the development of effective guidelines. Therapeutic/care management, level III.

Orthodontic treatment of a patient with cleidocranial dysplasia: A case report.

PubMed

Li, Zi-Jian; Wang, Jun-Yan; Gao, Ming-Fei; Wu, Da-Lei; Chang, Xin

2016-08-01

Cleidocranial dysplasia (CCD) is a rare autosomal dominant condition that affects ossification. The dental abnormalities associated with CCD present an obstacle to orthodontic treatment planning. Early diagnosis is crucial to provide the patient with different treatment modalities that will suit the particular patient. In the present case, combined surgical and orthodontic treatment were performed to guide multiple impacted teeth. A single nucleotide missense variation was identified in exon 3 of runt-related transcription factor 2 ( RUNX2 ) in this patient. The current results suggest a correlation between dental alterations and mutations in the runt domain of RUNX2 in CCD patients. Further clinical and genetic studies may required to confirm the association between phenotypes and genotypes in CCD and to identify other factors that may influence the clinical features of this disease. Patients with cleidocranial dysplasia require a team approach which demands good communication and cooperation from the patient. Timing of the intervention is critical, and numerous surgeries may be required. The patient in the present case report was treated by a team of practitioners, which involved several dental specialties to achieve an optimal result.

Does chronic warfarin cause increased blood loss and transfusion during lumbar spinal surgery?

PubMed

Young, Ernest Y; Ahmadinia, Kasra; Bajwa, Navkirat; Ahn, Nicholas U

2013-10-01

The use of oral anticoagulation therapy such as warfarin is projected to increase significantly as the population ages and the prevalence of cardiovascular disease increases. Current recommendations state that warfarin be discontinued before surgery and the international normalized ratio (INR) normalized. To determine if stopping warfarin 7 days before surgery and correcting INR had any effect on intraoperative blood loss or the requirements for blood product transfusion. This was a retrospective cohort study in a high-volume tertiary care center. Sample comprised 263 consecutive patients who underwent elective lumbar spinal surgery. The outcome measures were intraoperative blood loss, intraoperative blood transfusion, postoperative blood transfusion, and the number of blood products transfused. The records of patients undergoing elective spinal surgery were analyzed for patient demographic data, comorbidities, coagulation panel laboratory findings, operative characteristics, blood loss, and blood transfusion requirements. These included patients undergoing full laminectomies with or without posterolateral fusion and instrumentation. Patients on warfarin were analyzed for the mean dosage of warfarin and underlying pathology that required anticoagulation. All patients on warfarin had their anticoagulation therapy stopped 7 days before surgery and their INR checked preoperatively to confirm normalization. Both univariate and multiple linear regression analyses were performed. The patients on warfarin had a mean intraoperative blood loss of 839 mL compared with 441 mL for patients not on warfarin (p<.01). Multiple regression analysis determined that warfarin and number of spinal levels decompressed/fused/instrumented were predictors for increased blood loss (R(2)=0.37). Patients on warfarin also had increased postoperative blood transfusions (23.1% compared with 7.4%, p=.04). There was no significant difference between groups in terms of intraoperative blood transfusion or number of units transfused. Patients on chronic anticoagulation therapy with warfarin who have their therapy stopped 7 days before surgery and have their INR normalized still demonstrated increased intraoperative blood loss and requirement for postoperative transfusion. Surgeons should be aware of the increased propensity of these patients to bleed despite adherence to protocols and should attempt to mitigate this risk. Copyright © 2013 Elsevier Inc. All rights reserved.

How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions.

PubMed

Zulman, Donna M; Jenchura, Emily C; Cohen, Danielle M; Lewis, Eleanor T; Houston, Thomas K; Asch, Steven M

2015-08-01

Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear. To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology. After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants. Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes. Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96%), communicate with health care providers (92%), track medical information (83%), track medications (77%), and support decision-making about treatment (55%). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes. Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

Diagnosis and treatment of latent tuberculosis in patients with multiple sclerosis, expert consensus. On behalf of the Colombian Association of Neurology, Committee of Multiple Sclerosis.

PubMed

Navas, Carlos; Torres-Duque, Carlos A; Munoz-Ceron, Joe; Álvarez, Carlos; García, Juan R; Zarco, Luis; Vélez, Lázaro A; Awad, Carlos; Castro, Carlos Alberto

2018-01-01

Multiple sclerosis is an inflammatory and neurodegenerative demyelinating disease. Current treatment of multiple sclerosis focuses on the use of immunomodulatory, immunosuppressant, and selective immunosuppressant agents. Some of these medications may result in high risk of opportunistic infections including tuberculosis. The purpose of this study was to obtain consensus from a panel of neurologists, pulmonologists, infectious disease specialists, and epidemiology experts regarding the diagnosis, treatment, and monitoring of latent tuberculosis in patients with multiple sclerosis. A panel of experts in multiple sclerosis and tuberculosis was established. The methodological process was performed in three phases: definition of questions, answer using Delphi methodology, and the discussion of questions not agreed. Tuberculosis screening is suggested when multiple sclerosis drugs are prescribed. The recommended tests for latent tuberculosis are tuberculin and interferon gamma release test. When an anti-tuberculosis treatment is indicated, monitoring should be performed to determine liver enzyme values with consideration of age as well as comorbid conditions such as a history of alcoholism, age, obesity, concomitant hepatotoxic drugs, and history of liver disease. Latent tuberculosis should be considered in patients with multiple sclerosis who are going to be treated with immunomodulatory and immunosuppressant medications. Transaminase level monitoring is required on a periodic basis depending on clinical and laboratory characteristics. In addition to the liver impairment, other side effects should be considered when Isoniazid is prescribed.

Planning for patient privacy and hospitability: a must do in oncology care.

PubMed

Easter, James G

2003-01-01

The number one design challenge in the healthcare environment is the patient room. This space is one of the primary functional areas impacting hospital design and, quite often, the place of greatest controversy. This controversy is due to the length of time the patient spends in the room (compared to other areas), the amount of overall space required and the time dedicated to patient room utilization, maintenance, general arrangement and overall efficiency. In addition, there is a growing list of room types to be considered, many are of the ambulatory care, short stay and observation category. Other room types beyond the routine medical/surgical room include Intensive Care, Coronary Care, Surgical Intensive Care, Skilled Nursing, Rehabilitation and Oncology Care as well as more intensive Bone Marrow Transplantation, for example. Major features of the traditional acute care patient room require the space to be flexible, convertible, expandable and, most importantly, hospitable. For many, many years the patient room was considered a shared space with multiple beds and multiple users. The term semi-private has been used to describe the traditional two-bed and, sometimes 4-bed patient room. This article will address the programmatic elements of an inpatient area, the room and its functional components along with some examples for comparative purposes. For the oncology patient, the development of a family-focused, private room is mandatory. The private room is more flexible, less expensive to operate, safer and environmentally more appealing for the patient, family and staff.

Correction of anemia in a transfusion-dependent patient with primary myelofibrosis receiving iron chelation therapy with deferasirox (Exjade®, ICL670)

PubMed Central

Di Tucci, Anna Angela; Murru, Roberta; Alberti, Daniele; Rabault, Bertrand; Deplano, Simona; Angelucci, Emanuele

2007-01-01

Transfusional iron overload in patients with chronic anemias can result in multiple organ failure. Experience in the management of iron overload in patients with myelodysplastic syndromes is limited, as many do not receive chelation therapy due to short-life expectancy and the difficulties associated with the administration of the current reference standard chelator, deferoxamine. There have, however, been some reports of reduced transfusion requirement associated with chelation therapy in patients with myelodysplastic syndromes and myelofibrosis. Here, we discuss a patient with primary myelofibrosis and related transfusion-dependent anemia who received chelation therapy with the once-daily oral iron chelator, deferasirox. In addition to the reduced iron levels, the patient demonstrated an unexpected reduction in blood transfusion requirement, ultimately resulting in long-lasting transfusion-free survival. PMID:17391307

Utility of bortezomib retreatment in relapsed or refractory multiple myeloma patients: a multicenter case series.

PubMed

Wolf, Jeffrey; Richardson, Paul G; Schuster, Michael; LeBlanc, Annette; Walters, Ian B; Battleman, David S

2008-10-01

Bortezomib therapy has become an important part of the standard of care for patients with relapsed multiple myeloma, and preliminary clinical evidence suggests that bortezomib retreatment in patients previously treated with the drug may prolong disease control. This retrospective study was designed to clarify the utility of bortezomib as a repeat therapy. We reviewed records from 3 major cancer centers that had participated in the phase II (SUMMIT or CREST) or phase III (APEX) registration studies to identify patients who were subsequently retreated off protocol with bortezomib-based therapy. We found 22 patients who received bortezomib retreatment following a 60 or more day gap between bortezomib treatments. Twelve patients had intervening therapy between initial bortezomib treatment and bortezomib retreatment. During retreatment, 14 of 22 patients received bortezomib in combination with another antineoplastic agent. The overall response rate for bortezomib retreatment was 50% (9% complete responses). The median length of retreatment was 5.1 months in responding patients and 2.4 months in nonresponding patients. Therapy was terminated due to unmanageable toxicity in 2 patients during retreatment, compared with 6 patients during initial treatment. During retreatment, no patients required dose reduction due to peripheral neuropathy, compared to 4 patients during their initial treatment. Thus, bortezomib retreatment appears to be safe and effective. Favorable observed response rates with bortezomib retreatment suggest that it may be a viable option for relapsed or refractory multiple myeloma, even in patients previously exposed to bortezomib.

Survival in commercially insured multiple sclerosis patients and comparator subjects in the U.S.

PubMed

Kaufman, D W; Reshef, S; Golub, H L; Peucker, M; Corwin, M J; Goodin, D S; Knappertz, V; Pleimes, D; Cutter, G

2014-05-01

Compare survival in patients with multiple sclerosis (MS) from a U.S. commercial health insurance database with a matched cohort of non-MS subjects. 30,402 MS patients and 89,818 non-MS subjects (comparators) in the OptumInsight Research (OIR) database from 1996 to 2009 were included. An MS diagnosis required at least 3 consecutive months of database reporting, with two or more ICD-9 codes of 340 at least 30 days apart, or the combination of 1 ICD-9-340 code and at least 1 MS disease-modifying treatment (DMT) code. Comparators required the absence of ICD-9-340 and DMT codes throughout database reporting. Up to three comparators were matched to each patient for: age in the year of the first relevant code (index year - at least 3 months of reporting in that year were required); sex; region of residence in the index year. Deaths were ascertained from the National Death Index and the Social Security Administration Death Master File. Subjects not identified as deceased were assumed to be alive through the end of 2009. Annual mortality rates were 899/100,000 among MS patients and 446/100,000 among comparators. Standardized mortality ratios compared to the U.S. population were 1.70 and 0.80, respectively. Kaplan-Meier analysis yielded a median survival from birth that was 6 years lower among MS patients than among comparators. The results show, for the first time in a U.S. population, a survival disadvantage for contemporary MS patients compared to non-MS subjects from the same healthcare system. The 6-year decrement in lifespan parallels a recent report from British Columbia. Copyright © 2013 Elsevier B.V. All rights reserved.

Double stellate tongue reduction: a new method of treatment for macroglossia in patients with Beckwith-wiedemann syndrome.

PubMed

Hettinger, Patrick C; Denny, Arlen D

2011-09-01

Although multiple methods of tongue reduction have been described, recent literature suggests that the central reductions may be more favorable in patients with Beckwith-Wiedemann syndrome (BWS). In this case series, we review our experience with macroglossia associated with BWS, and we offer a new technique of central tongue reduction. Between 1993 and 2007, a retrospective chart review was conducted to include all patients with a diagnosis of BWS who have undergone stellate or double stellate tongue reduction at the Children's Hospital of Wisconsin. A total of 7 patients met all inclusion criteria. All patients had good tongue mobility at 1-year follow-up. One patient required speech therapy for persistent articulation errors postoperatively. A total of 2 patients required secondary procedures for recurrent macroglossia. There were no complaints of abnormal taste or sensation. The stellate and double stellate tongue reductions provide effective treatment in macroglossia associated with BWS.

Best Practice for the Administration of Daratumumab in Multiple Myeloma: Australian Myeloma Nurse Expert Opinion

PubMed Central

King, Tracy; Jagger, Jacqueline; Wood, Jodie; Woodrow, Carmel; Snowden, Alicia; Haines, Sally; Crosbie, Christina; Houdyk, Kristen

2018-01-01

Patients with multiple myeloma (MM) are typically of an advanced age and may have significant co-existing medical conditions. They have often had multiple lines of therapy and as such experience disease-related effects alongside associated treatment toxicities. Daratumumab is a monoclonal antibody approved for the treatment of MM in the relapsed/refractory setting. Clinical studies found that daratumumab showed good tolerability as a monotherapy and in combination with current standard therapies. However, the administration of daratumumab does require specific management considerations. It is administered as an intravenous infusion and infusion-related reactions (IRRs) may occur. Daratumumab also interferes with routine blood transfusion tests, giving false positives for the indirect antiglobulin test. This article highlights key nursing care considerations and practical management aspects to improve the treatment experience of patients receiving daratumumab infusions. Pretreatment aspects, patient education, pre- and post-medication, daratumumab administration, and the management of IRRs are discussed. An IRR management sheet that could be used by nurses and a patient information sheet are located at the end of this article.

Evaluating walking in patients with multiple sclerosis: which assessment tools are useful in clinical practice?

PubMed

Bethoux, Francois; Bennett, Susan

2011-01-01

Walking limitations are among the most visible manifestations of multiple sclerosis (MS). Regular walking assessments should be a component of patient management and require instruments that are appropriate from the clinician's and the patient's perspectives. This article reviews frequently used instruments to assess walking in patients with MS, with emphasis on their validity, reliability, and practicality in the clinical setting. Relevant articles were identified based on PubMed searches using the following terms: "multiple sclerosis AND (walking OR gait OR mobility OR physical activity) AND (disability evaluation)"; references of relevant articles were also searched. Although many clinician- and patient-driven instruments are available, not all have been validated in MS, and some are not sensitive enough to detect small but clinically important changes. Choosing among these depends on what needs to be measured, psychometric properties, the clinical relevance of results, and practicality with respect to space, time, and patient burden. Of the instruments available, the clinician-observed Timed 25-Foot Walk and patient self-report 12-Item Multiple Sclerosis Walking Scale have properties that make them suitable for routine evaluation of walking performance. The Dynamic Gait Index and the Timed Up and Go test involve other aspects of mobility, including balance. Tests of endurance, such as the 2- or 6-Minute Walk, may provide information on motor fatigue not captured by other tests. Quantitative measurement of gait kinetics and kinematics, and recordings of mobility in the patient's environment via accelerometry or Global Positioning System odometry, are currently not routinely used in the clinical setting.

Evaluating Walking in Patients with Multiple Sclerosis

PubMed Central

Bennett, Susan

2011-01-01

Walking limitations are among the most visible manifestations of multiple sclerosis (MS). Regular walking assessments should be a component of patient management and require instruments that are appropriate from the clinician's and the patient's perspectives. This article reviews frequently used instruments to assess walking in patients with MS, with emphasis on their validity, reliability, and practicality in the clinical setting. Relevant articles were identified based on PubMed searches using the following terms: “multiple sclerosis AND (walking OR gait OR mobility OR physical activity) AND (disability evaluation)”; references of relevant articles were also searched. Although many clinician- and patient-driven instruments are available, not all have been validated in MS, and some are not sensitive enough to detect small but clinically important changes. Choosing among these depends on what needs to be measured, psychometric properties, the clinical relevance of results, and practicality with respect to space, time, and patient burden. Of the instruments available, the clinician-observed Timed 25-Foot Walk and patient self-report 12-Item Multiple Sclerosis Walking Scale have properties that make them suitable for routine evaluation of walking performance. The Dynamic Gait Index and the Timed Up and Go test involve other aspects of mobility, including balance. Tests of endurance, such as the 2- or 6-Minute Walk, may provide information on motor fatigue not captured by other tests. Quantitative measurement of gait kinetics and kinematics, and recordings of mobility in the patient's environment via accelerometry or Global Positioning System odometry, are currently not routinely used in the clinical setting. PMID:24453700

Multiple Intravenous Infusions Phase 2b: Laboratory Study

PubMed Central

Pinkney, Sonia; Fan, Mark; Chan, Katherine; Koczmara, Christine; Colvin, Christopher; Sasangohar, Farzan; Masino, Caterina; Easty, Anthony; Trbovich, Patricia

2014-01-01

Background Administering multiple intravenous (IV) infusions to a single patient via infusion pump occurs routinely in health care, but there has been little empirical research examining the risks associated with this practice or ways to mitigate those risks. Objectives To identify the risks associated with multiple IV infusions and assess the impact of interventions on nurses’ ability to safely administer them. Data Sources and Review Methods Forty nurses completed infusion-related tasks in a simulated adult intensive care unit, with and without interventions (i.e., repeated-measures design). Results Errors were observed in completing common tasks associated with the administration of multiple IV infusions, including the following (all values from baseline, which was current practice): setting up and programming multiple primary continuous IV infusions (e.g., 11.7% programming errors) identifying IV infusions (e.g., 7.7% line-tracing errors) managing dead volume (e.g., 96.0% flush rate errors following IV syringe dose administration) setting up a secondary intermittent IV infusion (e.g., 11.3% secondary clamp errors) administering an IV pump bolus (e.g., 11.5% programming errors) Of 10 interventions tested, 6 (1 practice, 3 technology, and 2 educational) significantly decreased or even eliminated errors compared to baseline. Limitations The simulation of an adult intensive care unit at 1 hospital limited the ability to generalize results. The study results were representative of nurses who received training in the interventions but had little experience using them. The longitudinal effects of the interventions were not studied. Conclusions Administering and managing multiple IV infusions is a complex and risk-prone activity. However, when a patient requires multiple IV infusions, targeted interventions can reduce identified risks. A combination of standardized practice, technology improvements, and targeted education is required. PMID:26316919

Case Report: Perioperative management of a pregnant poly trauma patient for spine fixation surgery.

PubMed

Vandse, Rashmi; Cook, Meghan; Bergese, Sergio

2015-01-01

Trauma is estimated to complicate approximately one in twelve pregnancies, and is currently a leading non-obstetric cause of maternal death. Pregnant trauma patients requiring non-obstetric surgery pose a number of challenges for anesthesiologists. Here we present the successful perioperative management of a pregnant trauma patient with multiple injuries including occult pneumothorax who underwent T9 to L1 fusion in prone position, and address the pertinent perioperative anesthetic considerations and management.

'Postconditioning' the human heart: multiple balloon inflations during primary angioplasty may confer cardioprotection.

PubMed

Darling, Chad E; Solari, Patrick B; Smith, Craig S; Furman, Mark I; Przyklenk, Karin

2007-05-01

Growing evidence from experimental models suggests that relief of myocardial ischemia in a stuttering manner (i.e., 'postconditioning' [PostC] with brief cycles of reperfusion-reocclusion) limits infarct size. However, the potential clinical efficacy of PostC has, to date,been largely unexplored. Using a retrospective study design, our aim was to test the hypothesis that creatine kinase release (CK: clinical surrogate of infarct size) would be attenuated in ST-segment elevation myocardial infarction (STEMI) patients requiring multiple balloon inflations-deflations during primary angioplasty versus STEMI patients who received minimal balloon inflations and/or direct stenting. To investigate this concept, we reviewed the records of all STEMI patients with single vessel occlusion who presented to our institution from November 2004 - April 2006 for primary angioplasty. Exclusion criteria were: previous MI, cardiogenic shock, patients resuscitated from cardiac arrest, or pre-infarct angina. Patients were prospectively divided into two subsets: those receiving 1-3 balloon inflations (considered the minimum range to achieve patency and stent placement) versus those in whom 4 or more inflations were applied. Peak CK release was significantly lower in patients requiring > or =4 versus 1-3 inflations (1655 versus 2272 IU/L; p<0.05), an outcome consistent with the concept that relief of sustained ischemia in a stuttered manner (analogous to postconditioning) may evoke cardioprotection in the clinical setting.

Interprofessional education about patient decision support in specialty care.

PubMed

Politi, Mary C; Pieterse, Arwen H; Truant, Tracy; Borkhoff, Cornelia; Jha, Vikram; Kuhl, Laura; Nicolai, Jennifer; Goss, Claudia

2011-11-01

Specialty care involves services provided by health professionals who focus on treating diseases affecting one body system. In contrast to primary care - aimed at providing continuous, comprehensive care - specialty care often involves intermittent episodes of care focused around specific medical conditions. In addition, it typically includes multiple providers who have unique areas of expertise that are important in supporting patients' care. Interprofessional care involves multiple professionals from different disciplines collaborating to provide an integrated approach to patient care. For patients to experience continuity of care across interprofessional providers, providers need to communicate and maintain a shared sense of responsibility to their patients. In this article, we describe challenges inherent in providing interprofessional patient decision support in specialty care. We propose ways for providers to engage in interprofessional decision support and discuss promising approaches to teaching an interprofessional decision support to specialty care providers. Additional evaluation and empirical research are required before further recommendations can be made about education for interprofessional decision support in specialty care.

Sample size requirements for one-year treatment effects using deep gray matter volume from 3T MRI in progressive forms of multiple sclerosis.

PubMed

Kim, Gloria; Chu, Renxin; Yousuf, Fawad; Tauhid, Shahamat; Stazzone, Lynn; Houtchens, Maria K; Stankiewicz, James M; Severson, Christopher; Kimbrough, Dorlan; Quintana, Francisco J; Chitnis, Tanuja; Weiner, Howard L; Healy, Brian C; Bakshi, Rohit

2017-11-01

The subcortical deep gray matter (DGM) develops selective, progressive, and clinically relevant atrophy in progressive forms of multiple sclerosis (PMS). This patient population is the target of active neurotherapeutic development, requiring the availability of outcome measures. We tested a fully automated MRI analysis pipeline to assess DGM atrophy in PMS. Consistent 3D T1-weighted high-resolution 3T brain MRI was obtained over one year in 19 consecutive patients with PMS [15 secondary progressive, 4 primary progressive, 53% women, age (mean±SD) 50.8±8.0 years, Expanded Disability Status Scale (median, range) 5.0, 2.0-6.5)]. DGM segmentation applied the fully automated FSL-FIRST pipeline ( http://fsl.fmrib.ox.ac.uk ). Total DGM volume was the sum of the caudate, putamen, globus pallidus, and thalamus. On-study change was calculated using a random-effects linear regression model. We detected one-year decreases in raw [mean (95% confidence interval): -0.749 ml (-1.455, -0.043), p = 0.039] and annualized [-0.754 ml/year (-1.492, -0.016), p = 0.046] total DGM volumes. A treatment trial for an intervention that would show a 50% reduction in DGM brain atrophy would require a sample size of 123 patients for a single-arm study (one-year run-in followed by one-year on-treatment). For a two-arm placebo-controlled one-year study, 242 patients would be required per arm. The use of DGM fraction required more patients. The thalamus, putamen, and globus pallidus, showed smaller effect sizes in their on-study changes than the total DGM; however, for the caudate, the effect sizes were somewhat larger. DGM atrophy may prove efficient as a short-term outcome for proof-of-concept neurotherapeutic trials in PMS.

Pelvic fracture in the patient with multiple injuries: factors and lesions associated with mortality.

PubMed

Martínez, Fernando; Alegret, Núria; Carol, Federico; Laso, M Jesús; Zancajo, Juanjo; García, Esteban; Ros, Vanesa

2018-01-01

The main objective of this study was to identify demographic, clinical, analytical factors or injuries associated with 30-day mortality in patients with pelvic fractures. Prospective observational study of patients with multiple injuries including pelvic fractures between January 2009 and January 2017. We recorded demographic, clinical, and laboratory data on arrival at the emergency department; type of pelvic fracture; treatments; associated lesions; and 30-day mortality. Univariable and multivariable models were used to analyze the data. A total of 2061 multiple-injury patients were attended; 118 had pelvic fractures. Fifteen of the patients with pelvic fractures (12.7%) died within 30 days. Arterial blood pressure on admission was less than 90 mm Hg in 23.7%, heart rate was over 100 beats per minute in 41.52%, lactic acid level was 20 mg/dL or higher in 67.6%, and base excess of -6 or less was recorded for 26.3%. The mean Injury Severity Score was 20 points. Angiographic embolization was required in 80.6% and preperitoneal packing in 3.4%. The main associated lesions were rib fractures (35.6%), hemo-pneumothorax (31.3%), spinal injuries (35.6%), and head injuries (30%). The 6 independent variables associated with risk of death in multiple-injury patients with pelvic fractures are age, female sex, complex fractures (Tile type C), lactic acid level of 20 mg/dL or more, base excess of -6 or less, and bowel perforation.

A Case of Traumatic Retrograde Type A Aortic Dissection Accompanied by Multiorgan Injuries.

PubMed

Tsukioka, Katsuaki; Kono, Tetsuya; Takahashi, Kohei; Kehara, Hiromu; Urashita, Shuichi; Komatsu, Kazunori

2018-03-25

A 75-year-old woman was involved in a traffic accident and suffered retrograde type A aortic dissection, multiple rib fractures, and grade II hepatic injury accompanied by intraperitoneal bleeding. We performed total arch replacement using an open stent graft with cardiopulmonary bypass and circulatory arrest. This procedure requires anticoagulation and hypothermia, which are principally contraindicated in severe trauma patients. However, this situation was resolved by managing the patient non-operatively for 7 days, confirming the stabilization of other injured organs, and then performing the surgery. She required prolonged postoperative rehabilitation; however, she recovered steadily.

Continuity in health care: lessons from supply chain management.

PubMed

Meijboom, Bert R; Bakx, Saskia J W G C; Westert, Gert P

2010-01-01

In health care, multidisciplinary collaboration is both indispensable and complicated. We discuss organizational problems that occur in situations where multiple health care providers are required to cooperate for patients with complex needs. Four problem categories, labelled as communication, patient safety, waiting times and integration are distinguished. Then we develop a supply chain perspective on these problems in the sense of discussing remedies according to supply chain management (SCM) literature. This perspective implies a business focus on inter-organizational conditions and requirements necessary for delivering health care and cure across organizational borders. We conclude by presenting some strategic and policy recommendations.

OPTIMIZING LENVATINIB THERAPY IN PATIENTS WITH METASTATIC RADIOACTIVE IODINE-RESISTANT DIFFERENTIATED THYROID CANCERS.

PubMed

Jasim, Sina; Iniguez-Ariza, Nicole M; Hilger, Crystal R; Chintakuntlawar, Ashish V; Ryder, Mabel M; Morris, John C; Bible, Keith C

2017-10-01

Lenvatinib is approved for use in advanced radioactive iodine-resistant differentiated thyroid cancers (RAIR-DTCs). Its efficacy is indisputable, but toxicities are great, creating daunting challenges for patients and providers. Few data regarding early adverse events and impact on quality of life (QOL) exist; we sought to clarify these issues by analyzing our initial postapproval lenvatinib experience. Standardized patient education was implemented, providing detailed instructions and expert provider contacts to facilitate timely reporting of toxicities and guide responsive actions. Early adverse events, QOL outcomes, and response data from 25 consecutively treated DTC patients (02/2015 and 05/2016) were retrospectively analyzed. The median age was 55 years (range 27-81); 52% were female. Fourteen (56%) were on antihypertensive medication(s) at baseline. Most patients (21/25, 84%) developed adverse events during the first month of therapy. Hypertension arose in 16/25 (64%), requiring antihypertensive dose adjustment/addition in 6 (24%)/12 (48%) patients, respectively, during the first month of therapy. Dose reduction was required in 11 (44%) due to multiple adverse events; the median time to first dose reduction was 33 days (range 11-84); 8 (32%) required multiple dose reductions. Therapy interruption >3 weeks occurred in 4 (16%). The median change in patient-reported fatigue score was +2 (worsening, range -2 to +10, P<.007; 0-10 scales), but the median QOL change was 0 (range +4 to -9, P = .57). The mean duration of lenvatinib therapy was 6.5 months (range 1-12); median overall and progression-free survival have not yet been reached. Lenvatinib was discontinued in 7 (28%) patients; among 20 patients with available RECIST (Response Evaluation Criteria In Solid Tumors) measurements, 10 (50%) achieved partial response. Lenvatinib has promising efficacy in RAIR-DTC, but toxicities require frequent early interventions. QOL can be maintained on lenvatinib therapy. DTC = differentiated thyroid cancer; LASA = linear analog self-assessment; PR = partial response; QOL = quality of life; RAI = radioactive iodine; RAIR = RAI-resistant; RECIST = Response Evaluation Criteria In Solid Tumors; Tg = thyroglobulin; VEGFR = vascular endothelial growth factor receptor.

Multiple drilling combined with simvastatin versus multiple drilling alone for the treatment of avascular osteonecrosis of the femoral head: 3-year follow-up study.

PubMed

Yin, Han; Yuan, Zhenfeng; Wang, Dawei

2016-08-15

Multiple small drilling for core decompression is widely used to preserve the femoral head in patients with avascular necrosis of the femoral head (ANFH). Nevertheless, the clinical outcome remains controversial. Simvastatin has been demonstrated to promote bone formation and reduce bone adsorption. The purpose of this study was to determine whether simvastatin enhanced the effect of multiple decompressions in preventing progression of ANFH and to identify independent risk factors associated with poor results. We retrospectively analyzed 58 hips in 36 patients, with a follow-up of 36 months. 20 patients (32 hips) underwent multiple drilling combined with simvastatin treatment (SIM group); 16 patients (26 hips) underwent multiple drilling alone (MD group). We defined clinical failure as a requirement for subsequent hip surgery or Harris Hip Score < 75. New occurrence of collapse or increased collapse > 2 mm on plain radiographs was defined as radiological failure. Successful clinical results were achieved in 27 of 32 hips (84 %) in the SIM group compared with 15 of 26 hips (58 %) in the MD group (OR = 0.2, CI (0.1, 0.6.), P = 0.032). Successful radiological results were achieved in 27 of 32 hips (84 %) in the SIM group and in 16 of 26 hips (61.5 %) in the MD group (P = 0.048). Body mass index, disease stage and location of lesion were independent prognostic factors for overall survival. We believe that simvastatin could enhance the effects of multiple decompressions in preventing progression of ANFH and reducing the risk of femoral head collapse.

Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems.

PubMed

2014-05-01

Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, cost-effective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care. Copyright © 2014 by the American Academy of Pediatrics.

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome.

PubMed

Murad-Regadas, Sthela Maria; Regadas, Francisco Sergio P; Rodrigues, Lusmar Veras; Fernandes, Graziela Olivia da Silva; Buchen, Guilherme; Kenmoti, Viviane T

2012-01-01

Management of patients with obstructed defecation syndrome is still controversial. To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.

Survival of a highly toxic dose of caffeine.

PubMed

Bioh, Gabriel; Gallagher, Mark M; Prasad, Usha

2013-02-08

A 27-year-old woman with a history of depression and previous overdose presented within 60 min of ingestion of 50 g of caffeine powder. Initially alert but hypotensive and tachycardic, the patient developed a broad complex tachycardia followed by a seizure and multiple ventricular fibrillation (VF) arrests. Following multiple defibrillations for VF, eight cycles of cardiopulmonary resuscitation and treatment with amiodarone, lidocaine, magnesium and potassium supplementation, the patient went to the intensive care unit (ICU). While there, the patient had further VF and required haemofiltration for a profound metabolic acidaemia with cardiac rhythm instability. She developed a postcardiac arrest systemic inflammatory response syndrome with episodes of acute pulmonary oedema, profound vasoplegia, hypothermia and coagulopathy. After 5 days in the ICU, the patient was stable enough to be transferred to the ward, with a persistent sinus tachycardia, and was discharged 3 days later with cardiology and psychiatry follow-up.

Impact of Depression, Fatigue, and Global Measure of Cortical Volume on Cognitive Impairment in Multiple Sclerosis

PubMed Central

De Cola, Maria Cristina; D'Aleo, Giangaetano; Sessa, Edoardo; Marino, Silvia

2015-01-01

Objective. To investigate the influence of demographic and clinical variables, such as depression, fatigue, and quantitative MRI marker on cognitive performances in a sample of patients affected by multiple sclerosis (MS). Methods. 60 MS patients (52 relapsing remitting and 8 primary progressive) underwent neuropsychological assessments using Rao's Brief Repeatable Battery of Neuropsychological Tests (BRB-N), the Beck Depression Inventory-second edition (BDI-II), and the Fatigue Severity Scale (FSS). We performed magnetic resonance imaging to all subjects using a 3 T scanner and obtained tissue-specific volumes (normalized brain volume and cortical brain volume). We used Student's t-test to compare depressed and nondepressed MS patients. Finally, we performed a multivariate regression analysis in order to assess possible predictors of patients' cognitive outcome among demographic and clinical variables. Results. 27.12% of the sample (16/59) was cognitively impaired, especially in tasks requiring attention and information processing speed. From between group comparison, we find that depressed patients had worse performances on BRB-N score, greater disability and disease duration, and brain volume decrease. According to multiple regression analysis, the BDI-II score was a significant predictor for most of the neuropsychological tests. Conclusions. Our findings suggest that the presence of depressive symptoms is an important determinant of cognitive performance in MS patients. PMID:25861633

Baseline predictors of persistence to first disease-modifying treatment in multiple sclerosis.

PubMed

Zettl, U K; Schreiber, H; Bauer-Steinhusen, U; Glaser, T; Hechenbichler, K; Hecker, M

2017-08-01

Patients with multiple sclerosis (MS) require lifelong therapy. However, success of disease-modifying therapies is dependent on patients' persistence and adherence to treatment schedules. In the setting of a large multicenter observational study, we aimed at assessing multiple parameters for their predictive power with respect to discontinuation of therapy. We analyzed 13 parameters to predict discontinuation of interferon beta-1b treatment during a 2-year follow-up period based on data from 395 patients with MS who were treatment-naïve at study onset. Besides clinical characteristics, patient-related psychosocial outcomes were assessed as well. Among patients without clinically relevant fatigue, males showed a higher persistence rate than females (80.3% vs 64.7%). Clinically relevant fatigue scores decreased the persistence rate in men and especially in women (71.4% and 51.2%). Besides gender and fatigue, univariable and multivariable analyses revealed further factors associated with interferon beta-1b therapy discontinuation, namely lower quality of life, depressiveness, and higher relapse rate before therapy initiation, while higher education, living without a partner, and higher age improved persistence. Patients with higher grades of fatigue and depressiveness are at higher risk to prematurely discontinue MS treatment; especially, women suffering from fatigue have an increased discontinuation rate. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Just-in-time rescue plerixafor in combination with chemotherapy and granulocyte-colony stimulating factor for peripheral blood progenitor cell mobilization

PubMed Central

Smith, Veronica R.; Popat, Uday; Ciurea, Stefan; Nieto, Yago; Anderlini, Paolo; Rondon, Gabriela; Alousi, Amin; Qazilbash, Muzaffar; Kebriaei, Partow; Khouri, Issa; de Lima, Marcos; Champlin, Richard; Hosing, Chitra

2014-01-01

Plerixafor, a recently approved peripheral blood progenitor cell mobilizing agent, is often added to granulocyte-colony stimulating factor (G-CSF) to mobilize peripheral blood progenitor cells in patients with lymphoma or myeloma who cannot mobilize enough CD34+ cells with G-CSF alone to undergo autologous stem cell transplantation. However, data are lacking regarding the feasibility and efficacy of just-in-time plerixafor in combination with chemotherapy and G-CSF. We reviewed the peripheral blood stem cell collection data of 38 consecutive patients with lymphoma (Hodgkin’s and non-Hodgkin’s) and multiple myeloma who underwent chemomobilization and high-dose G-CSF and just-in-time plerixafor to evaluate the efficacy of this treatment combination. All patients with multiple myeloma and all but 1 patient with lymphoma collected the minimum required number of CD34+ cells to proceed with autologous stem cell transplantation (>2 × 106/kilogram of body weight). The median CD34+ cell dose collected in patients with non-Hodgkin lymphoma was 4.93 × 106/kilogram of body weight. The median CD34+ cell dose collected for patients with multiple myeloma was 8.81 × 106/kilogram of body weight. Plerixafor was well tolerated; no grade 2 or higher non- hematologic toxic effects were observed. PMID:23749720

The characteristics of patients frequently admitted to academic medical centers in the United States

PubMed Central

Williams, Mark V.; Carrier, Danielle; Hensley, Laurie; Thomas, Stephen; Cerese, Julie

2015-01-01

BACKGROUND The recent intense attention to hospital readmissions and their implications for quality, safety, and reimbursement necessitates understanding specific subsets of readmitted patients. Frequently admitted patients, defined as patients who are admitted 5 or more times within 1 year, may have some distinguishing characteristics that require novel solutions. METHODS A comprehensive administrative database (University HealthSystem Consortium's Clinical Data Base/Resource Manager™) was analyzed to identify demographic, social, and clinical characteristics of frequently admitted patients in 101 US academic medical centers. RESULTS We studied 28,291 frequently admitted patients with 180,185 admissions over a 1‐year period (2011–2012). These patients comprise 1.6% of all patients, but account for 8% of all admissions and 7% of direct costs. Their admissions are driven by multiple chronic conditions; compared to other hospitalized patients, they have significantly more comorbidities (an average of 7.1 vs 2.5), and 84% of their admissions are to medical services. A minority, but significantly more than other patients, have comorbidities of psychosis or substance abuse. Moreover, although they are slightly more likely than other patients to be on Medicaid or to be uninsured (27.6% vs 21.6%), nearly three‐quarters have private or Medicare coverage. CONCLUSIONS Patients who are frequently admitted to US academic medical centers are likely to have multiple complex chronic conditions and may have behavioral comorbidities that mediate their health behaviors, resulting in acute episodes requiring hospitalization. This information can be used to identify solutions for preventing repeat hospitalization for this small group of patients who consume a highly disproportionate share of healthcare resources. Journal of Hospital Medicine 2015;10:563–568. © 2015 The Authors Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine PMID:26018340

Role of whole-body 64-slice multidetector computed tomography in treatment planning for multiple myeloma.

PubMed

Razek, Ahmed Abdel Khalek Abdel; Ezzat, Amany; Azmy, Emad; Tharwat, Nehal

2013-08-01

The authors evaluated the role of whole-body 64-slice multidetector computed tomography (WB-MDCT) in treatment planning for multiple myeloma. This was a prospective study of 28 consecutive patients with multiple myeloma (19 men, nine women; age range, 51-73 years; mean age, 60 years) who underwent WB-MDCT and conventional radiography (CR) of the skeleton. The images were interpreted for the presence of bony lesions, medullary lesions, fractures and extraosseous lesions. We evaluated any changes in treatment planning as a result of WB-MDCT findings. WB-MDCT was superior to CR for detecting bony lesions (p=0.001), especially of the spine (p=0.001) and thoracic cage (p=0.006). WB-MDCT upstaged 14 patients, with a significant difference in staging (p=0.002) between WB-MDCT and CR. Medullary involvement either focal (n=6) or diffuse (n=3) had a positive correlation with the overall score (r=0.790) and stage (r=0.618) of disease. Spine fractures were better detected at WB-MDCT (n=4) than at CR (n=2). Extraosseous soft tissue lesions (n=7) were detected only at WB-MDCT. Findings detected at the WB-MDCT led to changes in the patient's treatment plan in 39% of cases. Upstaging of seven patients (25%) altered the medical treatment plan, and four of 28 (14%) patients required additional radiotherapy (7%) and vertebroplasty (7%). We conclude that WB-MDCT has an impact on treatment planning and prognosis in patients with multiple myeloma, as it has high rate of detecting cortical and medullary bone lesions, spinal fracture and extraosseous lesions. This information may alter treatment planning in multiple myeloma due to disease upstaging and detection of spine fracture and extraosseous spinal lesions.

Epidemiological study of multiple sclerosis in La Rioja.

PubMed

Bártulos Iglesias, M; Marzo Sola, M E; Estrella Ruiz, L A; Bravo Anguiano, Y

2015-01-01

Multiple sclerosis is a demyelinating disease that causes severe disability in younger patients. Many epidemiology studies have confirmed a variable prevalence. The objective of this study was to analyse the prevalence of this disease in La Rioja (Spain), using such variables as age and sex; type of progression, initial form of the disease, EDSS and number of relapses; disease-modifying treatment and reasons for treatment withdrawal; personal and family history of cancer; and incidence and mortality. Analysis of patients in La Rioja diagnosed with MS (according to Poser criteria or the 2005 McDonald criteria) during a 10-year period (2001-2011). Data were collected from hospital records, multiple sclerosis associations, and personal records kept by neurologists. The MS prevalence rate in La Rioja is 65 patients/100 000 inhabitants with an incidence rate of 3.5 cases/100 000 residents per year. Relapsing-remitting MS is present in 67.6% of the patient total. Mean age of onset is 20-29 years (range, 12 to 70). Most EDSS scores were mostly ≤ 2. Untreated MS cases account for 47.6% of the total and the most commonly used therapy is interferon. We detected 4 haematological tumours and 7 families with multiple members affected by MS. Prevalence and incidence are similar to those found in other regions Spain. The average age at onset age for primary progressive MS is slightly higher than in other papers (40-49 years). In families with multiple patients, MS may be more aggressive. Disability in these patients remains very severe. We require more epidemiology studies with a variety of data gathering methods to support findings for prevalence obtained in different provinces. Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier España, S.L.U. All rights reserved.

North Carolina Medicaid recipient management lock-in program: the pharmacist's perspective.

PubMed

Werth, S Rose; Sachdeva, Nidhi; Roberts, Andrew W; Garrettson, Mariana; Ringwalt, Chris; Moss, Leslie A; Pikoulas, Theodore; Skinner, Asheley Cockrell

2014-11-01

The misuse and abuse of prescription opioids have become an urgent health issue in North Carolina (NC), particularly among Medicaid patients who suffer high rates of morbidity and mortality due to abuse and overdose. The NC Division of Medical Assistance (DMA) implemented a recipient management lock-in program, which limits identified patients for a 12-month period to 1 prescriber and 1 pharmacy for benzodiazepine, opiate, and certain anxiolytic prescriptions in order to prevent misuse and reduce overutilization of Medicaid benefits.  To (a) evaluate pharmacists' perceptions of the implementation of the NC recipient management lock-in program (MLIP) and (b) determine how the beliefs and attitudes of pharmacists could promote or inhibit its success.  We conducted 12 structured phone interviews with NC pharmacists serving lock-in patients. Interview responses were analyzed through construct analysis, which identified themes organized into 3 domains: organization and implementation, perceived effectiveness, and acceptability.  Most respondents reported a positive experience with the program but expressed doubt concerning its impact on prescription drug abuse. The program successfully utilized the pharmacist role as a gatekeeper of controlled substances, and the procedures of the program required no active effort on pharmacists' part. However, respondents suggested that the DMA improve communication and outreach to address pharmacists' lack of knowledge about the program's purpose and confusion over remediating problems that arise with lock-in patients. The DMA should also address the ways in which the program can interfere with access to health care and treatment, allow patients to see multiple physicians within the same clinic, and clarify procedures for patients whose complex health issues require multiple specialists.  Although possible improvements were identified, the NC MLIP has strong potential for success as it utilizes pharmacists' medication gate-keeping role, while minimizing the effort required for successful implementation.

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

PubMed

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

2015-05-01

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

Patient safety - the role of human factors and systems engineering.

PubMed

Carayon, Pascale; Wood, Kenneth E

2010-01-01

Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety.

Randomised multicentre trial on safety and efficacy of rivastigmine in cognitively impaired multiple sclerosis patients.

PubMed

Mäurer, M; Ortler, S; Baier, M; Meergans, M; Scherer, P; Hofmann, We; Tracik, F

2013-04-01

Cognitive decline has been recognised as a frequent symptom in multiple sclerosis (MS). Cholinesterase inhibitors (ChEIs) are employed for the treatment of Alzheimer's disease, but there is some evidence that ChEIs might also be effective in MS patients with cognitive deficits, particularly deficits of memory function. The aim of this study was to evaluate efficacy on memory function and safety of the ChEI rivastigmine in MS patients with cognitive deficits as measured by the change from baseline of the total recall score of the selective reminding test (SRT) after 16 weeks of treatment. Efficacy and safety of rivastigmine were analysed in a 16-week, multicentre, double-blind, randomised, placebo-controlled study, followed by an optional one-year open-label treatment phase. Effects of rivastigmine and placebo were compared by an analysis of covariance. In total, 86 patients were enrolled. Patients who received rivastigmine (n = 43) showed a non-significant increase in total recall score (sum of all words immediately recalled over all six trials) over placebo (n = 38) after 16 weeks of treatment (p = 0.2576). Other outcome measures provided no evidence supporting benefits of rivastigmine. Treatment with rivastigmine was well tolerated. With the results of this study, the need for an effective therapy in cognitively impaired MS patients is still required. Thus, intensive and continued clinical research is required to explore therapeutic options for cognitive deficits in MS patients.

Development of a software based automatic exposure control system for use in image guided radiation therapy

NASA Astrophysics Data System (ADS)

Morton, Daniel R.

Modern image guided radiation therapy involves the use of an isocentrically mounted imaging system to take radiographs of a patient's position before the start of each treatment. Image guidance helps to minimize errors associated with a patients setup, but the radiation dose received by patients from imaging must be managed to ensure no additional risks. The Varian On-Board Imager (OBI) (Varian Medical Systems, Inc., Palo Alto, CA) does not have an automatic exposure control system and therefore requires exposure factors to be manually selected. Without patient specific exposure factors, images may become saturated and require multiple unnecessary exposures. A software based automatic exposure control system has been developed to predict optimal, patient specific exposure factors. The OBI system was modelled in terms of the x-ray tube output and detector response in order to calculate the level of detector saturation for any exposure situation. Digitally reconstructed radiographs are produced via ray-tracing through the patients' volumetric datasets that are acquired for treatment planning. The ray-trace determines the attenuation of the patient and subsequent x-ray spectra incident on the imaging detector. The resulting spectra are used in the detector response model to determine the exposure levels required to minimize detector saturation. Images calculated for various phantoms showed good agreement with the images that were acquired on the OBI. Overall, regions of detector saturation were accurately predicted and the detector response for non-saturated regions in images of an anthropomorphic phantom were calculated to generally be within 5 to 10 % of the measured values. Calculations were performed on patient data and found similar results as the phantom images, with the calculated images being able to determine detector saturation with close agreement to images that were acquired during treatment. Overall, it was shown that the system model and calculation method could potentially be used to predict patients' exposure factors before their treatment begins, thus preventing the need for multiple exposures.

Multidisciplinary Approach to Esophageal Achalasia: A Single Center Experience.

PubMed

Schlottmann, Francisco; Andolfi, Ciro; Kavitt, Robert T; Konda, Vani J A; Patti, Marco G

2017-04-01

The treatment of achalasia is palliative. Pneumatic dilatation (PD) or laparoscopic Heller myotomy (LHM) just eliminates the outflow obstruction allowing easier emptying of the esophagus. The aim of this study was to evaluate the results of a multidisciplinary approach to esophageal achalasia. A consecutive series of patients with achalasia treated by a multidisciplinary esophageal team consisting of radiologists, gastroenterologists, and surgeons in a quaternary care center between May 2008 and April 2015 were analyzed. A total of 147 patients with achalasia underwent LHM and partial fundoplication. Sixty-two patients (42%) had been treated preoperatively with PD and/or botulinum toxin (BT). The preoperative Eckardt score (ES) was 6.4 ± 2. At a median follow-up of 22 months, 128 patients (87%) did well and required no further treatment (ES 0.1). The remaining 19 patients (13%) had recurrence of symptoms and required further treatment: 12 were treated with PD and improved (ES 0.7); 4 were treated with PD and BT and improved (ES 1.3); 3 failed PD. These 3 patients had been treated with multiple sessions of PD and BT before the myotomy. Overall, 144 patients (98%) did well with laparoscopic (87%) or laparoscopic and endoscopic treatment (11%). The results of this study show that (a) LHM is an effective treatment modality, (b) PD improved symptoms in the majority of patients with recurrent dysphagia after myotomy and (c) multiple preoperative endoscopic treatments seem to affect outcomes of LHM. Patients with achalasia should be treated in a quaternary care center by a multidisciplinary team.

Thyroid storm with multiple organ failure, disseminated intravascular coagulation, and stroke with a normal serum FT3 level.

PubMed

Harada, Yuko; Akiyama, Hisanao; Yoshimoto, Tatsuji; Urao, Yasuko; Ryuzaki, Munekazu; Handa, Michiko

2012-01-01

Thyroid storm is a rare disorder with a sudden onset, rapid progression and high mortality. We experienced a case of thyroid storm which had a devastating course, including multiple organ failure (MOF), severe hypoglycemia, disseminated intravascular coagulation (DIC), and stroke. It was difficult to make a diagnosis of thyroid storm in the present patient, because she did not have a history of thyroid disease and her serum FT3 level was normal. Clinicians should be aware that thyroid storm can occur even when there is an almost normal level of thyroid hormones, and that intensive anticoagulation is required for patients with atrial fibrillation to prevent stroke after thyroid storm.

Aristotle score predicts outcome in patients requiring extracorporeal circulatory support following repair of congenital heart disease.

PubMed

Derby, Christopher D; Kolcz, Jacek; Kerins, Paul J; Duncan, Daniel R; Quezada, Emilio; Pizarro, Christian

2007-01-01

Extracorporeal membrane oxygenation (ECMO) has become the standard technique of mechanical support for the failing circulation following repair of congenital heart lesions. The objective of this study was to identify predictors of survival in patients requiring postcardiotomy ECMO. The Aristotle score, a method developed to evaluate quality of care based on complexity, was investigated as a potential predictor of outcome. Between 2003 and 2005, 37 patients required ECMO following corrective surgery for congenital heart disease. Records were reviewed retrospectively with emphasis on factors affecting survival to discharge. The comprehensive Aristotle complexity score was calculated for each patient. Overall, 28 patients (76%) survived to decannulation and 17 patients (46%) survived to discharge. There were 24 (65%) neonates and 10 patients (27%) with single ventricle physiology, with a hospital survival of 42% (10 of 24) and 50% (5 of 10), respectively. Univariate factors associated with survival included Aristotle score, duration of support, reexploration, multiple organ failure, and number of complications. Age, weight, and single-ventricle physiology were not significant. In a logistic regression model, an Aristotle score < 14 was identified as a predictor of survival (OR 0.12, CI 0.02-0.87). The Aristotle score is predictive of outcome in patients requiring postcardiotomy ECMO and may serve as a uniform criterion when comparing and evaluating quality of care and performance in this complex patient population.

Understanding and meeting injection device needs in multiple sclerosis: a survey of patient attitudes and practices

PubMed Central

Verdun di Cantogno, Elisabetta; Russell, Susan; Snow, Tom

2011-01-01

Background: All established disease-modifying drugs for multiple sclerosis require parenteral administration, which can cause difficulties for some patients, sometimes leading to suboptimal adherence. A new electronic autoinjection device has been designed to address these issues. Methods: Patients with relapsing multiple sclerosis currently receiving subcutaneous or intramuscular interferon beta-1a, interferon beta-1b, or glatiramer acetate completed an online questionnaire (July 4–25, 2008) that surveyed current injection practices, experiences with current injection methods, and impressions and appeal of the new device. Results: In total, 422 patients completed the survey, of whom 44% used autoinjectors, 43% prefilled syringes, and 13% syringes and vials; overall, 66% currently self-injected. Physical and psychological barriers to self-injection included difficulty with injections, needle phobia, and concerns over correct injection technique. Only 40% of respondents were “very satisfied” with their current injection method. The new electronic autoinjector was rated as “very appealing” by 65% of patients. The benefits of the new device included the ability to customize injection settings and to review dosing history. Conclusion: New technologies may help patients overcome physical and psychological barriers to self-injection. The combination of a reliable and flexible autoinjection device with dose-monitoring technology may improve communication between health care professionals and patients, and improve treatment adherence. PMID:21573048

Outcome of Split Thickness Skin Grafting and Multiple Z-Plasties in Postburn Contractures of Groin and Perineum: A 15-Year Experience

PubMed Central

Sajad, Wani; Hamid, Raashid

2014-01-01

Background. Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Aims. To study the outcome of surgical treatment (STSG and multiple Z-plasties) in postburn contractures of groin and perineum. Material and Methods. We conducted a study of 49 patients, with postburn groin and perineal contractures. Release of contracture with split thickness skin grafting (STSG) was done in 44 (89.79%) patients and release of contracture and closure by multiple Z-plasties was done in 5 (10.21%) patients. Results. Satisfactory functional and cosmetic outcome was seen in 44 (89.79%) patients. Minor secondary contractures of the graft were seen in 3 (6.81%) patients who were managed by physiotherapy and partial recurrence of the contracture in 4 (8.16%) patients required secondary surgery. Conclusion. We conclude that postburn contractures of the groin and perineum can be successfully treated with release of contracture followed by STSG with satisfactory functional and cosmetic results. Long term measures like regular physiotherapy, use of pressure garments, and messaging with emollient creams should not be neglected and should be instituted postoperatively to prevent secondary contractures of the graft and recurrence of the contracture. PMID:24967100

Outcome of split thickness skin grafting and multiple z-plasties in postburn contractures of groin and perineum: a 15-year experience.

PubMed

Sajad, Wani; Hamid, Raashid

2014-01-01

Background. Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Aims. To study the outcome of surgical treatment (STSG and multiple Z-plasties) in postburn contractures of groin and perineum. Material and Methods. We conducted a study of 49 patients, with postburn groin and perineal contractures. Release of contracture with split thickness skin grafting (STSG) was done in 44 (89.79%) patients and release of contracture and closure by multiple Z-plasties was done in 5 (10.21%) patients. Results. Satisfactory functional and cosmetic outcome was seen in 44 (89.79%) patients. Minor secondary contractures of the graft were seen in 3 (6.81%) patients who were managed by physiotherapy and partial recurrence of the contracture in 4 (8.16%) patients required secondary surgery. Conclusion. We conclude that postburn contractures of the groin and perineum can be successfully treated with release of contracture followed by STSG with satisfactory functional and cosmetic results. Long term measures like regular physiotherapy, use of pressure garments, and messaging with emollient creams should not be neglected and should be instituted postoperatively to prevent secondary contractures of the graft and recurrence of the contracture.

Foramen magnum decompression for Chiari I malformation: a procedure not to be underestimated.

PubMed

Duddy, John Charles; Allcutt, David; Crimmins, Darach; O'Brien, David; O'Brien, Donncha Finbarr; Rawluk, Daniel; Sattar, Mohammed Taufiq; Young, Steven; Caird, John

2014-06-01

Chiari I malformation may be treated with foramen magnum decompression (FMD). We aim to describe the symptoms with which patients initially present, and to determine the number and type of complications occurring after FMD for Chiari I malformation. Retrospective review of medical records for patients who had FMD performed for Chiari I malformation between January 2009 and December 2011. Post-operative outcomes were recorded and analysed. Patient demographic details and other relevant medical conditions were also noted. Between January 2009 and December 2011, 54 FMDs were performed for Chiari I malformation. Among them, 40(74%) patients were female and 14 patients (26%) were male. The majority of patients (42.6%) were aged 16-39 years and 24.07% of patients were children aged < 16 years. A total of 30(55.6%) patients had documented evidence of a syrinx pre-operatively. 18(33.3%) patients developed complications. Nine of these developed multiple complications while nine had a single problem. One mortality was reported. Ten (18.5%) patients developed hydrocephalus requiring shunting. Two patients developed subdural collections requiring evacuation associated with hydrocephalus. Six (11.1%) patients developed post-operative infections: two CNS infections; one wound infection; and three other infections. FMD for Chiari I malformation is a procedure which carries risk. In particular, the risk of developing post-operative hydrocephalus requiring permanent shunting is relatively high. ICP monitoring prior to FMD may be required to definitively rule out raised intracranial pressure.

Preoperative planning and perioperative management for minimally invasive total knee arthroplasty.

PubMed

Scuderi, Giles R

2006-07-01

The introduction of minimally invasive surgery (MIS) has led to new clinical pathways for total knee arthroplasty (TKA). MIS TKA outcomes are affected by multiple factors--the surgery itself; preoperative planning and medical management; preoperative patient education; preemptive perioperative and postoperative analgesia; mode of anesthesia; optimal rehabilitation; and enlightened home care and social services-and therefore an integrated team approach to patient and surgery is required.

[Physical rehabilitation in multiple sclerosis: general principles and high-tech approaches].

PubMed

Peresedova, A V; Chernikova, L A; Zavalishin, I A

2013-01-01

In a chronic and disabling disease like multiple sclerosis, rehabilitation programs are of major importance for the preservation of physical, physiological, social and professional functioning and improvement of quality of life. Currently, it is generally assumed that physical activity is an important component of non-pharmacological rehabilitation in multiple sclerosis. Properly organized exercise is a safe and efficient way to induce improvements in a number of physiological functions. A multidisciplinary rehabilitative approach should be recommended. The main recommendations for the use of exercise for patients with multiple sclerosis have been listed. An important aspect of the modern physical rehabilitation in multiple sclerosis is the usage of high-tech methods. The published results of robot-assisted training to improve the hand function and walking impairment have been represented. An important trend in the rehabilitation of patients with multiple sclerosis is the reduction of postural disorders through training balance coordination. The role of transcranial magnetic stimulation in spasticity reducing is being investigated. The use of telemedicine capabilities is quite promising. Due to the fact that the decline in physical activity can lead to the deterioration of many aspects of physiological functions and, ultimately, to mobility decrease, further research of the role of physical rehabilitation as an important therapeutic approach in preventing the progression of disability in multiple sclerosis is required.

Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients.

PubMed

Young, John; Geraci, Travis; Milman, Steven; Maslow, Andrew; Jones, Richard N; Ng, Thomas

2018-03-08

To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2-year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Mountain biking injuries in rural England.

PubMed

Jeys, L M; Cribb, G; Toms, A D; Hay, S M

2001-06-01

Off road mountain biking is now an extremely popular recreation and a potent cause of serious injury. To establish the morbidity associated with this sport. Data were collected prospectively over one year on all patients presenting with an injury caused by either recreational or competitive off road mountain biking. Eighty four patients were identified, 70 males and 14 females, with a mean age of 22.5 years (range 8-71). Most accidents occurred during the summer months, most commonly in August. Each patient had an average of 1.6 injuries (n = 133) and these were divided into 15 categories, ranging from minor soft tissue to potentially life threatening. Operative intervention was indicated for 19 patients (23%) and several required multiple procedures. The commonest injuries were clavicle fractures (13%), shoulder injuries (12%), and distal radial fractures (11%). However, of a more sinister nature, one patient had a C2/3 dislocation requiring urgent stabilisation, one required a chest drain for a haemopneumothorax, and another required an emergency and life saving nephrectomy. This sport has recently experienced an explosion in popularity, and, as it carries a significant risk of potentially life threatening injury across all levels of participation, the use of protective equipment to reduce this significant morbidity may be advisable.

Design and implementation of a secure and user-friendly broker platform supporting the end-to-end provisioning of e-homecare services.

PubMed

Van Hoecke, Sofie; Steurbaut, Kristof; Taveirne, Kristof; De Turck, Filip; Dhoedt, Bart

2010-01-01

We designed a broker platform for e-homecare services using web service technology. The broker allows efficient data communication and guarantees quality requirements such as security, availability and cost-efficiency by dynamic selection of services, minimizing user interactions and simplifying authentication through a single user sign-on. A prototype was implemented, with several e-homecare services (alarm, telemonitoring, audio diary and video-chat). It was evaluated by patients with diabetes and multiple sclerosis. The patients found that the start-up time and overhead imposed by the platform was satisfactory. Having all e-homecare services integrated into a single application, which required only one login, resulted in a high quality of experience for the patients.

Artificial intelligence in mitral valve analysis.

PubMed

Jeganathan, Jelliffe; Knio, Ziyad; Amador, Yannis; Hai, Ting; Khamooshian, Arash; Matyal, Robina; Khabbaz, Kamal R; Mahmood, Feroze

2017-01-01

Echocardiographic analysis of mitral valve (MV) has become essential for diagnosis and management of patients with MV disease. Currently, the various software used for MV analysis require manual input and are prone to interobserver variability in the measurements. The aim of this study is to determine the interobserver variability in an automated software that uses artificial intelligence for MV analysis. Retrospective analysis of intraoperative three-dimensional transesophageal echocardiography data acquired from four patients with normal MV undergoing coronary artery bypass graft surgery in a tertiary hospital. Echocardiographic data were analyzed using the eSie Valve Software (Siemens Healthcare, Mountain View, CA, USA). Three examiners analyzed three end-systolic (ES) frames from each of the four patients. A total of 36 ES frames were analyzed and included in the study. A multiple mixed-effects ANOVA model was constructed to determine if the examiner, the patient, and the loop had a significant effect on the average value of each parameter. A Bonferroni correction was used to correct for multiple comparisons, and P = 0.0083 was considered to be significant. Examiners did not have an effect on any of the six parameters tested. Patient and loop had an effect on the average parameter value for each of the six parameters as expected (P < 0.0083 for both). We were able to conclude that using automated analysis, it is possible to obtain results with good reproducibility, which only requires minimal user intervention.

Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management.

PubMed

Le-Wendling, Linda; Glick, Wesley; Tighe, Patrick

2017-12-01

As newer pharmacologic and procedural interventions, technology, and data on outcomes in pain management are becoming available, effective acute pain management will require a dedicated Acute Pain Service (APS) to help determine the most optimal pain management plan for the patients. Goals for pain management must take into consideration the side effect profile of drugs and potential complications of procedural interventions. Multiple objective optimization is the combination of multiple different objectives for acute pain management. Simple use of opioids, for example, can reduce all pain to minimal levels, but at what cost to the patient, the medical system, and to public health as a whole? Many models for APS exist based on personnel's skills, knowledge and experience, but effective use of an APS will also require allocation of time, space, financial, and personnel resources with clear objectives and a feedback mechanism to guide changes to acute pain medicine practices to meet the constantly evolving medical field. Physician-based practices have the advantage of developing protocols for the management of low-variability, high-occurrence scenarios in addition to tailoring care to individual patients with high-variability, low-occurrence scenarios. Frequent feedback and data collection/assessment on patient outcomes is essential in evaluating the efficacy of the Acute Pain Service's intervention in improving patient outcomes in the acute and perioperative setting.

Many diseases, one model of care?

PubMed Central

Albreht, Tit; Dyakova, Mariana; Schellevis, François G.

2016-01-01

Patients with multiple chronic conditions (multimorbidity) have complex and extensive health and social care needs that are not well served by current silo-based models of care. A lack of integration between care providers often leads to fragmented, incomplete, and ineffective care, leaving many patients overwhelmed and unable to navigate their way towards better health outcomes. In planning for the future, healthcare policies and models of care are required that cater for the complex needs of patients with multimorbidity and that deliver coordinated care that is patient-centred and focused on disease prevention, multidisciplinary teamwork and shared decision-making, and on empowering patients to self-manage. Salient lessons can be learnt from the work undertaken at a European and national level to develop care models in cancer and diabetes – two complex and often co-occurring conditions requiring coordinated long-term care. Innovative work is also underway in many European countries aimed at improving the integration of care for people with multimorbidity, resulting in more efficient and cost-effective health outcomes. This article reviews some of the most innovative programmes that have been initiated across and within Europe with the aim of improving the way care is delivered to people with complex and multiple long-term conditions. This work provides a foundation upon which to build better, more effective models of care for people with multimorbidity. PMID:29090167

Facilitating the Information Exchange Using a Modular Electronic Discharge Summary.

PubMed

Denecke, Kerstin; Dittli, Pascal A; Kanagarasa, Niveadha; Nüssli, Stephan

2018-01-01

Discharge summaries are a standard communication tool delivering important clinical information from inpatient to ambulatory care. To ensure a high quality, correctness and completeness, the generation process is time consuming. It requires also contributions of multiple persons. This is problematic since the primary care provider needs the information from the discharge summary for continuing the intended treatment. To address this challenge, we developed a concept for exchanging a modular electronic discharge summary. Through a literature review and interviews with multiple stakeholders, we analysed existing processes and derived requirements for an improved communication of the discharge summary. In this paper, we suggest a concept of a modular electronic discharge summary that is exchanged through the electronic patient dossier in CDA CH level 2 documents. Until 2020, all Swiss hospitals are obliged to connect to the electronic patient dossier. Our concept allows to access already completed modules of the discharge summary from the primary care side, before the entire report is entirely finalised. The data is automatically merged with the local patient record on the physician side and prepared for data integration into the practice information system. Our concept offers the opportunity not only to improve the information exchange between hospital and primary care, but it also provides a potential use case and demonstrates a benefit of the electronic patient dossier for primary care providers who are so far not obliged to connect to the patient dossier in Switzerland.

How general practitioners perceive and assess self-care in patients with multiple chronic conditions: a qualitative study.

PubMed

Kristensen, Mads Aage Toft; Hølge-Hazelton, Bibi; Waldorff, Frans Boch; Guassora, Ann Dorrit

2017-12-22

It is not known how general practitioners (GPs) perceive the concept of self-care and how they assess self-care ability in patients with multiple chronic conditions. As a part of the strategy to improve the care of people living with chronic conditions, disease management programs in Denmark require GPs and other health care workers to assess and support patients' self-care ability. The aim of the present study was to explore GPs' perceptions and assessment of self-care ability in patients with multiple chronic conditions who have difficulty following a given treatment. A qualitative study conducted through in-depth, semi-structured interviews with a purposive sample of 12 GPs in rural areas of Denmark with economically disadvantaged populations. The interviews involved 36 complex patient cases selected by the GPs themselves. Our analysis followed the principles of systematic text condensation. Most GPs in our study had a health-related perception of self-care, but some had a broader perception encompassing the situational context of the patient's life. The GPs' assessments of patients' self-care ability were based on information from the ongoing and often long-term relationships with the patients. GPs identified four major factors that influenced patients' self-care ability, which accumulated and fluctuated over time: multimorbidity, cognitive resources, material resources, and the patients' social contexts. The GPs in this study had dual perceptions of self-care, related to both the chronic health conditions and to the broader situational contexts of their patients' lives. GPs' assessments of self-care ability depended largely on their experiences from the doctor-patient relationship, and they emphasized that the factors affecting self-care ability were highly dynamic over the patient's lifetime. However, these findings might be resisted by the Danish disease management programs, which tend to have a static and more narrow, health-related view of patient self-care. The Danish programs require GPs to assess self-care ability upfront at the beginning of treatment and do not consider whether a relationship with the patient is established. If GPs' perceptions and assessments of self-care ability are not included in chronic disease management models, there is a risk that they vill be insufficiently implemented in general practice.

Multiple Sclerosis and Catastrophic Health Expenditure in Iran.

PubMed

Juyani, Yaser; Hamedi, Dorsa; Hosseini Jebeli, Seyede Sedighe; Qasham, Maryam

2016-09-01

There are many disabling medical conditions which can result in catastrophic health expenditure. Multiple Sclerosis is one of the most costly medical conditions through the world which encounter families to the catastrophic health expenditures. This study aims to investigate on what extent Multiple sclerosis patients face catastrophic costs. This study was carried out in Ahvaz, Iran (2014). The study population included households that at least one of their members suffers from MS. To analyze data, Logit regression model was employed by using the default software STATA12. 3.37% of families were encountered with catastrophic costs. Important variables including brand of drug, housing, income and health insurance were significantly correlated with catastrophic expenditure. This study suggests that although a small proportion of MS patients met the catastrophic health expenditure, mechanisms that pool risk and cost (e.g. health insurance) are required to protect them and improve financial and access equity in health care.

[Modern concepts of trauma care and multiple trauma management in oral and maxillofacial region].

PubMed

Tan, Yinghui

2015-06-01

Multiple trauma management requires the application of modem trauma care theories. Optimal treatment results can be achieved by reinforcing cooperation and stipulating a treatment plan together with other disciplines. Based on modem theories in trauma care and our understanding of the theoretical points, this paper analyzes the injury assessment strategies and methods in oral and maxillofacial multiple trauma management. Moreover, this paper discusses operating time and other influencing factors as well as proposed definitive surgical timing and indications in comprehensive management of oral and maxillofacial multiple trauma patients associated with injuries in other body parts. We hope that this paper can help stomatological physicians deepen their understanding of modem trauma care theories and improve their capacity and results in the treatment of oral and maxillofacial multiple trauma.

Ten Years of Equine-related Injuries: Severity and Implications for Emergency Physicians.

PubMed

Davidson, Scott B; Blostein, Paul A; Schrotenboer, Andrew; Sloffer, Chris A; VandenBerg, Sheri L

2015-11-01

The size, speed, and unpredictable nature of horses present a significant risk for injury in all equine-related activities. We sought to examine the mechanism, severity, frequency, body regions affected, surgical requirements, rehabilitation needs, safety equipment utilization, and outcomes of equine-related injured patients. Records of inpatients who sustained an equine-related injury from 2002-2011 with International Classification of Diseases, Ninth Revision codes E828 and E906 were retrospectively reviewed for pertinent data. Ninety patients, 70% female, age (mean ± SD) 37.3 ± 19.4 years, length of stay 3.7 ± 4.5 days, Injury Severity Score 12.9 ± 8.4. Predominant mechanism of injury was fall from horse (46.7%). The chest (23%) was most frequently injured, followed by brain/head (21.5%). Thirty patients (33%) required 57 surgical procedures. Twenty percent of patients required occupational therapy and 33.3% required physical therapy while hospitalized. Only 3% required rehabilitation, with 90% discharged directly home. Safety equipment was not used in 91.9% of patients. One patient sustained a cord injury. Six patients expired, all from extensive head injuries. The majority of equine-related injuries occur while pursuing recreational activities and are due to falls. Our patients experienced more severe injuries to the trunk and head and required more surgical intervention for pelvic, facial, and brain injuries than previously reported. Failure to use safety equipment contributes to the risk of severe injury. Education and injury prevention is essential. The need for complex surgical intervention by multiple specialties supports transfer to Level I trauma centers. Copyright © 2015 Elsevier Inc. All rights reserved.

Health perceptions and clinical characteristics of relapsing-remitting multiple sclerosis patients: baseline data from an international clinical trial.

PubMed

Robinson, D; Zhao, N; Gathany, T; Kim, L-L; Cella, D; Revicki, D

2009-05-01

Baseline clinical and health-related quality of life (HRQoL) data from a phase 2, multi-site, international, randomized, controlled trial were analyzed to: (1) characterize the health status of patients with relapsing-remitting multiple sclerosis (RRMS), (2) explore cross-sectional relationships between HRQoL and clinical measures, and (3) evaluate differences in HRQoL scores for subsequent validation as minimally important differences (MID). www.clinicaltrials.gov, NCT00207727. Baseline clinical and HRQoL data were selected and analyzed. HRQoL questionnaires included the Short Form-36 (SF-36), Fatigue Severity Scale (FSS), a Patient Assessment of multiple sclerosis (MS) Impact (PAMSI), and MS-specific symptom scales for Bladder and Bowel Control, Cognition, and Sexual Satisfaction. Standard summary statistics described the population while Pearson and Spearman correlations evaluated the baseline association between HRQoL and clinical measures. Cross-sectional estimates of MID in HRQoL scores were derived using several clinical anchors, the PAMSI, and two tests: Tukey multiple comparisons and adjacent mean difference. Patients (n = 249) had a mean age of 39.0 (Standard deviation, SD = 10.5), 70% were female, 63% resided in Europe, and 96% were Caucasian. Baseline median Expanded Disability Severity Scale (EDSS) was 2.5 (range = 0.0-6.5); median disease duration was 1.9 years (range = 0.1-33.6). The worst baseline mean (normalized) SF-36 scores were for General Health (39.9), Role Physical (40.4), Physical Functioning (41.0), and Vitality (42.7). The worst MS symptom mean scores were for Cognition (6.3) and FSS (4.4). Fatigue scores indicated substantial burden and were consistent with SF-36 Vitality results. Baseline HRQoL scores (SF-36, FSS, MS symptom scales) correlated most with EDSS, Multiple Sclerosis Functional Composite (MSFC), age and disease duration. Lesion count and pre-baseline relapse rate had no meaningful association with HRQoL or other clinical measures. The MID for several HRQoL measures are proposed for confirmation in longitudinal patient datasets. Clinical and HRQoL assessments documented health impairments in physical functioning, fatigue, and cognition among these RRMS patients with relatively short disease duration. HRQoL data varied with clinical measures and contributed new information regarding disease burden. The association between clinical and HRQoL measures was limited to cross-sectional analysis and requires confirmation in longitudinal datasets. These findings reflect an ambulatory, early-stage RRMS population that was mostly European in location or descent. The PAMSI also requires further validation as a measure of patient health status.

Levamisole-Adulterated Cocaine-Induced Skin Lesions: A Case Report and Literature Review.

PubMed

Khanapara, Dipen B; Panwala, Amruta; Dedania, Bhavtosh; Naut, Edgar R

2017-02-01

Levamisole is used as an agent to increase the total weight of street cocaine. We report the case of a 28-year-old female who presented with multiple painful, ulcerating lesions. She tested positive for cocaine and levamisole. Her skin lesions improved with abstinence from cocaine. Patients with levamisole-induced toxicity most often present with skin manifestations or joint pain. Leukopenia, neutropenia, and agranulocytosis are common lab abnormalities seen in these patients. Complete resolution of the skin lesions are observed approximatelythree weeks after abstinence. Patients known to use street drugs, who present with unexplained skin rash, neutropenia, and multiple immunological abnormalities, should be tested for both cocaine and levamisole. Urine toxicology screen is positive for cocaine approximately 72 hours after ingestion. Levamisole requires specialized testing that is not readily available commercially andis positive forless than 48 hours after exposure.

Computed tomography of deep fat masses in multiple symmetrical lipomatosis

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

Enzi, G.; Biondetti, P.R.; Fiore, D.

1982-07-01

Deep fat masses were evaluated by computed tomography (CT) in 15 patients with multiple symmetrical lipomatosis. In 4 patients, peritracheal accumulations of fat were observed. In 3 of them, tracheal compression by lipomatous tissue was demonstrated: 2 were asymptomatic and the third severe respiratory insufficiency secondary to blockage of the air was by the vocal cords as the result of recurrent nerve palsy. In 6 patients, lipomatous tissue occupied the potential space between the spina scapulae and the trapezius, supraspinatus, and infraspinatus muscles. In 2, calcification of lipomatous masses was observed. There was no relationship between extension of subcutaneous fatmore » and accumulation at deep sites. CT facilitates early detection of peritracheal lipomatous tissue and is helpful in follow-up when deep fat accumulation is responsible for space-occupying lesions requiring surgery.« less

Treatment of Adults with Idiopathic Recurrent Pericarditis: Novel Use of Immunotherapy.

PubMed

Schwier, Nicholas C; Hale, Genevieve M; Davies, Marie L

2017-03-01

Idiopathic recurrent pericarditis (IRP) can be challenging to treat. Even after guideline-directed first-line treatment consisting of aspirin (ASA) or a nonsteroidal antiinflammatory drug (NSAID) in combination with colchicine therapy, recurrences still occur in greater than 20% of patients. Many patients then require treatment with long-term corticosteroids, which is not a favorable option due to their short- and long-term adverse effects. Because it is theorized that the pathophysiology of IRP may possess autoimmune sequelae, the use of immunotherapy for the treatment of IRP has emerged. In this review, we describe the literature associated with immunotherapy used to treat IRP in an adult population as well as provide an overview of the safety and monitoring parameters for each agent. The most common immunotherapies used after patients have had multiple recurrences of IRP are anakinra, intravenous immunoglobulin (IVIG), and azathioprine. In most cases, these immunotherapies are adjunctive therapy, with the goal of tapering and discontinuing immunosuppressive corticosteroids. After reviewing the data, anakinra resulted in more patients discontinuing corticosteroids and prevented further recurrences of pericarditis. IVIG resulted in symptom resolution and no further recurrences in most of the patients. Azathioprine was associated with more than half of patients becoming recurrence free; however, many patients required a restart of corticosteroids due to recurrence. Clinicians should be aware of the adverse effects of immunotherapy, ranging from mild gastrointestinal events to risk of infection and serious blood dyscrasias that may require diligent monitoring. The use of immunotherapy for the treatment of adults with IRP should be restricted to patients who have multiple recurrences. Ideally, immunotherapy would be adjunctive to first-line combination therapy with ASA/NSAID plus colchicine, with the goal of tapering and discontinuing immunosuppressive corticosteroids. Furthermore, clinicians should consider cost, drug-drug and drug-disease interactions, and safety, as well as the quality of the retrospective evidence before considering any immunotherapy. © 2017 Pharmacotherapy Publications, Inc.

Use of hyperbaric oxygen therapy and PEGylated carboxyhemoglobin bovine in a Jehovah's Witness with life-threatening anemia following postpartum hemorrhage.

PubMed

Thenuwara, K; Thomas, J; Ibsen, M; Ituk, U; Choi, K; Nickel, E; Goodheart, M J

2017-02-01

We present a case of a Jehovah's Witness patient who refused blood products, with the exception of albumin and clotting factors, and underwent cesarean section under spinal anesthesia complicated by postpartum hemorrhage. She was fluid resuscitated and treated with multiple uterotonics and internal iliac artery embolization. Because of agitation she required emergency tracheal intubation. Her hemoglobin concentration dropped from a preoperative value of 12mg/dL to 3mg/dL on postoperative day one. She was acidotic, requiring vasopressors for hemodynamic stability and remained ventilated and sedated. She was treated with daily erythropoietin, iron therapy and cyanocobalamin. Because of ongoing hemorrhage, continued acidemia and vasopressor requirements she was co-treated with PEGylated carboxyhemoglobin bovine and hyperbaric oxygen therapy to reverse her oxygen debt. On postoperative day eight her hemoglobin concentration was 7mg/dL, she was hemodynamically stable and vasopressors were discontinued. She was extubated and discharged from the intensive care unit on postoperative day eight. This report highlights the multiple modalities used in treating a severely anemic patient who refused blood, the use of an investigational new drug, the process of obtaining this drug via the United States Food and Drug Administration emergency expanded access regulation for single patient clinical treatment, and ethical dilemmas faced during treatment. Copyright © 2016 Elsevier Ltd. All rights reserved.

Barriers to Implementation of Recommendations for Transport of Children in Ground Ambulances.

PubMed

Woods, Rashida H; Shah, Manish; Doughty, Cara; Gilchrest, Anthony

2017-10-16

The National Highway Traffic Safety Administration (NHTSA) released draft recommendations in 2010 on the safe transport of children in ground ambulances. The purpose of this study was to assess awareness of these guidelines among emergency medical service (EMS) agencies and to identify implementation barriers. We conducted a cross-sectional, anonymous online survey of 911-responding, ground transport EMS agencies in Texas. Demographics, modes of transport based on case scenarios, and barriers to implementation were assessed. Of 62 eligible EMS agencies that took the survey, 35.7% were aware of the NHTSA guidelines, 62.5% agreed they would improve safety, and 41.1% planned to implement them. Seventy-five percent of EMS agencies used the ideal or acceptable alternative to transport children requiring continuous monitoring, and 69.5% chose ideal or acceptable alternatives for children requiring spinal immobilization. The ideal or acceptable alternative was not chosen for children who were not injured or ill (93.2%), ill or injured but not requiring continuous monitoring (53.3%), and situations when multiple patients required transport (57.6%). The main requirements for implementation were provider education, ambulance interior modifications, new guidelines in the EMS agency, and purchase of new equipment. Few EMS agencies are aware of the NHTSA guidelines on safe transport of children in ground ambulances. Although most agencies appropriately transport children who require monitoring, interventions, or spinal immobilization, they use inappropriate means to transport children in situations with multiple patients, lack of injury or illness, or lack of need for monitoring.

A Survey of Restraint Methods for the Safe Transport of Children in Ground Ambulances.

PubMed

Woods, Rashida H; Shah, Manish; Doughty, Cara; Gilchrest, Anthony

2018-03-01

The National Highway Traffic Safety Administration (NHTSA) released draft recommendations in 2010 on the safe transport of children in ground ambulances. The purpose of this study was to assess awareness of these guidelines among emergency medical service (EMS) agencies and to identify implementation barriers. We conducted a cross-sectional, anonymous online survey of 911-responding, ground transport EMS agencies in Texas. Demographics, modes of transport based on case scenarios, and barriers to implementation were assessed. Of 62 eligible EMS agencies that took the survey, 35.7% were aware of the NHTSA guidelines, 62.5% agreed they would improve safety, and 41.1% planned to implement them. Seventy-five percent of EMS agencies used the ideal or acceptable alternative to transport children requiring continuous monitoring, and 69.5% chose ideal or acceptable alternatives for children requiring spinal immobilization. The ideal or acceptable alternative was not chosen for children who were not injured or ill (93.2%), ill or injured but not requiring continuous monitoring (53.3%), and situations when multiple patients required transport (57.6%). The main requirements for implementation were provider education, ambulance interior modifications, new guidelines in the EMS agency, and purchase of new equipment. Few EMS agencies are aware of the NHTSA guidelines on safe transport of children in ground ambulances. Although most agencies appropriately transport children who require monitoring, interventions, or spinal immobilization, they use inappropriate means to transport children in situations with multiple patients, lack of injury or illness, or lack of need for monitoring.

Cost-Effectiveness of POC Coagulation Testing Using Multiple Electrode Aggregometry.

PubMed

Straub, Niels; Bauer, Ekaterina; Agarwal, Seema; Meybohm, Patrick; Zacharowski, Kai; Hanke, Alexander A; Weber, Christian F

2016-01-01

The economic effects of Point-of-Care (POC) coagulation testing including Multiple Electrode Aggregometry (MEA) with the Multiplate device have not been examined. A health economic model with associated clinical endpoints was developed to calculate the effectiveness and estimated costs of coagulation analyses based on standard laboratory testing (SLT) or POC testing offering the possibility to assess platelet dysfunction using aggregometric measures. Cost estimates included pre- and perioperative costs of hemotherapy, intra- and post-operative coagulation testing costs, and hospitalization costs, including the costs of transfusion-related complications. Our model calculation using a simulated true-to-life cohort of 10,000 cardiac surgery patients assigned to each testing alternative demonstrated that there were 950 fewer patients in the POC branch who required any transfusion of red blood cells. The subsequent numbers of massive transfusions and patients with transfusion-related complications were reduced with the POC testing by 284 and 126, respectively. The average expected total cost in the POC branch was 288 Euro lower for every treated patient than that in the SLT branch. Incorporating aggregometric analyses using MEA into hemotherapy algorithms improved medical outcomes in cardiac surgery patients in the presented health economic model. There was an overall better economic outcome associated with POC testing compared with SLT testing despite the higher costs of testing.

Duplicative medications in patients who visit multiple medical institutions among the insured of a corporate health insurance society in Japan.

PubMed

Kinoshita, Hiroki; Kobayashi, Yasuki; Fukuda, Takashi

2008-01-01

The objective of this paper is to describe the frequency of duplicative medication use and to estimate the drug cost associated with duplicative medications in patients who visit multiple medical institutions in Japan. The subjects of this study were insurants of a corporate health insurance society. We examined claims of insurants who received prescriptions from multiple medical institutions in April 2002. We examined characteristics of insurants who received duplicative medications and calculated the cost of duplicated drugs. 8.8% received drugs with the same mechanism of action for overlapping administration periods. In terms of comparison among three age groups, 0-19 years old, 20-69 years old, and 70 years old or older, the percentage was higher in 0-19-year-old patients than in the other age groups. The cost of duplicated drugs was found to be 0.7% or 0.5% of the total drug cost, when calculated with higher-priced drugs and lower-priced drugs, respectively. This study suggests that pediatric and teenage patients as well as elderly patients require prudent management of medication to avoid duplicative medications and that at least an estimated 5.2-7.2 billion yen may be saved if duplicative medications can be completely eliminated nationwide.

Difficulties with diagnosis and consequential poor outcome due to stigma of acquired immunodeficiency syndrome - a case report.

PubMed

Vuletic, Vladimira; Nevajda, Branimir; Spero, Martina; Chudy, Darko

2013-09-01

Low incidence of human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) has been detected in Croatia so far. Toxoplasmic encephalitis (TE) is the most common opportunistic cerebral infection in AIDS patients and is highly responsive to antiparasitic chemotherapy, if treated at an early stage. We present the case of the brain biopsy confirmed as TE on a 36-year-old female patient who at admission presented with unconsciousness and a right hemiplegia. A MSCT was performed and two hypodense lesions were diagnosed. The patient's family initially denied the presence or history of any medical problem or infection. An MRI showed multiple ring-enhanced mass lesions. An infectologist required a brain biopsy to exclude cerebral lymphoma and multiple metastases. Pathohistological analysis suggested TE. Meanwhile, patient's blood samples were found to be HIV positive. The patient was transferred to University Hospital for Infectious Diseases in Zagreb, where she died 2 days following admission. The patient's family terminally confessed that the patient had been HIV positive for 10 years and had refused any treatment. Family's denial of infection as well as 'hiding information' concerning patient's health from physicians involved in her treatment caused a delay in proper on-time patient treatment. We would like to emphasize that TE must be considered as a differential diagnosis in patients presenting with multiple cerebral lesions, including patients without acknowledged past history of HIV infection. A stigma towards HIV infection and ignorance of the disease still exist and therefore hinders proper treatment.

Effective quality improvement of thromboprophylaxis in acute medicine.

PubMed

Clark, Barbara M; d'Ancona, Grainne; Kinirons, Mark; Hunt, Beverley J; Hopper, Adrian

2011-05-01

The Health Select Committee Report on the prevalence of venous thromboembolism (VTE) in 2005 suggested that poor awareness of the risks of VTE contributed significantly to mortality and morbidity in hospitalised patients. It recommended that all hospitalised patients should undergo a VTE risk assessment. In 2006, an audit in medical patients at Guy's and St Thomas' NHS Foundation Trust (GSTFT) revealed a lack of documentation of VTE risk assessment and poor use of thromboprophylaxis in 'at risk' patients. In 2007, the GSTFT 'Venous Thromboembolism in Adult Medical Inpatients' guideline was approved. The aim was to achieve a thromboprophylaxis culture within Acute Medicine and, in doing so, achieve a high adherence rate. The guideline was launched and implemented using a multidisciplinary and multiple intervention approach involving education and feedback, IT intervention, verbal and written reminders, regular audit and process redesign. An audit in 2008 showed that the rate of adherence had increased from 56% preguideline to 96%. However, a repeat audit in 2009 suggested that even though the majority of patients were receiving appropriate thromboprophylaxis, risk assessment documentation was poor. This resulted in treatment being provided to some low-risk patients when it was not required. In conclusion, the most effective means of achieving VTE guideline adherence is to establish a thromboprophylaxis culture. This can be accomplished through a multiple intervention and continuous feedback approach. However, it is essential to ensure that a comprehensive VTE risk assessment is carried out to ensure that those not requiring treatment do not receive it unnecessarily.

Information analytics for healthcare service discovery.

PubMed

Sun, Lily; Yamin, Mohammad; Mushi, Cleopa; Liu, Kecheng; Alsaigh, Mohammed; Chen, Fabian

2014-01-01

The concept of being 'patient-centric' is a challenge to many existing healthcare service provision practices. This paper focuses on the issue of referrals, where multiple stakeholders, such as General Practitioners (GPs) and patients, are encouraged to make a consensual decision based on patients' needs. In this paper, we present an ontology-enabled healthcare service provision, which facilitates both patients and GPs in jointly deciding upon the referral decision. In the healthcare service provision model, we define three types of profiles which represent different stakeholders' requirements. This model also comprises a set of healthcare service discovery processes: articulating a service need, matching the need with the healthcare service offerings, and deciding on a best-fit service for acceptance. As a result, the healthcare service provision can carry out coherent analysis using personalised information and iterative processes that deal with requirements which change over time.

Improving Clinical Trial Efficiency: Thinking outside the Box.

PubMed

Mandrekar, Sumithra J; Dahlberg, Suzanne E; Simon, Richard

2015-01-01

Clinical trial design strategies have evolved over the past few years as a means to accelerate the drug development process so that the right therapies can be delivered to the right patients. Basket, umbrella, and adaptive enrichment strategies represent a class of novel designs for testing targeted therapeutics in oncology. Umbrella trials include a central infrastructure for screening and identification of patients, and focus on a single tumor type or histology with multiple subtrials, each testing a targeted therapy within a molecularly defined subset. Basket trial designs offer the possibility to include multiple molecularly defined subpopulations, often across histology or tumor types, but included in one cohesive design to evaluate the targeted therapy in question. Adaptive enrichment designs offer the potential to enrich for patients with a particular molecular feature that is predictive of benefit for the test treatment based on accumulating evidence from the trial. This review will aim to discuss the fundamentals of these design strategies, the underlying statistical framework, the logistical barriers of implementation, and, ultimately, the interpretation of the trial results. New statistical approaches, extensive multidisciplinary collaboration, and state of the art data capture technologies are needed to implement these strategies in practice. Logistical challenges to implementation arising from centralized assay testing, requirement of multiple specimens, multidisciplinary collaboration, and infrastructure requirements will also be discussed. This review will present these concepts in the context of the National Cancer Institute's precision medicine initiative trials: MATCH, ALCHEMIST, Lung MAP, as well as other trials such as FOCUS4.

Hematopoietic Stem Cell Transplantation From Unrelated Donors in 2 Cases of Interleukin-10 Receptor Deficiency: Is Surgery Not a Requirement?

PubMed

Kocacik Uygun, Dilara F; Uygun, Vedat; Daloğlu, Hayriye; Öztürkmen, Seda; Karasu, Gülsün; Reisli, İsmail; Sayar, Ersin; Yüksekkaya, Hasan A; Glocker, Erik-Oliver; Boztuğ, Kaan; Yeşilipek, Akif

2018-04-20

Mutations in interleukin-10 and its receptors cause infantile inflammatory bowel disease (IBD), a hyperinflammatory disorder characterized by severe, treatment-refractory colitis, multiple abscesses, and enterocutaneous fistulas. Patients with infantile IBD often require several surgical interventions, including complete colectomy, and hematopoietic stem cell transplantation is currently the only known medical therapy. Traditionally, operative management has been preferred before stem cell transplantation because of the latter's increased susceptibility to procedural complications; however, surgical intervention could be delayed, and possibly reconsidered, because our 2 patients with infantile IBD demonstrated a rapid response to treatment via engraftment.

The development of a disease oriented eFolder for multiple sclerosis decision support

NASA Astrophysics Data System (ADS)

Ma, Kevin; Jacobs, Colin; Fernandez, James; Amezcua, Lilyana; Liu, Brent

2010-03-01

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. The chronic nature of MS necessitates multiple MRI studies to track disease progression. Currently, MRI assessment of multiple sclerosis requires manual lesion measurement and yields an estimate of lesion volume and change that is highly variable and user-dependent. In the setting of a longitudinal study, disease trends and changes become difficult to extrapolate from the lesions. In addition, it is difficult to establish a correlation between these imaged lesions and clinical factors such as treatment course. To address these clinical needs, an MS specific e-Folder for decision support in the evaluation and assessment of MS has been developed. An e-Folder is a disease-centric electronic medical record in contrast to a patient-centric electronic health record. Along with an MS lesion computer aided detection (CAD) package for lesion load, location, and volume, clinical parameters such as patient demographics, disease history, clinical course, and treatment history are incorporated to make the e-Folder comprehensive. With the integration of MRI studies together with related clinical data and informatics tools designed for monitoring multiple sclerosis, it provides a platform to improve the detection of treatment response in patients with MS. The design and deployment of MS e-Folder aims to standardize MS lesion data and disease progression to aid in decision making and MS-related research.

Minimally disruptive medicine is needed for patients with multimorbidity: time to develop computerised medical record systems to meet this requirement.

PubMed

Schattner, Peter; Barker, Fiona; de Lusignan, Simon

2015-02-19

Minimally disruptive medicine (MDM) is proposed as a method for more appropriately managing people with multiple chronic disease. Much clinical management is currently single disease focussed, with people with multimorbidity being managed according to multiple single disease guidelines. Current initiatives to improve care include education about individual conditions and creating an environment where multiple guidelines might be simultaneously supported. The patient-centred medical home (PCMH) is an example of the latter. However, educational programmes and PCMH may increase the burden on patients. The cumulative workload for patients in managing the impact of multiple disease-specific guidelines is only relatively recently recognised. There is an intellectual vacuum as to how best to manage multimorbidity and how informatics might support implementing MDM. There is currently no alternative to multiple single-condition- specific guidelines and a lack of certainty, should the treatment burden need to be reduced, as to which guideline might be 'dropped'. The best information about multimorbidity is recorded in primary care computerised medical record (CMR) systems and in an increasing number of integrated care organisations. CMR systems have the potential to flag individuals who might be in greatest need. However, CMR systems may also provide insights into whether there are ameliorating factors that might make it easier for them to be resilient to the burden of care. Data from such CMR systems might be used to develop the evidence base about how to better manage multimorbidity. There is potential for these information systems to help reduce the management burden on patients and clinicians. However, substantial investment in research-driven CMR development is needed if we are to achieve this.

Impact of multiple-dose versus single-dose inhaler devices on COPD patients’ persistence with long-acting β2-agonists: a dispensing database analysis

PubMed Central

van Boven, Job FM; van Raaij, Joost J; van der Galiën, Ruben; Postma, Maarten J; van der Molen, Thys; Dekhuijzen, PN Richard; Vegter, Stefan

2014-01-01

Background: With a growing availability of different devices and types of medication, additional evidence is required to assist clinicians in prescribing the optimal medication in relation to chronic obstructive pulmonary disease (COPD) patients’ persistence with long-acting β2-agonists (LABAs). Aims: To assess the impact of the type of inhaler device (multiple-dose versus single-dose inhalers) on 1-year persistence and switching patterns with LABAs. Methods: A retrospective observational cohort study was performed comparing a cohort of patients initiating multiple-dose inhalers and a cohort initiating single-dose inhalers. The study population consisted of long-acting bronchodilator naive COPD patients, initiating inhalation therapy with mono-LABAs (formoterol, indacaterol or salmeterol). Analyses were performed using pharmacy dispensing data from 1994 to 2012, obtained from the IADB.nl database. Study outcomes were 1-year persistence and switching patterns. Results were adjusted for initial prescriber, initial medication, dosing regimen and relevant comorbidities. Results: In all, 575 patients initiating LABAs were included in the final study cohort. Among them, 475 (83%) initiated a multiple-dose inhaler and 100 (17%) a single-dose inhaler. Further, 269 (47%) initiated formoterol, 9 (2%) indacaterol and 297 (52%) salmeterol. There was no significant difference in persistence between users of multiple-dose or single-dose inhalers (hazard ratio: 0.98, 95% confidence interval: 0.76–1.26, P=0.99). Over 80% re-started or switched medication. Conclusions: There seems no impact of inhaler device (multiple-dose versus single-dose inhalers) on COPD patients’ persistence with LABAs. Over 80% of patients who initially seemed to discontinue LABAs, re-started their initial medication or switched inhalers or medication within 1 year. PMID:25274453

Use of multiple methods to determine factors affecting quality of care of patients with diabetes.

PubMed

Khunti, K

1999-10-01

The process of care of patients with diabetes is complex; however, GPs are playing a greater role in its management. Despite the research evidence, the quality of care of patients with diabetes is variable. In order to improve care, information is required on the obstacles faced by practices in improving care. Qualitative and quantitative methods can be used for formation of hypotheses and the development of survey procedures. However, to date few examples exist in general practice research on the use of multiple methods using both quantitative and qualitative techniques for hypothesis generation. We aimed to determine information on all factors that may be associated with delivery of care to patients with diabetes. Factors for consideration on delivery of diabetes care were generated by multiple qualitative methods including brainstorming with health professionals and patients, a focus group and interviews with key informants which included GPs and practice nurses. Audit data showing variations in care of patients with diabetes were used to stimulate the brainstorming session. A systematic literature search focusing on quality of care of patients with diabetes in primary care was also conducted. Fifty-four potential factors were identified by multiple methods. Twenty (37.0%) were practice-related factors, 14 (25.9%) were patient-related factors and 20 (37.0%) were organizational factors. A combination of brainstorming and the literature review identified 51 (94.4%) factors. Patients did not identify factors in addition to those identified by other methods. The complexity of delivery of care to patients with diabetes is reflected in the large number of potential factors identified in this study. This study shows the feasibility of using multiple methods for hypothesis generation. Each evaluation method provided unique data which could not otherwise be easily obtained. This study highlights a way of combining various traditional methods in an attempt to overcome the deficiencies and bias that may occur when using a single method. Similar methods can also be used to generate hypotheses for other exploratory research. An important responsibility of health authorities and primary care groups will be to assess the health needs of their local populations. Multiple methods could also be used to identify and commission services to meet these needs.

Management of high-risk Myeloma: an evidence-based review of treatment strategies.

PubMed

Lehners, Nicola; Hayden, Patrick J; Goldschmidt, Hartmut; Raab, Marc-Steffen

2016-08-01

Despite the progress made in the treatment of patients with multiple myeloma over recent decades, a significant cohort with high-risk disease as defined by specific clinical and genetic criteria continue to respond poorly to standard treatment. These patients represent a particular challenge to the treating physician and require early identification as well as personalized treatment strategies. In this review, we discuss the prognostic impact of adverse clinical, radiological and genetic factors, evaluate available scoring systems and highlight key aspects of the therapeutic management of high-risk myeloma. MEDLINE and recent scientific meetings' databases were searched for the keywords 'high-risk' and 'multiple myeloma' and relevant studies relating to both diagnostic and therapeutic approaches were identified. Expert commentary: A case is made for intensive induction using combinations of novel agents, early high-dose therapy supported by autologous stem cell transplantation and the widespread use of maintenance therapies. Novel therapeutic options, especially in the field of immunotherapy, are currently explored in clinical trials and have the potential to further improve outcomes for patients with high-risk multiple myeloma.

Spine Tango registry data collection in a conservative spinal service: a feasibility study.

PubMed

Morris, Samuel; Booth, James; Hegarty, James

2016-09-01

The study reports the feasibility of implementing routine registry data collection and sustaining a high rate of data capture within a secondary care spinal osteopathy service, using the Spine Tango Conservative registry data collection tool (STC) with multiple patient-reported outcome measures (PROMs): Oswestry Disability Index (ODI), Neck Disability Index (NDI), COMI Low Back Conservative, COMI Neck Conservative and EQ-5D-3L. Data collection rates were studied during the implementation of a registry data collection project from October 2011 to June 2015. The primary outcome was completion rate of PROMs and the STC, measured as a percentage of total expected data collection. Descriptive statistics were used to illustrate completion rates by year, age group, sex, region of spinal complaint, baseline ODI or NDI score and number of PROMs required to complete the data set. Data were collected on 349 patients. Overall data collection rates increased from 54.8 % in January-June 2012 to 90.4 % in January-June 2015. The percentage of fully completed data sets was lower in the patient group required to complete 4-5 PROMs at each data collection point (15.4 %) than it was in the patient group required to complete 2-3 PROMs (37.4 %). Other comparisons showed no clear patterns. Our analysis shows that a high rate of data capture can be sustained in a clinical setting using the STC and multiple PROMs. However, increasing the burden of data collection on patients and practitioners was associated with increased data loss. We describe measures taken to reduce data loss in the future and to increase the efficiency of the data collection project.

Continuous subcutaneous insulin infusion in diabetes: patient populations, safety, efficacy, and pharmacoeconomics

PubMed Central

Battelino, Tadej; Danne, Thomas; Hovorka, Roman; Jarosz‐Chobot, Przemyslawa; Renard, Eric

2015-01-01

Summary The level of glycaemic control necessary to achieve optimal short‐term and long‐term outcomes in subjects with type 1 diabetes mellitus (T1DM) typically requires intensified insulin therapy using multiple daily injections or continuous subcutaneous insulin infusion. For continuous subcutaneous insulin infusion, the insulins of choice are the rapid‐acting insulin analogues, insulin aspart, insulin lispro and insulin glulisine. The advantages of continuous subcutaneous insulin infusion over multiple daily injections in adult and paediatric populations with T1DM include superior glycaemic control, lower insulin requirements and better health‐related quality of life/patient satisfaction. An association between continuous subcutaneous insulin infusion and reduced hypoglycaemic risk is more consistent in children/adolescents than in adults. The use of continuous subcutaneous insulin infusion is widely recommended in both adult and paediatric T1DM populations but is limited in pregnant patients and those with type 2 diabetes mellitus. All available rapid‐acting insulin analogues are approved for use in adult, paediatric and pregnant populations. However, minimum patient age varies (insulin lispro: no minimum; insulin aspart: ≥2 years; insulin glulisine: ≥6 years) and experience in pregnancy ranges from extensive (insulin aspart, insulin lispro) to limited (insulin glulisine). Although more expensive than multiple daily injections, continuous subcutaneous insulin infusion is cost‐effective in selected patient groups. This comprehensive review focuses on the European situation and summarises evidence for the efficacy and safety of continuous subcutaneous insulin infusion, particularly when used with rapid‐acting insulin analogues, in adult, paediatric and pregnant populations. The review also discusses relevant European guidelines; reviews issues that surround use of this technology; summarises the effects of continuous subcutaneous insulin infusion on patients' health‐related quality of life; reviews relevant pharmacoeconomic data; and discusses recent advances in pump technology, including the development of closed‐loop ‘artificial pancreas’ systems. © 2015 The Authors. Diabetes/Metabolism Research and Reviews Published by John Wiley & Sons Ltd. PMID:25865292

Cryotherapy for conjunctival primary acquired melanosis and malignant melanoma. Experience with 62 cases.

PubMed

Jakobiec, F A; Rini, F J; Fraunfelder, F T; Brownstein, S

1988-08-01

Sixty-two patients were treated by some combination of cryotherapy and surgery with an average follow-up of 3.3 years for one of the following diseases: focal or diffuse flat conjunctival primary acquired melanosis (PAM) with atypia but without a nodule of melanoma (10 cases); unifocal malignant melanoma with or without focal or diffuse PAM (30 cases); and multinodular/multicentric melanoma with and without PAM (22 cases). Of the ten patients who had PAM with atypia, invasive nodules of malignant melanoma did not develop. A second treatment was required to control the disease in four of the ten patients with extensive or diffuse lesions, and one has mild persistent disease. Of the 30 patients with unifocal nodules of malignant melanoma, 27 remained free of recurrence after one treatment, and 2 are asymptomatic after two treatments. One patient with a thick nodule at presentation required a parotidectomy and radical neck dissection for cervical metastases after recurrence in the conjunctival sac. In the group of 22 patients with multinodular malignant melanoma, only two did not have recurrent disease after one treatment. Of those who received multiple therapies, seven remained free of recurrence for at least 2 years after the last treatment; regional or distant metastases developed in nine; four required exenteration; and eight died. Conjunctival adjunctive cryotherapy avoids exenteration in extensive lesions of pure PAM and in unifocal melanoma, but even after multiple therapies, multinodular malignant melanoma had a 45% rate of metastasis. Metastasis was related to the presence of PAM sine pigmento in four patients (microscopically but not clinically detectable PAM); to the location of the nodules (9 of 10 patients who experienced metastases had forniceal, palpebral, and/or caruncular nodules); to the thickness or depth of invasion of the nodules (greater than 2 mm); and to the development of intralymphatic spread ("in-transit" local metastasis) within the conjunctival sac in six patients. No metastases were encountered among patients with strictly limbal nodules and among five patients with invasive nodules composed of spindle cells in part or in toto. Therapeutic success in this spectrum of melanocytic proliferations is closely correlated with the clinical extent of the disease when initiating definitive therapy.

Personalizing guidelines for diabetes management: twilight or dawn of the expert?

PubMed

Paschou, Stavroula A; Leslie, Richard David

2013-07-10

This opinion article on the management of type 2 diabetes considers the old and new format of guidelines and critical changes in the character of such guidelines. We highlight limitations of the guidelines and make recommendations for how treatment can be more personalised. Published guidelines for the management of adult-onset non-insulin requiring diabetes have adopted a formulaic approach to patient management that can be overseen centrally and delivered by personnel with limited training. Recently, guidelines have taken a patient-centered, multiple risk-factor approach. Importantly, local funding issues are considered, but drive the final action and not the decision-making process. The nature of the disease can be determined by laboratory tests, including screening for diabetes-associated autoantibodies. The strategy remains step-up, with intensification of drug or insulin dose. As with past guidelines, there is an assumption that in each patient with type 2 diabetes, metformin is used initially, but targets and therapies then veer in different directions to create a matrix of options based on the features and responses of each individual. Factors to consider include: (A)ge, (B)ody weight, (C)omplications and co-morbidities, Diabetes (D)uration and (E)xpense, but also patient preference and patient response. Guidelines for the management of type 2 diabetes have important limitations and a patient-centered, multiple target, multiple therapy approach is proposed.

Impact of emotional competence on supportive care needs, anxiety and depression symptoms of cancer patients: a multiple mediation model.

PubMed

Baudry, A-S; Lelorain, S; Mahieuxe, M; Christophe, V

2018-01-01

The aim of this study was to test the effect of intrapersonal and interpersonal emotional competence on cancer patients' supportive care needs, as mediated by anxiety and depression symptoms. Cross-sectional design: 137 cancer patients (42% breast or ovarian cancer, 58% gastrointestinal cancer) in 4 French hospitals completed the Profile of Emotional Competence (PEC), the Hospital Anxiety and Depression Scale (HADS), and the Supportive Care Needs Survey Short Form (SCNS-SF). Bootstrap methods with PROCESS Macro were used to test multiple mediation models. Emotional competence presented a direct or indirect beneficial effect on the satisfaction of supportive care needs, anxiety and depression symptoms. As expected, anxiety and depression symptoms had also strong positive correlations with unmet needs. All multiple mediation models were significant, except for physical needs: intrapersonal and interpersonal emotional competence impacted anxiety and depression symptoms, which in turn impacted psychological, sexual, care/support, and information needs. These innovative results show the important effect of patients' emotional competence on their supportive care need satisfaction, as mediated by anxiety and depression. Consequently, patients with high emotional competence may require less psychosocial input from medical clinicians. Thus, emotional competence may be integrated into health models and psychosocial interventions to improve patient adjustment. Further investigation is, however, needed to know which are the most beneficial specific emotional competences and at what point of the cancer pathway.

Just-in-time rescue plerixafor in combination with chemotherapy and granulocyte-colony stimulating factor for peripheral blood progenitor cell mobilization.

PubMed

Smith, Veronica R; Popat, Uday; Ciurea, Stefan; Nieto, Yago; Anderlini, Paolo; Rondon, Gabriela; Alousi, Amin; Qazilbash, Muzaffar; Kebriaei, Partow; Khouri, Issa; de Lima, Marcos; Champlin, Richard; Hosing, Chitra

2013-09-01

Plerixafor, a recently approved peripheral blood progenitor cell mobilizing agent, is often added to granulocyte-colony stimulating factor (G-CSF) to mobilize peripheral blood progenitor cells in patients with lymphoma or myeloma who cannot mobilize enough CD34+ cells with G-CSF alone to undergo autologous stem cell transplantation. However, data are lacking regarding the feasibility and efficacy of just-in-time plerixafor in combination with chemotherapy and G-CSF. We reviewed the peripheral blood stem cell collection data of 38 consecutive patients with lymphoma (Hodgkin's and non-Hodgkin's) and multiple myeloma who underwent chemomobilization and high-dose G-CSF and just-in-time plerixafor to evaluate the efficacy of this treatment combination. All patients with multiple myeloma and all but one patient with lymphoma collected the minimum required number of CD34+ cells to proceed with autologous stem cell transplantation (>2 × 10(6) /kg of body weight). The median CD34+ cell dose collected in patients with non-Hodgkin lymphoma was 4.93 × 10(6) /kg of body weight. The median CD34+ cell dose collected for patients with multiple myeloma was 8.81 × 10(6) /kg of body weight. Plerixafor was well tolerated; no grade 2 or higher non-hematologic toxic effects were observed. Copyright © 2013 Wiley Periodicals, Inc.

Osteoblastic and fibroblastic multicentric osteosarcoma

PubMed Central

Cabello, Raúl Romero; Sánchez, Carlos J.; Padilla, Marco A. Duran; De la Garza Navarro, José M.; Feregrino, Raul Romero; Vázquez, Avissai Alcántara; González, Mercedes Hernández; Feregrino, Rodrigo Romero

2011-01-01

Bone sarcomas are uncommon tumours, of which osteosarcoma is the least rare, as well as the third most common malignant tumour in childhood, appearing usually between the 10 and 20 years of age. The case the authors present in this work is of a patient suffering from a long-standing condition encompassing skin and soft tissue lesions. After multiple medical treatments, the patient was diagnosed with squamous osteosarcoma, which required aggressive surgical management and chemotherapy. PMID:22674697

Patient Safety: The Role of Human Factors and Systems Engineering

PubMed Central

Carayon, Pascale; Wood, Kenneth E.

2011-01-01

Patient safety is a global challenge that requires knowledge and skills in multiple areas, including human factors and systems engineering. In this chapter, numerous conceptual approaches and methods for analyzing, preventing and mitigating medical errors are described. Given the complexity of healthcare work systems and processes, we emphasize the need for increasing partnerships between the health sciences and human factors and systems engineering to improve patient safety. Those partnerships will be able to develop and implement the system redesigns that are necessary to improve healthcare work systems and processes for patient safety. PMID:20543237

[Cost analysis of emergency room patients in the German diagnosis-related groups system. A practice relevant depiction subject to clinical parameters].

PubMed

Garving, C; Santosa, D; Bley, C; Pape, H-C

2014-08-01

Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population. The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS < 16 and group II ISS ≥ 16. A total of 442 patients with an average age of 40.5 ± 9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15 ± 6.3 was -2,752 per patient. Patients in group I (n = 296, ISS 6.3) showed a value of -1,163 with an average length of stay of 8 ± 4.6 days. In group II (n = 146, ISS 23.6) the average amount of coverage was -5,973 during an average hospital stay of 23 ± 8.7 days. Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.

Compounding pharmacy conundrum: "we cannot live without them but we cannot live with them" according to the present paradigm.

PubMed

Guharoy, Roy; Noviasky, John; Haydar, Ziad; Fakih, Mohamad G; Hartman, Christian

2013-04-01

Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. Multiple outbreaks have been linked to compounding pharmacies, including a recent outbreak of fungal meningitis related to contaminated methylprednisolone, exposing > 14,000 patients in multiple states. This tragedy underscores the urgency of addressing safety related to compounding pharmacies. There is a call for action at the federal and state levels to set minimum production standards, impose new labeling conditions on compounded drugs, and require large-scale compounders be regulated by the FDA. "Industrial" compounding must come under FDA oversight, require those pharmacies to meet GMP standards, and ensure quality and safe products for patient use. Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.

Frontal sinus revision rate after nasal polyposis surgery including frontal recess clearance and middle turbinectomy: A long-term analysis.

PubMed

Benkhatar, Hakim; Khettab, Idir; Sultanik, Philippe; Laccourreye, Ollivier; Bonfils, Pierre

2018-08-01

To determine the frontal sinus revision rate after nasal polyposis (NP) surgery including frontal recess clearance (FRC) and middle turbinectomy (MT), to search for predictive factors and to analyse surgical management. Longitudinal analysis of 153 patients who consecutively underwent bilateral sphenoethmoidectomy with FRC and MT for NP with a minimum follow-up of 7 years. Decision of revision surgery was made in case of medically refractory chronic frontal sinusitis or frontal mucocele. Univariate and multivariate analysis incorporating clinical and radiological variables were performed. The frontal sinus revision rate was 6.5% (10/153). The mean time between the initial procedure and revision surgery was 3 years, 10 months. Osteitis around the frontal sinus outflow tract (FSOT) was associated with a higher risk of frontal sinus revision surgery (p=0.01). Asthma and aspirin intolerance did not increase the risk, as well as frontal sinus ostium diameter or residual frontoethmoid cells. Among revised patients, 60% required multiple procedures and 70% required frontal sinus ostium enlargement. Our long-term study reports that NP surgery including FRC and MT is associated with a low frontal sinus revision rate (6.5%). Patients developing osteitis around the FSOT have a higher risk of frontal sinus revision surgery. As mucosal damage can lead to osteitis, FSOT mucosa should be preserved during initial NP surgery. However, as multiple procedures are common among NP patients requiring frontal sinus revision, frontal sinus ostium enlargement should be considered during first revision in the hope of reducing the need of further revisions. Copyright © 2018 Elsevier B.V. All rights reserved.

Rasch analysis of SF-Qualiveen in multiple sclerosis.

PubMed

Milinis, Kristijonas; Tennant, Alan; A Young, Carolyn

2017-04-01

A 30-item Qualiveen questionnaire was developed to measure the impact of urinary problems on everyday living in spinal cord injury, and subsequently an 8-item SF-Qualiveen was developed for those with multiple sclerosis (MS). The validity of this short form has not been previously examined using modern psychometric techniques, such as the Rasch measurement model. The aim of this study is to test if the short form meets the requirements of the Rasch model. A total of 401 patients with clinically definite MS were given the questionnaire at three neuroscience centres in the UK. A total of 258 patients (64.3% response) completed the questionnaire. The original scale failed to meet the expectations of the Rasch model. A two-testlet solution was sought to account for local dependence, differential item functioning and disordered thresholds. After the modifications were made the scale fitted the model (χ 2  = 5.93 P = 0.4305), had high internal consistency (α = 0.88) and was unidimensional. SF-Qualiveen is a simple and valid measure of the impact of urinary problems in multiple sclerosis, which meets the requirements of the Rasch measurement model. Summed ordinal scores can be converted to interval-level using the transformation table provided. © 2016 Wiley Periodicals, Inc.

Ocular Changes and Approaches of Ophthalmopathy in Basedow – Graves- Parry- Flajani Disease

PubMed Central

SARACI, George; TRETA, Anamaria

2011-01-01

ABSTRACT Basedow-Graves disease is an autoimmune condition with multiple local and systemic aspects. Among these, oculopathy has a major impact on patient's life from both functional and esthetic point of view. Basedow-Graves oculopathy requires an appropriate positive and differential diagnosis using clinical and imagistic approaches. Treatment is always required in moderate or severe forms and it begins with simple general points and continues with medical and surgical therapies. Current article stresses upon the most characteristic clinical signs of thyroidian ophthalmopathy and the required current therapeutic approaches. PMID:22205899

A case of gabapentin-induced rhabdomyolysis requiring renal replacement therapy.

PubMed

Choi, Min Seok; Jeon, Howook; Kim, Hyo Suk; Jang, Bo Hyun; Lee, Yoon Hee; Park, Hoon Suk; Kim, HyungWook; Jin, Dong Chan

2017-01-01

Gabapentin is commonly used for controlling convulsions, restless pain syndrome, and pain in diabetic neuropathy. Common side effects include dizziness, somnolence, ataxia, peripheral edema, and confusion; gabapentin-induced rhabdomyolysis is rarely reported. To date, the reported cases of gabapentin-induced rhabdomyolysis have been associated with patients with multiple underlying diseases and assuming multiple medicines for various reasons. In this report, we describe a case of gabapentin-induced rhabdomyolysis in a 32-year-old woman with no medical history. We also review related literature and discuss the possible mechanism and the association with other factors. This case shows that gabapentin can induce rhabdomyolysis in healthy patients and that clinicians must consider the possible association between gabapentin and rhabdomyolysis. © 2016 International Society for Hemodialysis.

Alterations in bone marrow and blood mononuclear cell polyamine and methylglyoxal bis(guanylhydrazone) levels: phase I evaluation of alpha-difluoromethylornithine and methylglyoxal bis(guanylhydrazone) treatment of human hematological malignancies.

PubMed

Maddox, A M; Freireich, E J; Keating, M J; Haddox, M K

1988-03-01

Nine patients with hematological malignancies were treated with difluoromethylornithine and methylglyoxal bis(guanylhydrazone). The number of circulating blast cells decreased in all of the patients treated with DFMO and MGBG for longer than 1 wk. Morphological evidence of myeloid maturation was evident in four patients with leukemia and the circulating M Protein decreased in one patient with multiple myeloma. The polyamine content of the mononuclear cells in both the peripheral blood and bone marrow was transiently increased after the initial MGBG dose. During administration of DFMO decreases were achieved in the peripheral blood mononuclear cell putrescine levels in 7 patients, spermidine levels in 5 patients, and spermine levels in 4 patients. Alterations in bone marrow mononuclear cell polyamine levels were similar to those which occurred in the peripheral cells. An average of 9 days of DFMO treatment was required to lower mononuclear cell polyamine levels. Three of the 4 evaluable patients receiving multiple MGBG doses had an increased mononuclear cell content of MGBG after DFMO pretreatment. Enhancement of cellular MGBG levels was not directly correlated to the degree of cellular polyamine depletion.

A web-based decision support tool for prognosis simulation in multiple sclerosis.

PubMed

Veloso, Mário

2014-09-01

A multiplicity of natural history studies of multiple sclerosis provides valuable knowledge of the disease progression but individualized prognosis remains elusive. A few decision support tools that assist the clinician in such task have emerged but have not received proper attention from clinicians and patients. The objective of the current work is to implement a web-based tool, conveying decision relevant prognostic scientific evidence, which will help clinicians discuss prognosis with individual patients. Data were extracted from a set of reference studies, especially those dealing with the natural history of multiple sclerosis. The web-based decision support tool for individualized prognosis simulation was implemented with NetLogo, a program environment suited for the development of complex adaptive systems. Its prototype has been launched online; it enables clinicians to predict both the likelihood of CIS to CDMS conversion, and the long-term prognosis of disability level and SPMS conversion, as well as assess and monitor the effects of treatment. More robust decision support tools, which convey scientific evidence and satisfy the needs of clinical practice by helping clinicians discuss prognosis expectations with individual patients, are required. The web-based simulation model herein introduced proposes to be a step forward toward this purpose. Copyright © 2014 Elsevier B.V. All rights reserved.

Airway Management in a Patient with Wolf-Hirschhorn Syndrome.

PubMed

Gamble, John F; Kurian, Dinesh J; Udani, Andrea G; Greene, Nathaniel H

2016-01-01

We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation.

Airway Management in a Patient with Wolf-Hirschhorn Syndrome

PubMed Central

Udani, Andrea G.

2016-01-01

We present a case of a 3-month-old female with Wolf-Hirschhorn syndrome (WHS) undergoing general anesthesia for laparoscopic gastrostomy tube placement with a focus on airway management. WHS is a rare 4p microdeletion syndrome resulting in multiple congenital abnormalities, including craniofacial deformities. Microcephaly, micrognathia, and glossoptosis are common features in WHS patients and risk factors for a pediatric airway that is potentially difficult to intubate. We discuss anesthesia strategies for airway preparation and management in a WHS patient requiring general anesthesia with endotracheal intubation. PMID:27752382

Surgical management of cutaneous infection caused by atypical mycobacteria after penetrating injury: the hidden dangers of horticulture.

PubMed

Holland, J; Smith, C; Childs, P A; Holland, A J

1997-02-01

We identified two patients in a 12-month period who presented with cutaneous infection and secondary lymph node involvement from atypical mycobacterial infection after minor gardening injuries. One patient had a coinfection with Nocardia asteroides. Both patients required multiple surgical interventions, despite appropriate antibiotic therapy, before resolution of the disease. The course of the infection was characterized by chronic relapses with complete healing at 12 to 18 months after the original injury. The identification and management of this clinical problem are reviewed.

Traumatic injury to the portal vein.

PubMed Central

Mattox, K L; Espada, R; Beall, A R

1975-01-01

Traumatic injuries to the upper abdominal vasculature pose difficult management problems related to both exposure and associated injuries. Among those injuries that are more difficult to manage are those involving the portal vein. While occurring rarely, portal vein injuries require specific therapeutic considerations. Between January, 1968, and July, 1974, over 2000 patients were treated operatively for abdominal trauma at the Ben Taub General Hospital. Among these patients, 22 had injury to the portal vein. Seventeen portal vein injuries were secondary to gunshot wounds, 3 to stab wounds, and 2 to blunt trauma. Associated injuries to the inferior vena cava, pancreas, liver and bile ducts were common. Three patients had associated abdominal aortic injuries, two with acute aorto-caval fistulae. Nine patients died from from failure to control hemorrhage. Eleven were long-term survivors, including two who required pancreataico-duodenectomy as well as portal venorrhaphy. Late complications were rare. The operative approach to patients with traumatic injuries to multiple organs in the upper abdomen, including the portal vein, requires aggressive management and predetermined sequential methods of repair. In spite of innumerable associated injuries, portal vein injuries can be successfully managed in a significant number of patients using generally available surgical techniques and several adjunctive maneuvers. PMID:1130870

Demographic, socioeconomic and clinical correlates of self-management in multiple sclerosis.

PubMed

Wilski, Maciej; Tasiemski, Tomasz; Kocur, Piotr

2015-01-01

Our aim was to identify demographic, clinical and socioeconomic predictors of self-management in multiple sclerosis (MS). The study was performed on a group of 283 patients with multiple sclerosis who completed Multiple Sclerosis Self-Management Scale - Revised (MSSM-R), Multiple Sclerosis Impact Scale (MSIS-29), Actually Received Support Scale (part of Berlin Social Support Scale), Expanded Disability Status Scale (EDSS) and Socioeconomic resources scale. Patients were recruited through cooperation with Multiple Sclerosis Rehabilitation Centre in Borne Sulinowo and Polish Society of Multiple Sclerosis. Demographic and illness-related problems were determined with self-report survey. The group consisted of 185 women and 98 men, with a mean age of 48 years. The level of disability and disease severity varied, mean time elapsed since MS diagnosis was 13 years. The final predictive model of self-management in MS was based on two main predictors: received support and available socioeconomic resources. Patients with MS who received adequate support from the closest relatives (R(2 )= 0.07, F(1, 279) = 21.84, p ≤ 0.01) and had larger available socioeconomic resources (R(2) = 0.11, F(2, 278) = 17.06, p ≤ 0.01), turned out to be the most effective in self-management. Moreover, a relationship between self-management in MS and gender as well as monthly income attributable to one family member was documented. We identified a group of MS patients who are at an increased risk of poor self-management and therefore require more attention from medical staff. This group includes patients with low level of received support, low socioeconomic resources and to a lesser degree men, and also persons receiving low monthly income. Implications for Rehabilitation Self-management of chronic illness is a key component of active participation in rehabilitation process. Low self-management in multiple sclerosis (MS) is considered to be one of the most important factors contributing to low rehabilitation efficacy, more severe long-term complications and increase in healthcare costs. Knowledge on predictors of self-management should be used in clinical practice when providing treatment, support, education and rehabilitation for patients with MS. Increasing support and improving social conditions are potentially important targets for interventions aimed at optimization of self-management, and thereby reduction of health care costs and improvement of health.

Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden

PubMed Central

2014-01-01

Background Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital. Methods This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009. Results The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days. Conclusions Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals. PMID:25124882

Performance measurement for people with multiple chronic conditions: conceptual model.

PubMed

Giovannetti, Erin R; Dy, Sydney; Leff, Bruce; Weston, Christine; Adams, Karen; Valuck, Tom B; Pittman, Aisha T; Blaum, Caroline S; McCann, Barbara A; Boyd, Cynthia M

2013-10-01

Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs. To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model. Framework development and a national stakeholder panel. We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment. The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement. This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients' overall healthcare needs.

Long-term surgical outcomes of retinal detachment in patients with Stickler syndrome

PubMed Central

Reddy, Devasis N; Yonekawa, Yoshihiro; Thomas, Benjamin J; Nudleman, Eric D; Williams, George A

2016-01-01

Purpose The aim of the study was to present the long-term anatomical and visual outcomes of retinal detachment repair in patients with Stickler syndrome. Patients and methods This study is a retrospective, interventional, consecutive case series of patients with Stickler syndrome undergoing retinal reattachment surgery from 2009 to 2014 at the Associated Retinal Consultants, William Beaumont Hospital. Results Sixteen eyes from 13 patients were identified. Patients underwent a mean of 3.1 surgical interventions (range: 1–13) with a mean postoperative follow-up of 94 months (range: 5–313 months). Twelve eyes (75%) developed proliferative vitreoretinopathy. Retinal reattachment was achieved in 100% of eyes, with ten eyes (63%) requiring silicone oil tamponade at final follow-up. Mean preoperative visual acuity (VA) was 20/914, which improved to 20/796 at final follow-up (P=0.81). There was a significant correlation between presenting and final VA (P<0.001), and patients with poorer presenting VA were more likely to require silicone oil tamponade at final follow-up (P=0.04). Conclusion Repair of retinal detachment in patients with Stickler syndrome often requires multiple surgeries, and visual outcomes are variable. Presenting VA is significantly predictive of long-term VA outcomes. PMID:27574392

Management of cystinuric patients: an observational, retrospective, single-centre analysis.

PubMed

Ahmed, Kamran; Khan, Mohammad Shamim; Thomas, Kay; Challacombe, Ben; Bultitude, Matthew; Glass, Jonathan; Tiptaft, Richard; Dasgupta, Prokar

2008-01-01

A critical appraisal of the management of patients with cystine stones treated in our unit in the past 6 years and to analyze the outcome of multimodality therapies. An observational, single-centre retrospective study. We reviewed the records of all patients with stones referred to our centre over a 6-year period from 1998 to 2005. Data recorded included demographic details, medical therapies received/prescribed, compliance with medical therapies, mode of treatment, stone clearance and any recurrence during this period of study. A total of 30 cystinuric patients were treated in our institution over the period of 6 years from 1998 to early 2005. Of these 16 were males and 14 females with an average age at last follow-up of 39 years (range 15-70). Two patients were successfully managed medically. The remaining patients (n = 28) underwent a total of 237 procedures (pre- and postreferral to our unit), with an average of 7.9 procedures per patient for 126 stone episodes (4.2 episodes/patient). The modes of treatment included extracorporeal shockwave lithotripsy (n = 143), ureterorenoscopy and intracorporeal lithotripsy (n = 50), percutaneous nephrolithotomy (n = 28) and open procedures (n = 16). Two patients needed open surgery at our unit. Prior to referral to our dedicated unit, patients had received treatment with extracorporeal shockwave lithotripsy (multiple sessions), ureteroscopy (n = 14), percutaneous nephrolithotomy (n = 4) and open stone removal (n = 14). Most of the stones at our unit were managed using minimally invasive therapies. Compliance of cystinuric patients with medical treatment is often poor and patients experience recurrent stone episodes requiring multiple interventions. Modern management of cystine calculi should be with staged minimally invasive procedures to avoid the complications of multiple open procedures wherever possible along with appropriate medical prophylaxis.

Numeracy of multiple sclerosis patients: A comparison of patients from the PERCEPT study to a German probabilistic sample.

PubMed

Gaissmaier, Wolfgang; Giese, Helge; Galesic, Mirta; Garcia-Retamero, Rocio; Kasper, Juergen; Kleiter, Ingo; Meuth, Sven G; Köpke, Sascha; Heesen, Christoph

2018-01-01

A shared decision-making approach is suggested for multiple sclerosis (MS) patients. To properly evaluate benefits and risks of different treatment options accordingly, MS patients require sufficient numeracy - the ability to understand quantitative information. It is unknown whether MS affects numeracy. Therefore, we investigated whether patients' numeracy was impaired compared to a probabilistic national sample. As part of the larger prospective, observational, multicenter study PERCEPT, we assessed numeracy for a clinical study sample of German MS patients (N=725) with a standard test and compared them to a German probabilistic sample (N=1001), controlling for age, sex, and education. Within patients, we assessed whether disease variables (disease duration, disability, annual relapse rate, cognitive impairment) predicted numeracy beyond these demographics. MS patients showed a comparable level of numeracy as the probabilistic national sample (68.9% vs. 68.5% correct answers, P=0.831). In both samples, numeracy was higher for men and the highly educated. Disease variables did not predict numeracy beyond demographics within patients, and predictability was generally low. This sample of MS patients understood quantitative information on the same level as the general population. There is no reason to withhold quantitative information from MS patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Advising patients seeking stem cell interventions for multiple sclerosis.

PubMed

von Wunster, Beatrice; Bailey, Steven; Wilkins, Alastair; Marks, David I; Scolding, Neil J; Rice, Claire M

2018-05-30

Given the intuitive potential of stem cell therapy and limitations of current treatment options for progressive multiple sclerosis (MS), it is not surprising that patients consider undertaking significant clinical and financial risks to access stem cell transplantation. However, while increasing evidence supports autologous haematopoietic stem cell transplantation (AHSCT) in aggressive relapsing-remitting MS, interventions employing haematopoietic or other stem cells should otherwise be considered experimental and recommended only in the context of a properly regulated clinical study. Understandably, most neurologists are unfamiliar with AHSCT procedures and the specific requirements for quality assurance and safety standards, as well as post-procedure precautions and follow-up. Consequently they may feel ill-equipped to advise patients. Here, we highlight important points for discussion in consultations with patients considering stem cell 'tourism' for MS. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pregnancy outcomes following maternal and paternal exposure to teriflunomide during treatment for relapsing-remitting multiple sclerosis.

PubMed

Kieseier, Bernd C; Benamor, Myriam

2014-12-01

Teriflunomide, indicated for the treatment of relapsing-remitting multiple sclerosis, is contraindicated in pregnancy based on signs of developmental toxicity in the offspring of rats and rabbits; developmental toxicity has also been observed in preclinical studies of other disease-modifying therapies. Despite the requirement to use reliable contraception in clinical trials evaluating the safety and efficacy of teriflunomide, a number of pregnancies have been reported. This work reports pregnancy outcomes in teriflunomide clinical trials. Pregnancy outcomes were evaluated in a retrospective analysis of the global pharmacovigilance database. The following information was collected from the pharmacovigilance database or individual patient files: treatment allocation, pregnancy outcome, teriflunomide exposure, and use of the accelerated elimination procedure. At data cut-off, 83 pregnancies were reported in female patients and 22 pregnancies were documented in partners of male patients. All newborns were healthy and did not have any structural or functional abnormalities at birth. Available data do not indicate any teratogenic signals in patients treated with teriflunomide.

Integrated Patient-Derived Models Delineate Individualized Therapeutic Vulnerabilities of Pancreatic Cancer.

PubMed

Witkiewicz, Agnieszka K; Balaji, Uthra; Eslinger, Cody; McMillan, Elizabeth; Conway, William; Posner, Bruce; Mills, Gordon B; O'Reilly, Eileen M; Knudsen, Erik S

2016-08-16

Pancreatic ductal adenocarcinoma (PDAC) harbors the worst prognosis of any common solid tumor, and multiple failed clinical trials indicate therapeutic recalcitrance. Here, we use exome sequencing of patient tumors and find multiple conserved genetic alterations. However, the majority of tumors exhibit no clearly defined therapeutic target. High-throughput drug screens using patient-derived cell lines found rare examples of sensitivity to monotherapy, with most models requiring combination therapy. Using PDX models, we confirmed the effectiveness and selectivity of the identified treatment responses. Out of more than 500 single and combination drug regimens tested, no single treatment was effective for the majority of PDAC tumors, and each case had unique sensitivity profiles that could not be predicted using genetic analyses. These data indicate a shortcoming of reliance on genetic analysis to predict efficacy of currently available agents against PDAC and suggest that sensitivity profiling of patient-derived models could inform personalized therapy design for PDAC. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.

Differences in early speech patterns between Parkinson variant of multiple system atrophy and Parkinson's disease.

PubMed

Huh, Young Eun; Park, Jongkyu; Suh, Mee Kyung; Lee, Sang Eun; Kim, Jumin; Jeong, Yuri; Kim, Hee-Tae; Cho, Jin Whan

2015-08-01

In Parkinson variant of multiple system atrophy (MSA-P), patterns of early speech impairment and their distinguishing features from Parkinson's disease (PD) require further exploration. Here, we compared speech data among patients with early-stage MSA-P, PD, and healthy subjects using quantitative acoustic and perceptual analyses. Variables were analyzed for men and women in view of gender-specific features of speech. Acoustic analysis revealed that male patients with MSA-P exhibited more profound speech abnormalities than those with PD, regarding increased voice pitch, prolonged pause time, and reduced speech rate. This might be due to widespread pathology of MSA-P in nigrostriatal or extra-striatal structures related to speech production. Although several perceptual measures were mildly impaired in MSA-P and PD patients, none of these parameters showed a significant difference between patient groups. Detailed speech analysis using acoustic measures may help distinguish between MSA-P and PD early in the disease process. Copyright © 2015 Elsevier Inc. All rights reserved.

Pelvic pain: a pathway for care developed for both men and women by the British Pain Society.

PubMed

Baranowski, A P; Lee, J; Price, C; Hughes, J

2014-03-01

This paper aims to explain the key points and highlight some of the controversies in the development of the British Pain Society's pelvic pain patient pathway map. Many clinicians lack experience and confidence with this group of patients, and this issue is highlighted. Additionally, the difficulties of classification and definitions in this area are discussed in detail. These are historical causes of disagreement among specialists which can lead to confused clinical care. This group of patients have multiple issues that cross many professional boundaries; they are best managed by the co-ordinated involvement of multiple teams. Patients suffer from significant distress and disability that often needs specialist assessment and intervention (interdisciplinary). This suggests that an integrated approach is required across the historic boundaries of primary and secondary care. A variety of interventions, including opioids and neuromodulation are recommended in the pathway and the controversies surrounding these inclusions are aired in detail.

[Wandering in dementia].

PubMed

Strubel, Denise; Corti, Mariana

2008-12-01

Wandering is a frequent behavior disorder in demented patients. However, it remains ill defined and insufficiently studied. It is characterized by repeated, prolonged and sometimes compulsive need to walk, with or without aim. Its frequency increases with the severity of dementia among institutionalized subjects and Alzheimer's disease patients. It may result in severe consequences for the patient who may get lost, become exhausted and suffer from traumas. It also represents a burden for patient's family and care providers, especially in case of running away. Multiple hypotheses may be formulated to explain this symptom, going from an occupational or automatic activity to a finalized activity, inscribed into the subject's mental life. The badly codified treatment requires sometimes medications (modest effect of low-doses antipsychotic drugs), but it is mainly based on varied and multiple non-medicinal approaches. Unfortunately, these ones are insufficiently assessed. More studies are needed to bring out a better definition of wandering, and improve its analysis, comprehension and the assessment of its caring.

Severe Legionnaire's disease requiring intensive care treatment.

PubMed

van Riemsdijk-van Overbeeke, I C; van den Berg, B

1996-11-01

Legionnaire's disease is well known as severe pneumonia requiring intensive care treatment in many cases. In this study the clinical course is described of patients admitted to the medical ICU of the University Hospital of Rotterdam for respiratory distress due to Legionnaire's disease. From the register of admissions to the medical ICU all patients suffering from Legionnaire's disease were identified. All data on clinical signs and symptoms present on admission were collected. The circumstances in which the infections were contracted were sought, as well as the tests establishing the diagnosis. The occurrence of various organ failures and complications were noted, as were the causes of death on the ICU. From 1978 till 1995 the diagnosis of Legionella pneumonia was made in 17 patients admitted to the ICU: in 13 patients a community-acquired infection was established. As in 12 patients Legionnaire's disease was diagnosed on serological tests, it took several weeks before the diagnosis could be established in these patients. In all patients the circumstances predisposing to Legionnaire's disease were noted. Respiratory distress was present in all patients, ventilatory support was required in 14. Apart from this, both profound shock and renal failure were commonly encountered. As complications jaundice, rhabdomyolysis and polyneuropathy were frequently noted. Three patients died: 2 due to irreversible shock and 1 due to hospital-acquired sepsis. Legionnaire's disease can develop into life-threatening pneumonia requiring intensive care treatment in previously healthy subjects. As the clinical features are aspecific, careful search for predisposing circumstances such as recent travel or use of a contaminated water-supply is mandatory. As the diagnosis required positive serological tests in most patients, a considerable delay in diagnosis was noted. Despite the frequent occurrence of multiple organ failure, a favourable outcome can be anticipated in most cases.

Multiple myeloma in the very elderly patient: challenges and solutions

PubMed Central

Willan, John; Eyre, Toby A; Sharpley, Faye; Watson, Caroline; King, Andrew J; Ramasamy, Karthik

2016-01-01

Diagnosis and management of myeloma in the very elderly patient is challenging. Treatment options have vastly improved for elderly myeloma patients but still require the clinician to personalize therapy. In this paper, we offer evidence-based, pragmatic advice on how to overcome six of the main challenges likely to arise: 1) diagnosis of myeloma in this age group, 2) assessment of the need for treatment, and the fitness for combination chemotherapy, 3) provision of the best quality of supportive care, 4) choice of combination chemotherapy in those fit enough for it, 5) treatment of relapsed myeloma, and 6) provision of end of life care. With an increased burden of comorbidities and a reduced resilience to treatment and its associated toxicities, the management of myeloma in this age group requires a different approach to that in younger patients to maximize both quality and length of life. PMID:27143866

Specifying process requirements for holistic care.

PubMed

Poulymenopoulou, M; Malamateniou, F; Vassilacopoulos, G

2013-09-01

Holistic (health and social) care aims at providing comprehensive care to the community, especially to elderly people and people with multiple illnesses. In turn, this requires using health and social care resources more efficiently through enhanced collaboration and coordination among the corresponding organizations and delivering care closer to patient needs and preferences. This paper takes a patient-centered, process view of holistic care delivery and focuses on requirements elicitation for supporting holistic care processes and enabling authorized users to access integrated patient information at the point of care when needed. To this end, an approach to holistic care process-support requirements elicitation is presented which is based on business process modeling and places particular emphasis on empowering collaboration, coordination and information sharing among health and social care organizations by actively involving users and by providing insights for alternative process designs. The approach provides a means for integrating diverse legacy applications in a process-oriented environment using a service-oriented architecture as an appropriate solution for supporting and automating holistic care processes. The approach is applied in the context of emergency medical care aiming at streamlining and providing support technology to cross-organizational health and social care processes to address global patient needs.

Mountain biking injuries in rural England

PubMed Central

Jeys, L; Cribb, G; Toms, A; Hay, S

2001-01-01

Background—Off road mountain biking is now an extremely popular recreation and a potent cause of serious injury. Aim—To establish the morbidity associated with this sport. Methods—Data were collected prospectively over one year on all patients presenting with an injury caused by either recreational or competitive off road mountain biking. Results—Eighty four patients were identified, 70 males and 14 females, with a mean age of 22.5 years (range 8–71). Most accidents occurred during the summer months, most commonly in August. Each patient had an average of 1.6 injuries (n = 133) and these were divided into 15 categories, ranging from minor soft tissue to potentially life threatening. Operative intervention was indicated for 19 patients (23%) and several required multiple procedures. The commonest injuries were clavicle fractures (13%), shoulder injuries (12%), and distal radial fractures (11%). However, of a more sinister nature, one patient had a C2/3 dislocation requiring urgent stabilisation, one required a chest drain for a haemopneumothorax, and another required an emergency and life saving nephrectomy. Conclusion—This sport has recently experienced an explosion in popularity, and, as it carries a significant risk of potentially life threatening injury across all levels of participation, the use of protective equipment to reduce this significant morbidity may be advisable. Key Words: mountain biking; injury PMID:11375881

Artificial Intelligence in Mitral Valve Analysis

PubMed Central

Jeganathan, Jelliffe; Knio, Ziyad; Amador, Yannis; Hai, Ting; Khamooshian, Arash; Matyal, Robina; Khabbaz, Kamal R; Mahmood, Feroze

2017-01-01

Background: Echocardiographic analysis of mitral valve (MV) has become essential for diagnosis and management of patients with MV disease. Currently, the various software used for MV analysis require manual input and are prone to interobserver variability in the measurements. Aim: The aim of this study is to determine the interobserver variability in an automated software that uses artificial intelligence for MV analysis. Settings and Design: Retrospective analysis of intraoperative three-dimensional transesophageal echocardiography data acquired from four patients with normal MV undergoing coronary artery bypass graft surgery in a tertiary hospital. Materials and Methods: Echocardiographic data were analyzed using the eSie Valve Software (Siemens Healthcare, Mountain View, CA, USA). Three examiners analyzed three end-systolic (ES) frames from each of the four patients. A total of 36 ES frames were analyzed and included in the study. Statistical Analysis: A multiple mixed-effects ANOVA model was constructed to determine if the examiner, the patient, and the loop had a significant effect on the average value of each parameter. A Bonferroni correction was used to correct for multiple comparisons, and P = 0.0083 was considered to be significant. Results: Examiners did not have an effect on any of the six parameters tested. Patient and loop had an effect on the average parameter value for each of the six parameters as expected (P < 0.0083 for both). Conclusion: We were able to conclude that using automated analysis, it is possible to obtain results with good reproducibility, which only requires minimal user intervention. PMID:28393769

Rationale of technical requirements for NRG-BR001: The first NCI-sponsored trial of SBRT for the treatment of multiple metastases.

PubMed

Al-Hallaq, Hania A; Chmura, Steven; Salama, Joseph K; Winter, Kathryn A; Robinson, Clifford G; Pisansky, Thomas M; Borges, Virginia; Lowenstein, Jessica R; McNulty, Susan; Galvin, James M; Followill, David S; Timmerman, Robert D; White, Julia R; Xiao, Ying; Matuszak, Martha M

In 2014, the NRG Oncology Group initiated the first National Cancer Institute-sponsored, phase 1 clinical trial of stereotactic body radiation therapy (SBRT) for the treatment of multiple metastases in multiple organ sites (BR001; NCT02206334). The primary endpoint is to test the safety of SBRT for the treatment of 2 to 4 multiple lesions in several anatomic sites in a multi-institutional setting. Because of the technical challenges inherent to treating multiple lesions as their spatial separation decreases, we present the technical requirements for NRG-BR001 and the rationale for their selection. Patients with controlled primary tumors of breast, non-small cell lung, or prostate are eligible if they have 2 to 4 metastases distributed among 7 extracranial anatomic locations throughout the body. Prescription and organ-at-risk doses were determined by expert consensus. Credentialing requirements include (1) irradiation of the Imaging and Radiation Oncology Core phantom with SBRT, (2) submitting image guided radiation therapy case studies, and (3) planning the benchmark. Guidelines for navigating challenging planning cases including assessing composite dose are discussed. Dosimetric planning to multiple lesions receiving differing doses (45-50 Gy) and fractionation (3-5) while irradiating the same organs at risk is discussed, particularly for metastases in close proximity (≤5 cm). The benchmark case was selected to demonstrate the planning tradeoffs required to satisfy protocol requirements for 2 nearby lesions. Examples of passing benchmark plans exhibited a large variability in plan conformity. NRG-BR001 was developed using expert consensus on multiple issues from the dose fractionation regimen to the minimum image guided radiation therapy guidelines. Credentialing was tied to the task rather than the anatomic site to reduce its burden. Every effort was made to include a variety of delivery methods to reflect current SBRT technology. Although some simplifications were adopted, the successful completion of this trial will inform future designs of both national and institutional trials and would allow immediate clinical adoption of SBRT trials for oligometastases. Copyright © 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Quality of life after major trauma with multiple rib fractures.

PubMed

Marasco, Silvana; Lee, Geraldine; Summerhayes, Robyn; Fitzgerald, Mark; Bailey, Michael

2015-01-01

Rib fractures are a common injury presenting to major trauma centres and community hospitals. Aside from the acute impact of rib fracture injury, longer-term morbidity of pain, disability and deformity have been described. Despite this, the mainstay of management for the vast majority of rib fracture injuries remains supportive only with analgesia and where required respiratory support. This study aimed to document the long-term quality of life in a cohort of major trauma patients with rib fracture injury over 24 months. Retrospective review (July 2006-July 2011) of 397 major trauma patients admitted to The Alfred Hospital with rib fractures and not treated with operative rib fixation. The main outcome measures were quality of life over 24 months post injury assessed using the Glasgow Outcome Scale Extended and SF12 health assessment forms and a pain questionnaire. Assessment over 24 months of major trauma patients with multiple rib fractures demonstrated significantly lower quality of life compared with published Australian norms at all time points measured. Return to work rates were poor with only 71% of those who were working prior to their accident, returning to any work. This study demonstrates a significant reduction in quality of life for rib fracture patients requiring admission to hospital, which does not return to the level of Australian norms for at least two years. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

The number of operations required for completing breast reconstruction.

PubMed

Eom, Jin Sup; Kobayashi, Mark Robert; Paydar, Keyianoosh; Wirth, Garrett A; Evans, Gregory R D

2014-10-01

Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient's expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. The mean number of operations per breast was 2.37 (range, 1-9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.

The Esophageal Anastomotic Stricture Index (EASI) for the management of esophageal atresia.

PubMed

Sun, Linda Yi-Chan; Laberge, Jean-Martin; Yousef, Yasmine; Baird, Robert

2015-01-01

Anastomotic stricture is the most common complication following repair of esophageal atresia. An Esophageal Anastomotic Stricture Index (EASI) based on the postoperative esophagram may identify patients at high risk of stricture formation. Digital images of early postoperative esophagrams of patients undergoing EA repair from 2005 to 2013 were assessed. Demographics and outcomes including dilations were prospectively collected. Upper (U-EASI) and lower (L-EASI) pouch ratios were generated using stricture diameter divided by maximal respective pouch diameter. Score performances were evaluated with area under the receiver operator curves (AUC) and the Fisher's exact test for single and multiple (>3) dilatations. Interrater agreement was evaluated using the intraclass correlation coefficient (ICC). Forty-five patients had esophagrams analyzed; 28 (62%) required dilatation and 19 received >3 (42%). U-EASI and L-EASI ratios ranged from 0.17 to 0.70, with L-EASI outperforming the U-EASI as follows: L-EASI AUC: 0.66 for a single dilatation, 0.65 for >3 dilatations; U-EASI AUC: 0.56 for a single dilatation, 0.67 for >3 dilatations. All patients with an L-EASI ratio of ≤0.30 (n=8) required multiple esophageal dilatations, p=0.0006. The interrater ICC was 0.87. The EASI is a simple, reproducible tool to predict the development and severity of anastomotic stricture after esophageal atresia repair and can direct postoperative surveillance. Copyright © 2015 Elsevier Inc. All rights reserved.

Review of the patient positioning reproducibility in head-and-neck radiotherapy using Statistical Process Control.

PubMed

Moore, Sarah J; Herst, Patries M; Louwe, Robert J W

2018-05-01

A remarkable improvement in patient positioning was observed after the implementation of various process changes aiming to increase the consistency of patient positioning throughout the radiotherapy treatment chain. However, no tool was available to describe these changes over time in a standardised way. This study reports on the feasibility of Statistical Process Control (SPC) to highlight changes in patient positioning accuracy and facilitate correlation of these changes with the underlying process changes. Metrics were designed to quantify the systematic and random patient deformation as input for the SPC charts. These metrics were based on data obtained from multiple local ROI matches for 191 patients who were treated for head-and-neck cancer during the period 2011-2016. SPC highlighted a significant improvement in patient positioning that coincided with multiple intentional process changes. The observed improvements could be described as a combination of a reduction in outliers and a systematic improvement in the patient positioning accuracy of all patients. SPC is able to track changes in the reproducibility of patient positioning in head-and-neck radiation oncology, and distinguish between systematic and random process changes. Identification of process changes underlying these trends requires additional statistical analysis and seems only possible when the changes do not overlap in time. Copyright © 2018 Elsevier B.V. All rights reserved.

Preemptive intravenous immunoglobulin allows safe and timely administration of antineoplastic therapies in patients with multiple myeloma and parvovirus B19 disease.

PubMed

Katragadda, L; Shahid, Z; Restrepo, A; Muzaffar, J; Alapat, D; Anaissie, E

2013-08-01

Parvovirus B19 (B19) disease is a rare cause of anemia in cancer patients and often goes unrecognized, causing delays in anticancer therapy. A retrospective review was carried out of the records of patients with multiple myeloma who underwent melphalan-based autologous stem cell transplantation (MEL-ASCT) and developed B19 infection (January 2009-December 2011). Cases were defined by the presence of clinical and laboratory findings consistent with B19 disease in patients with repeatedly positive plasma quantitative polymerase chain reaction for parvovirus. Six patients qualified as cases; 5 presented with trilineage cytopenias (chronic in 1) and 1 with anemia later progressing to pancytopenia. Transfusion-dependent thrombocytopenia led to testing in 5 patients. Two of these patients also had manifestations of autoimmune disease. Therapy with intravenous immunoglobulin (IVIG) resulted in clinical and hematologic response in all; however, 1 patient, whose white blood cell counts and serum hemoglobin levels improved, required splenectomy for persistent thrombocytopenia. All patients required additional IVIG for recurrent B19 disease. Although viral load at diagnosis did not correlate with the severity of cytopenia, its decrease was associated with response during 17 of 20 evaluable episodes (P = 0.02). Preemptive IVIG allowed the safe administration of chemotherapy in 3 patients, including MEL-ASCT in 1. Parvovirus B19 can cause severe disease in myeloma patients including ASCT recipients. Thrombocytopenia - not anemia - was the leading presentation and may be associated with autoimmune conditions. Patients with unexplained cytopenias, particularly when prolonged, should undergo testing for circulating parvovirus. A reduction in viral load was associated with response to IVIG, although additional therapy was needed for recurrent disease. Most importantly, preemptive IVIG allowed for safe and timely administration of antineoplastic therapy in patients with ongoing B19 disease. © 2013 John Wiley & Sons A/S.

Multiple myeloma: diagnosis and treatment.

PubMed

Nau, Konrad C; Lewis, William D

2008-10-01

Multiple myeloma, the most common bone malignancy, is occurring with increasing frequency in older persons. Typical symptoms are bone pain, malaise, anemia, renal insufficiency, and hypercalcemia. Incidental discovery on comprehensive laboratory panels is common. The disease is diagnosed with serum or urine protein electrophoresis or immunofixation and bone marrow aspirate analysis. Skeletal radiographs are important in staging multiple myeloma and revealing lytic lesions, vertebral compression fractures, and osteoporosis. Magnetic resonance imaging and positron emission tomography or computed tomography are emerging as useful tools in the evaluation of patients with myeloma; magnetic resonance imaging is preferred for evaluating acute spinal compression. Nuclear bone scans and dual energy x-ray absorptiometry have no role in the diagnosis and staging of myeloma. The differential diagnosis of monoclonal gammopathies includes monoclonal gammopathy of uncertain significance, smoldering (asymptomatic) and symptomatic multiple myeloma, amyloidosis, B-cell non-Hodgkin lymphoma, Waldenström macroglobulinemia, and rare plasma cell leukemia and heavy chain diseases. Patients with monoclonal gammopathy of uncertain significance or smoldering multiple myeloma should be followed closely, but not treated. Symptomatic multiple myeloma is treated with chemotherapy followed by autologous stem cell transplantation, if possible. Melphalan, prednisolone, dexamethasone, vincristine, doxorubicin, bortezomib, and thalidomide and its analogue lenalidomide have been used successfully. It is important that family physicians recognize and appropriately treat multiple myeloma complications. Bone pain is treated with opiates, bisphosphonates, radiotherapy, vertebroplasty, or kyphoplasty; nephrotoxic nonsteroidal anti-inflammatory drugs should be avoided. Hypercalcemia is treated with isotonic saline infusions, steroids, furosemide, or bisphosphonates. Because of susceptibility to infections, patients require broad-spectrum antibiotics for febrile illness and immunization against influenza, pneumococcus, and Haemophilus influenzae B. Five-year survival rates approach 33 percent, and the median survival rate is 33 months.

Expression and functional analysis of menin in a multiple endocrine neoplasia type 1 (MEN1) patient with somatic loss of heterozygosity in chromosome 11q13 and unidentified germline mutation of the MEN1 gene.

PubMed

Naito, Junko; Kaji, Hiroshi; Sowa, Hideaki; Kitazawa, Riko; Kitazawa, Sohei; Tsukada, Toshihiko; Hendy, Geoffrey N; Sugimoto, Toshitsugu; Chihara, Kazuo

2006-06-01

In some patients with multiple endocrine neoplasia type 1 (MEN1) it is not possible to identify a germline mutation in the MEN1 gene. We sought to document the loss of expression and function of the MEN1 gene product, menin, in the tumors of such a patient. The proband is an elderly female patient with primary hyperparathyroidism, pancreatic islet tumor, and breast cancer. Her son has primary hyperparathyroidism. No germline MEN1 mutation was identified in the proband or her son. However, loss of heterozygosity at the MEN1 locus and complete lack of menin expression were demonstrated in the proband's tumor tissue. The proband's cultured parathyroid cells lacked the normal reduction in proliferation and parathyroid hormone secretion in response to transforming growth factor- beta. This assessment provided insight into the molecular pathogenesis of the patient and provides evidence for a critical requirement for menin in the antiproliferative action of transforming growth factor-beta.

Multiple Sclerosis-related Uveitis: Does MS Treatment Affect Uveitis Course?

PubMed

Jouve, Léa; Benrabah, Rabah; Héron, Emmanuel; Bodaghi, Bahram; Le Hoang, Phuc; Touitou, Valérie

2017-06-01

Few data are available regarding the optimal treatment of multiple sclerosis (MS)-related uveitis. The aim of this study was to describe clinical features of MS-associated uveitis and determine how MS treatment affects the course of uveitis. Retrospective, multicenter study. Patients were divided into two groups according to the use (group 2) or not (group 1) of immunomodulatory drugs. Characteristics of uveitis and treatment were reviewed. A total of 68 eyes from 36 patients (17 in group 1 and 19 in group 2) were included. All patients were treated with topical and/or systemic steroids for uveitis. Uveitis occurred 1-17 years prior to neurologic symptoms in 78% of patients. Uveitis was more severe in group 2 (p<0.05), with a tendency toward a higher rate of chronic uveitis (p = 0.06). MS-related uveitis has often a favorable evolution. Patients on interferon-beta have more severe and chronic uveitis. As far as we are concerned, interferon-beta given on the sole indication of uveitis is not recommended. If steroid-sparing agent is required for intraocular inflammation, immunosuppressive drugs should be considered.

Labial adhesions and outcomes of office management.

PubMed

Granada, Catalina; Sokkary, Nancy; Sangi-Haghpeykar, Haleh; Dietrich, Jennifer E

2015-04-01

To evaluate clinical outcomes of labial adhesions (LA) and to examine the association between LA, lichen sclerosus (LS), eczema (ECZ), or asthma. Retrospective study. Single pediatric and adolescent gynecology clinic, Houston, Texas. 50 girls diagnosed with LA from 2006-2011. Resolution, recurrence, single vs multiple treatments, need for surgery, and conditions such as LS, ECZ, and asthma were reviewed. Mean age was 19.6 months (range 0-84 months), and 48% were Caucasian. Most patients were symptomatic (62%) and all 50 patients chose estrogen treatment. The majority (74%) required multiple treatments, as opposed to a single treatment (26%). Patients with multiple treatments were more likely to be severely agglutinated (P = .05) and to need manual separation after failed topical treatment (P = .08). The prevalence of asthma, LS, and ECZ was 9.8%, 7.8%, and 3.9% respectively. There was no association between LS, ECZ, or asthma, and number of treatments. Both asthma (N = 3; 8%), and LS (N = 2; 5%) were present among the severe agglutinated group; however, this difference was not statistically significant (P values .59 and .99). No association with ECZ was seen in either group. Severe agglutination tends to be associated with need of multiple treatments and manual separation. A concurrent diagnosis of LS, ECZ, or asthma was not associated with number of treatments but there appears to be a trend towards severity of LA in patients with asthma and LS. Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Superior mesenteric vein thrombosis - unusual management of unusual complication of Whipple procedure.

PubMed

Huťan, Martin; Bartko, Christian; Slyško, Roman; Sekáč, Jaroslav; Prochotský, Augustín; Majeský, Ivan; Skultéty, Ján

2014-01-01

Pancreatoduodenectomy is an extensive procedure carrying risk of a number of postoperative complications. Of these the most common are surgical site infections (SSI), bleeding, delayed gastric emptying, and anastomotic leakage. However, the most serious complications are ones, that are rare, clinically hardly diagnosed, and if untreated, leading to the death of a patient. Among the latter complications is thrombosis of superior mesenteric vein. Its clinical signs are unspecific and diagnostics complicated. Treatment requires aggressive approach. If this is absent, intestinal necrosis with septic state, Multiple Organ Dysfunction Syndrome (MODS) and Multiple Organ Failure (MOF) lead to a death of a patient. Authors present a case of a patient after pancreatoduodenectomy, complicated by the thrombosis of superior mesenteric vein. Patient was managed by resection of the necrotic bowel, venous decompression by venous bypass from superior mesenteric vein to the right ovarian vein, and open abdomen with negative pressure wound therapy (NPWT). Patient suffered severe abdominal sepsis with need for intensive organ support. Abdomen was definitely closed on fourth NPWT redress. Patient healed without any further complications, is well and was released to the ambulatory setting. Superior mesenteric vein (VMS) thrombosis is a rare complication. It diagnosis requires high level of vigilance and once diagnosed, aggressive therapy is essential. Two goals of surgical treatment exist: resection of the necrotic bowel and facilitation of the blood outflow. Mesenteroovarian anastomosis is one of the options in treatment of thrombosis of VMS if thrombectomy is not feasible. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.

ProFUSO: Business process and ontology-based framework to develop ubiquitous computing support systems for chronic patients' management.

PubMed

Jimenez-Molina, Angel; Gaete-Villegas, Jorge; Fuentes, Javier

2018-06-01

New advances in telemedicine, ubiquitous computing, and artificial intelligence have supported the emergence of more advanced applications and support systems for chronic patients. This trend addresses the important problem of chronic illnesses, highlighted by multiple international organizations as a core issue in future healthcare. Despite the myriad of exciting new developments, each application and system is designed and implemented for specific purposes and lacks the flexibility to support different healthcare concerns. Some of the known problems of such developments are the integration issues between applications and existing healthcare systems, the reusability of technical knowledge in the creation of new and more sophisticated systems and the usage of data gathered from multiple sources in the generation of new knowledge. This paper proposes a framework for the development of chronic disease support systems and applications as an answer to these shortcomings. Through this framework our pursuit is to create a common ground methodology upon which new developments can be created and easily integrated to provide better support to chronic patients, medical staff and other relevant participants. General requirements are inferred for any support system from the primary attention process of chronic patients by the Business Process Management Notation. Numerous technical approaches are proposed to design a general architecture that considers the medical organizational requirements in the treatment of a patient. A framework is presented for any application in support of chronic patients and evaluated by a case study to test the applicability and pertinence of the solution. Copyright © 2018 Elsevier Inc. All rights reserved.

Intestinal volvulus and perforation caused by multiple magnet ingestion: report of a case.

PubMed

Ilçe, Zekeriya; Samsum, Hakan; Mammadov, Emil; Celayir, Sinan

2007-01-01

Ingested magnets can cause intestinal fistulas, perforation, and obstruction. There have been reports of magnet ingestion causing intestinal volvulus, but multiple magnet ingestion causing perforation and intestinal volvulus in a child is very unusual. We report the case of a 4-year-old girl, who ingested four magnets she acquired as toys, which caused intestinal volvulus and perforation as a result of pressure necrosis, several days after ingestion. At surgery we repaired two perforations, but additional bowel resection was not required. The patient was discharged on postoperative day 10. If multiple magnet ingestion is suspected in a child, the child must be monitored carefully. If there are signs of obstruction, emergency surgery is mandatory.

Multiorgan Failure and Refractory Lactic Acidosis due to Pasteurella multocida Septicemia in a Patient with No Animal Exposure

PubMed Central

Pena, Damaris; Santana, Yaneidy; Perez Lara, Jose; Gonzalez, Efrain

2018-01-01

Introduction Pasteurella multocida is a gram-negative coccobacillus pathogenic to animals. It can cause infection in humans by a bite, scratch, or lick from a cat or dog. P. multocida can cause a variety of infections in humans, including cellulitis, osteomyelitis, endocarditis, peritonitis, and septic shock. Case Presentation A 56-year-old male presented to our hospital with a 2-day history of fever, abdominal pain, nausea, and vomiting. He denied exposure to cats, dogs or other pets. He had severe respiratory distress requiring ventilator support, profound septic shock requiring multiple vasopressors, severe lactic acidosis, and renal failure requiring emergent hemodialysis. Blood cultures confirmed the presence of P. multocida. The patient subsequently died of cardiopulmonary arrest due to multiorgan failure with refractory shock. Conclusion P. multocida septicemia can lead to septic shock. Early identification of this organism may decrease mortality. Although our patient had no known cat or dog exposure, physicians should enquire about a history of animal exposure when a patient presents with an infection with no obvious cause. PMID:29765783

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta-analysis.

PubMed

Jeitler, K; Horvath, K; Berghold, A; Gratzer, T W; Neeser, K; Pieber, T R; Siebenhofer, A

2008-06-01

We compared the effects of continuous subcutaneous insulin infusion (CSII) with those of multiple daily insulin (MDI) injections on glycaemic control, risk of hypoglycaemic episodes, insulin requirements and adverse events in type 1 and type 2 diabetes mellitus. The electronic databases MEDLINE, EMBASE and CENTRAL were systematically searched for randomised controlled trials up to March 2007. A systematic review and meta-analysis were performed. Overall, 22 studies were included (17 on type 1 diabetes mellitus, two on type 2 diabetes mellitus, three on children). With regard to adults with type 1 diabetes mellitus, our meta-analysis found a between-treatment difference of -0.4% HbA(1c) (six studies) in favour of CSII therapy. Available median rates of mild or overall hypoglycaemic events were comparable between the different interventions (1.9 [0.9-3.1] [CSII] vs 1.7 [1.1-3.3] [MDI] events per patient per week). Total daily insulin requirements were lower with CSII than with MDI therapy. In patients with type 2 diabetes mellitus, CSII and MDI treatment showed no statistically significant difference for HbA(1c). The incidence of mild hypoglycaemic events was comparable between the treatment groups. In adolescents with type 1 diabetes mellitus, glycated haemoglobin and insulin requirements were significantly lower in the CSII groups; no data were available on hypoglycaemic events. The only study performed in younger children did not provide enough data for conclusive inferences. No overall conclusions were possible for severe hypoglycaemia and adverse events for any of the different patient groups due to rareness of such events, different definitions and insufficient reporting. CSII therapy in adults and adolescents with type 1 diabetes mellitus resulted in a greater reduction of glycated haemoglobin, in adult patients without a higher rate of hypoglycaemia. No beneficial effect of CSII therapy could be detected for patients with type 2 diabetes mellitus.

Outcome of Extended Thymectomy in Myasthenia Crisis Patient.

PubMed

Aftabuddin, M; Bhandari, S

2016-07-01

Myasthenic crisis is a life-threatening condition. We studied the demographic, frequency, causes and clinical presentation of isolated Myasthenic crisis, steps of treatment and to review our experience of extended thymectomy on patients with at least one episode myasthenic crisis. A prospective and retrospective study was conducted on patients with at least one episode of myasthenic crisis, from March 2010 to September 2014, at the Department of Cardiac Surgery, BSMMU, Dhaka, Bangladesh who were referred for thymectomy. Eighteen patients (13.6% of the total 132 patients with myasthenia gravis were admitted with single to multiple episodes of myasthenic crisis, median crisis was 2.5 episodes. Mean age of the patient was 35.5 (18-72) years with male predominance. All eighteen patients had undergone extended thymectomy after completion of 5 cycle plasmapheresis, of which 2 had experienced postoperative respiratory crisis, required invasive ventilator support for median 14 days. One patient required invasive ventilator support after third post operative day. Six patients had thymoma and 12 had thymic hyperplasia. Three patients needed Intravenous immunoglobin. Nine patients needed post operative anti acetylcholinesterase inhibitor after median 2.5 post days. Post thymectomy remission and decreases the frequency of myasthenic crisis was seen in follow up and post operative medication requirement reduced significantly as compared to the preoperative requirement. This report highlights that the patients who had extended thymectomy after episodes of myasthenia crisis are benefitted even in the histhopathology report does not confirmed thymoma. After thymectomy, there was remission of myasthenic crisis. Patients with myasthenic crisis should have judicious drug adjustments under supervision and should be treated aggressively during impending myasthenic crisis. With modern management of myasthenia gravis, early surgery with myasthenic crisis is safe with good long-term outcomes.

Xp11.2 translocation renal cell carcinoma with multiple bone metastases: A case report

PubMed Central

LIU, JIAJU; SU, ZHENGMING; LI, YIFAN; CHEN, DUQUN; NI, LIANGCHAO; MAO, XIANGMING; YANG, SHANGQI; LAI, YONGQING

2016-01-01

Xp11.2 translocation/transcription factor enhancer 3 (TFE3) fusion gene associated with renal cell carcinoma (Xp11.2 translocation RCC) is rare and occurs predominantly in children and adolescents. The current study reports the case of a 14-year-old male with Xp11.2 translocation RCC, who presented with chest pain that had persisted for 1 month. A solid neoplasm was located in the left kidney of the patient. Contrast-enhanced computed tomography revealed the presence of a solid mass in the kidney, with uneven enhancement. Destruction of multiple bones was also observed. The patient was treated with a radical nephrectomy. The pathological examination of the tumor revealed that the tumor cells contained an eosinophilic cytoplasm in the renal interstitial tissue. Immunohistochemistry revealed that the tumor cells expressed P504S, cluster of differentiation 10, pan-cytokeratin, vimentin and TFE3. In conclusion, Xp11.2 translocation RCC is a rare type of kidney cancer. Diagnosing this disease prior to surgery is challenging, and providing a definite diagnosis requires histopathological and immunohistochemical examination, while genetic analysis may also be required. PMID:26998154

Xp11.2 translocation renal cell carcinoma with multiple bone metastases: A case report.

PubMed

Liu, Jiaju; Su, Zhengming; Li, Yifan; Chen, Duqun; Ni, Liangchao; Mao, Xiangming; Yang, Shangqi; Lai, Yongqing

2016-03-01

Xp11.2 translocation/transcription factor enhancer 3 (TFE3) fusion gene associated with renal cell carcinoma (Xp11.2 translocation RCC) is rare and occurs predominantly in children and adolescents. The current study reports the case of a 14-year-old male with Xp11.2 translocation RCC, who presented with chest pain that had persisted for 1 month. A solid neoplasm was located in the left kidney of the patient. Contrast-enhanced computed tomography revealed the presence of a solid mass in the kidney, with uneven enhancement. Destruction of multiple bones was also observed. The patient was treated with a radical nephrectomy. The pathological examination of the tumor revealed that the tumor cells contained an eosinophilic cytoplasm in the renal interstitial tissue. Immunohistochemistry revealed that the tumor cells expressed P504S, cluster of differentiation 10, pan-cytokeratin, vimentin and TFE3. In conclusion, Xp11.2 translocation RCC is a rare type of kidney cancer. Diagnosing this disease prior to surgery is challenging, and providing a definite diagnosis requires histopathological and immunohistochemical examination, while genetic analysis may also be required.

A Next-Generation Sequencing Strategy for Evaluating the Most Common Genetic Abnormalities in Multiple Myeloma.

PubMed

Jiménez, Cristina; Jara-Acevedo, María; Corchete, Luis A; Castillo, David; Ordóñez, Gonzalo R; Sarasquete, María E; Puig, Noemí; Martínez-López, Joaquín; Prieto-Conde, María I; García-Álvarez, María; Chillón, María C; Balanzategui, Ana; Alcoceba, Miguel; Oriol, Albert; Rosiñol, Laura; Palomera, Luis; Teruel, Ana I; Lahuerta, Juan J; Bladé, Joan; Mateos, María V; Orfão, Alberto; San Miguel, Jesús F; González, Marcos; Gutiérrez, Norma C; García-Sanz, Ramón

2017-01-01

Identification and characterization of genetic alterations are essential for diagnosis of multiple myeloma and may guide therapeutic decisions. Currently, genomic analysis of myeloma to cover the diverse range of alterations with prognostic impact requires fluorescence in situ hybridization (FISH), single nucleotide polymorphism arrays, and sequencing techniques, which are costly and labor intensive and require large numbers of plasma cells. To overcome these limitations, we designed a targeted-capture next-generation sequencing approach for one-step identification of IGH translocations, V(D)J clonal rearrangements, the IgH isotype, and somatic mutations to rapidly identify risk groups and specific targetable molecular lesions. Forty-eight newly diagnosed myeloma patients were tested with the panel, which included IGH and six genes that are recurrently mutated in myeloma: NRAS, KRAS, HRAS, TP53, MYC, and BRAF. We identified 14 of 17 IGH translocations previously detected by FISH and three confirmed translocations not detected by FISH, with the additional advantage of breakpoint identification, which can be used as a target for evaluating minimal residual disease. IgH subclass and V(D)J rearrangements were identified in 77% and 65% of patients, respectively. Mutation analysis revealed the presence of missense protein-coding alterations in at least one of the evaluating genes in 16 of 48 patients (33%). This method may represent a time- and cost-effective diagnostic method for the molecular characterization of multiple myeloma. Copyright © 2017 American Society for Investigative Pathology and the Association for Molecular Pathology. 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.

Multiple composite grafts (k, π or double-Y) in coronary artery surgery: a choice or a necessity?

PubMed

Mannacio, Vito; Cirillo, Plinio; Mannacio, Luigi; Antignano, Anita; Mottola, Michele; Vosa, Carlo

2015-01-01

Composite grafts allow complete arterial revascularization with minimal aortic manipulations. The Y-T configuration supplies all distal branches adequately, whereas it is unclear whether complex composite configurations (K, Π or double-Y) are equally at rest or when challenged by maximal requirements. Forty-seven patients who underwent off-pump coronary artery revascularization by multiple arterial composite grafts (K, Π or double-Y) were retrospectively evaluated. Indication for this surgical option was porcelain aorta or conduit unavailability. Composite systems were evaluated by intraoperative flow measurements and perioperative transthoracic Doppler ultrasonography, 12 months later also by exercise test, sestamibi scintigraphy at rest and during induced hyperaemia and by 64-slice multidetector CT angiography. A total of 141 distal anastomoses were implanted as composite grafts. Perioperative flow measurements and 12-month Doppler ultrasonography were adequate at rest. At stress test, chest pain and/or induced ECG evidence of ischaemia are found in 16 patients (39%). During dipyridamole-induced hyperaemia, single-photon emission computed tomography image revealed that mean summed stress score was 7.2 ± 5.7, summed difference score 5.3 ± 4.2 and coronary flow reserve 1.7 ± 0.2. Multiple composite grafts, albeit adequate at rest, were unable to meet flow requirements during maximal hyperaemia. In daily practice, their use must be not a choice but rather a necessity in those patients without alternative options. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Comorbid Conditions in Neonates With Congenital Heart Disease.

PubMed

Krishnamurthy, Ganga; Ratner, Veniamin; Bacha, Emile; Aspelund, Gudrun

2016-08-01

The objectives of this review are to discuss the pathophysiology, clinical impact and treatment of major noncardiac anomalies, and prematurity in infants with congenital heart disease. MEDLINE and PubMed. Mortality risk is significantly higher in patients with congenital heart disease and associated anomalies compared with those in whom the heart defect occurs in isolation. Although most noncardiac structural anomalies do not require surgery in the neonatal period, several require surgery for survival. Management of such infants poses multiple challenges. Premature infants with congenital heart disease face challenges imposed by their immature organ systems, which are susceptible to injury or altered function by congenital heart disease and abnormal circulatory physiology independent of congenital heart disease. For optimal outcomes in premature infants or in infants with multiple congenital anomalies, a collaborative interdisciplinary approach is necessary.

Investigation of Severe Craniomaxillofacial Battle Injuries Sustained by U.S. Service Members: A Case Series

PubMed Central

Brown Baer, Pamela R.; Wenke, Joseph C.; Thomas, Steven J.; Hale, Colonel Robert G.

2012-01-01

This case series describes craniomaxillofacial battle injuries, currently available surgical techniques, and the compromised outcomes of four service members who sustained severe craniomaxillofacial battle injuries in Iraq or Afghanistan. Demographic information, diagnostic evaluation, surgical procedures, and outcomes were collected and detailed with a follow-up of over 2 years. Reconstructive efforts with advanced, multidisciplinary, and multiple revision procedures were indicated; the full scope of conventional surgical options and resources were utilized. Patients experienced surgical complications, including postoperative wound dehiscence, infection, flap failure, inadequate mandibular healing, and failure of fixation. These complications required multiple revisions and salvage interventions. In addition, facial burns complicated reconstructive efforts by delaying treatment, decreasing surgical options, and increasing procedural numbers. All patients, despite multiple surgeries, continue to have functional and aesthetic deficits as a result of their injuries. Currently, no conventional treatments are available to satisfactorily reconstruct the face severely ravaged by explosive devices to an acceptable level, much less to natural form and function. PMID:24294409

Successful treatment of severe sinusoidal obstruction syndrome despite multiple organ failure with defibrotide after allogeneic stem cell transplantation: a case report.

PubMed

Behre, Gerhard; Theurich, Sebastian; Christopeit, Maximilian; Weber, Thomas

2009-03-10

We report a case of sinusoidal obstruction syndrome, a typical and life-threatening complication after allogeneic stem-cell transplantation, successfully treated with defibrotide despite massive multiple organ failure. A 64-year-old Caucasian woman underwent allogeneic peripheral blood stem-cell transplantation from her human leukocyte antigen-identical sister against aggressive lymphoplasmocytoid immunocytoma. Seven days later, the patient developed severe sinusoidal obstruction syndrome according to the modified Seattle criteria. We initiated treatment with defibrotide. Despite early treatment, multiple organ failure with kidney failure requiring dialysis and ventilator-dependent lung failure aggravated the clinical course. Furthermore, central nervous dysfunction occurred as well as transfusion refractory thrombocytopenia. As highlighted in our report, defibrotide is the most promising drug in the treatment of the formerly, almost lethal, severe sinusoidal obstruction syndrome to date. This is demonstrated very clearly in our patient. She improved completely, even after renal, cerebral and respiratory failure.

Successful treatment of severe sinusoidal obstruction syndrome despite multiple organ failure with defibrotide after allogeneic stem cell transplantation: a case report

PubMed Central

2009-01-01

Introduction We report a case of sinusoidal obstruction syndrome, a typical and life-threatening complication after allogeneic stem-cell transplantation, successfully treated with defibrotide despite massive multiple organ failure. Case presentation A 64-year-old Caucasian woman underwent allogeneic peripheral blood stem-cell transplantation from her human leukocyte antigen-identical sister against aggressive lymphoplasmocytoid immunocytoma. Seven days later, the patient developed severe sinusoidal obstruction syndrome according to the modified Seattle criteria. We initiated treatment with defibrotide. Despite early treatment, multiple organ failure with kidney failure requiring dialysis and ventilator-dependent lung failure aggravated the clinical course. Furthermore, central nervous dysfunction occurred as well as transfusion refractory thrombocytopenia. Conclusion As highlighted in our report, defibrotide is the most promising drug in the treatment of the formerly, almost lethal, severe sinusoidal obstruction syndrome to date. This is demonstrated very clearly in our patient. She improved completely, even after renal, cerebral and respiratory failure. PMID:19830097

The use of a personal digital assistant for wireless entry of data into a database via the Internet.

PubMed

Fowler, D L; Hogle, N J; Martini, F; Roh, M S

2002-01-01

Researchers typically record data on a worksheet and at some later time enter it into the database. Wireless data entry and retrieval using a personal digital assistant (PDA) at the site of patient contact can simplify this process and improve efficiency. A surgeon and a nurse coordinator provided the content for the database. The computer programmer created the database, placed the pages of the database on the PDA screen, and researched and installed security measures. Designing the database took 6 months. Meeting Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements for patient confidentiality, satisfying institutional Information Services requirements, and ensuring connectivity required an additional 8 months before the functional system was complete. It is now possible to achieve wireless entry and retrieval of data using a PDA. Potential advantages include collection and entry of data at the same time, easy entry of data from multiple sites, and retrieval of data at the patient's bedside.

Robot training of upper limb in multiple sclerosis: comparing protocols with or without manipulative task components.

PubMed

Carpinella, Ilaria; Cattaneo, Davide; Bertoni, Rita; Ferrarin, Maurizio

2012-05-01

In this pilot study, we compared two protocols for robot-based rehabilitation of upper limb in multiple sclerosis (MS): a protocol involving reaching tasks (RT) requiring arm transport only and a protocol requiring both objects' reaching and manipulation (RMT). Twenty-two MS subjects were assigned to RT or RMT group. Both protocols consisted of eight sessions. During RT training, subjects moved the handle of a planar robotic manipulandum toward circular targets displayed on a screen. RMT protocol required patients to reach and manipulate real objects, by moving the robotic arm equipped with a handle which left the hand free for distal tasks. In both trainings, the robot generated resistive and perturbing forces. Subjects were evaluated with clinical and instrumental tests. The results confirmed that MS patients maintained the ability to adapt to the robot-generated forces and that the rate of motor learning increased across sessions. Robot-therapy significantly reduced arm tremor and improved arm kinematics and functional ability. Compared to RT, RMT protocol induced a significantly larger improvement in movements involving grasp (improvement in Grasp ARAT sub-score: RMT 77.4%, RT 29.5%, p=0.035) but not precision grip. Future studies are needed to evaluate if longer trainings and the use of robotic handles would significantly improve also fine manipulation.

International Myeloma Working Group Consensus Statement for the Management, Treatment, and Supportive Care of Patients With Myeloma Not Eligible for Standard Autologous Stem-Cell Transplantation

PubMed Central

Palumbo, Antonio; Rajkumar, S. Vincent; San Miguel, Jesus F.; Larocca, Alessandra; Niesvizky, Ruben; Morgan, Gareth; Landgren, Ola; Hajek, Roman; Einsele, Hermann; Anderson, Kenneth C.; Dimopoulos, Meletios A.; Richardson, Paul G.; Cavo, Michele; Spencer, Andrew; Stewart, A. Keith; Shimizu, Kazuyuki; Lonial, Sagar; Sonneveld, Pieter; Durie, Brian G.M.; Moreau, Philippe; Orlowski, Robert Z.

2014-01-01

Purpose To provide an update on recent advances in the management of patients with multiple myeloma who are not eligible for autologous stem-cell transplantation. Methods A comprehensive review of the literature on diagnostic criteria is provided, and treatment options and management of adverse events are summarized. Results Patients with symptomatic disease and organ damage (ie, hypercalcemia, renal failure, anemia, or bone lesions) require immediate treatment. The International Staging System and chromosomal abnormalities identify high- and standard-risk patients. Proteasome inhibitors, immunomodulatory drugs, corticosteroids, and alkylating agents are the most active agents. The presence of concomitant diseases, frailty, or disability should be assessed and, if present, treated with reduced-dose approaches. Bone disease, renal damage, hematologic toxicities, infections, thromboembolism, and peripheral neuropathy are the most frequent disabling events requiring prompt and active supportive care. Conclusion These recommendations will help clinicians ensure the most appropriate care for patients with myeloma in everyday clinical practice. PMID:24419113

Safety in the operating theatre--a transition to systems-based care.

PubMed

Weiser, Thomas G; Porter, Michael P; Maier, Ronald V

2013-03-01

All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.

Randomized, controlled, two-arm, interventional, multicenter study on risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple-trauma patients.

PubMed

Rixen, Dieter; Steinhausen, Eva; Sauerland, Stefan; Lefering, Rolf; Maegele, Marc G; Bouillon, Bertil; Grass, Guido; Neugebauer, Edmund A M

2016-01-25

Long bone fractures, particularly of the femur, are common in multiple-trauma patients, but their optimal management has not yet been determined. Although a trend exists toward the concept of "damage control orthopedics" (DCO), current literature is inconclusive. Thus, a need exists for a more specific controlled clinical study. The primary objective of this study was to clarify whether a risk-adapted procedure for treating femoral fractures, as opposed to an early definitive treatment strategy, leads to an improved outcome (morbidity and mortality). The study was designed as a randomized controlled multicenter study. Multiple-trauma patients with femur shaft fractures and a calculated probability of death of 20 to 60 % were randomized to either temporary fracture fixation with external fixation and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective was to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score. Thirty-four patients were randomized to two groups of 17 patients each. Both groups were comparable regarding sex, age, injury severity score, Glasgow Coma Scale, prothrombin time, base excess, calculated probability of death, and other physiologic variables. The maximum SOFA score was comparable (nonsignificant) between the groups. Regarding the secondary endpoints, the patients with external fixation required a significantly longer ventilation period (p = 0.049) and stayed on the intensive care significantly longer (p = 0.037), whereas the in-hospital length of stay was balanced for both groups. Unfortunately, the study had to be terminated prior to reaching the anticipated sample size because of unexpected low patient recruitment. Thus, the results of this randomized study reflect the ambivalence in the literature. No advantage of the damage control concept could be detected in the treatment of femur fractures in multiple-trauma patients. The necessity for scientific evaluation of this clinically relevant question remains. Current Controlled Trials ISRCTN10321620 Date assigned: 9 February 2007.

Posterior all-pedicle screw instrumentation combined with multiple chevron and concave rib osteotomies in the treatment of adolescent congenital kyphoscoliosis.

PubMed

Ayvaz, Mehmet; Olgun, Z Deniz; Demirkiran, H Gokhan; Alanay, Ahmet; Yazici, Muharrem

2014-01-01

Congenital kyphoscoliosis is a disorder that often requires surgical treatment. Although many methods of surgical treatment exist, posterior-only vertebral column resection with instrumentation and fusion seem to have become the gold standard for very severe and very rigid curves. Multiple chevron and concave rib osteotomies have been previously reported to be effective in the treatment of neglected severe idiopathic curves. We hypothesized that this method may also be used successfully in the treatment of congenital kyphoscoliosis. To evaluate the effectiveness and safety of multiple chevron osteotomies combined with concave rib osteotomy and posterior pedicle screw instrumentation. Retrospective chart review in the spine service of a large university hospital. Adolescent patients undergoing a specific surgical treatment for the indication of rigid congenital kyphoscoliotic deformity. Radiographic images were used for the measurement of deformity correction. The Turkish version of the Scoliosis Research Society 22 (SRS-22) Patient Questionnaire has been used as a clinical outcome measure in the patient population. A retrospective chart review was performed. Patients admitted to Hacettepe Hospital Spine Center during the period of 2005 to 2009 were included. Criteria for inclusion were as follows: adolescent age group (10-16 years); congenital kyphoscoliosis; formation and/or segmentation defect of at least two vertebral motion segments; surgical treatment of deformity by posterior all-pedicle screw instrumentation, multiple chevron osteotomies, and multiple concave rib osteotomies; follow-up of at least 24 months; and a complete set of preoperative, postoperative, and follow-up standing posteroanterior and lateral full spinal radiographs. The patients' hospital records and X-rays were reviewed. Duration of surgery, intraoperative blood loss, postoperative transfusion requirements, postoperative stay in postanesthesia care unit (PACU), time of hospitalization, and complications were recorded. Deformity in both coronal and sagittal planes was analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. Patients' health-related quality of life was assessed using the SRS-22 questionnaire at the final follow-up. Eighteen patients met the inclusion criteria. Their average age was 13.6 years (range, 11-16 years). Chevron osteotomies were performed at apical segments (three to seven levels) and concave rib osteotomies at Cobb-to-Cobb (five to eight levels). No patient had preoperative cord compression because of the sharply angulated deformity or neurologic deficit. The average preoperative scoliosis was 66.0° (range, 31°-116°), 52.4° (range, 22°-85°) on flexibility X-rays, and became 24.9° (range, 12°-52°) postoperatively. The average preoperative global kyphosis (T2-T12) of 75.9° (range, 50°-106°) became 49.5° (range, 18°-66°). The average preoperative local kyphosis of 71.9° (range, 35°-114°) became 31.4° (range, -44° to 64°). The average intraoperative bleeding was 989 cc, surgical time was 292 minutes, and intraoperative transfusion was 2.3 units. The maximum PACU stay was overnight. There were no neurologic complications except one pneumothorax and one pneumonia. The average follow-up was 34.3 months. At follow-up, average scoliosis was 27.5° (range, 10°-50°), global kyphosis was 50.3° (range, 28°-73°), and local kyphosis was 36.9°(range, -36° to 58°). Performed on the last follow-up, the average scores for the five domains of SRS-22 were 4.3, 4.4, 4.2, 4.1, and 4.8 for function, pain, self-image, mental health, satisfaction, and total, respectively. Multiple chevron and concave rib osteotomies with posterior instrumentation provide an acceptable rate of deformity correction and maintenance of correction at 2 years with acceptable intraoperative bleeding, surgical time, postoperative morbidity, and rate of complications. It can be considered as an alternative in the treatment of rigid congenital curves involving more than three levels or multiple curves separated by at least two segments that would otherwise require multiple vertebral resections. Copyright © 2014 Elsevier Inc. All rights reserved.

Defective sensorimotor integration in preparation for reaction time tasks in patients with multiple sclerosis.

PubMed

Cabib, Christopher; Llufriu, Sara; Casanova-Molla, Jordi; Saiz, Albert; Valls-Solé, Josep

2015-03-01

Slowness of voluntary movements in patients with multiple sclerosis (MS) may be due to various factors, including attentional and cognitive deficits, delays in motor conduction time, and impairment of specific central nervous system circuits. In 13 healthy volunteers and 20 mildly disabled, relapsing-remitting MS patients, we examined simple reaction time (SRT) tasks requiring sensorimotor integration in circuits involving the corpus callosum and the brain stem. A somatosensory stimulus was used as the imperative signal (IS), and subjects were requested to react with either the ipsilateral or the contralateral hand (uncrossed vs. crossed SRT). In 33% of trials, a startling auditory stimulus was presented together with the IS, and the percentage reaction time change with respect to baseline SRT trials was measured (StartReact effect). The difference between crossed and uncrossed SRT, which requires interhemispheric conduction, was significantly larger in patients than in healthy subjects (P = 0.021). The StartReact effect, which involves activation of brain stem motor pathways, was reduced significantly in patients with respect to healthy subjects (uncrossed trials: P = 0.015; crossed trials: P = 0.005). In patients, a barely significant correlation was found between SRT delay and conduction abnormalities in motor and sensory pathways (P = 0.02 and P = 0.04, respectively). The abnormalities found specifically in trials reflecting interhemispheric transfer of information, as well as the evidence for reduced subcortical motor preparation, indicate that a delay in reaction time execution in MS patients cannot be explained solely by conduction slowing in motor and sensory pathways but suggest, instead, defective sensorimotor integration mechanisms in at least the two circuits examined. Copyright © 2015 The American Physiological Society.

Simultaneous Iliac Vein Bovine Pericardial Patch Venoplasty and Creation of PTFE Lower Limb Arteriovenous Fistula Graft for Rescue Vascular Access.

PubMed

Meecham, Lewis; Fisher, Owain; Kirby, George; Evans, Richard; Buxton, Pauline; Legge, Jocelyn; Rajagopalan, Sriram; Asquith, John; Pherwani, Arun

2016-10-01

We present a case of external iliac vein patch venoplasty to accommodate rescue vascular access via a polytetrafluoroethylene loop arteriovenous fistula graft (AVG) for a patient with multiple central venous stenoses. A 35-year-old female with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Repeated occlusion and/or thrombosis of long-term central venous access cannulae, to facilitate dialysis, had caused stenosis of brachiocephalic veins: right external iliac vein and occlusion of the left common iliac vein. A previous right brachiobasilic fistula had occluded within 1 year. No other upper limb options for arteriovenous fistula (AVF) were available. A right external iliac vein bovine patch angioplasty concurrently with a polytetrafluoroethylene AV graft between common femoral artery and common femoral vein was performed to restore venous patency and allow rescue dialysis access. At 3-year follow-up, the fistula remains widely patent with 2 L/min flow rates and no recurrent stenosis to the treated iliac vein. She has not required any further surgical or interventional radiological procedures to maintain fistula or central venous patency. Central venous stenosis or occlusion is common for patients requiring dialysis, especially those with multiple previous long-term central venous cannulations. If restriction of outflow is present, AVF may fail. Venous patch angioplasty in these cases is a successful technique, allowing AVF formation and long-term patency. Central venous stenosis can be treated successfully with patch venoplasty to accommodate AVF/AVG formation for rescue vascular access; this is a potentially lifesaving intervention for patients requiring dialysis. Copyright © 2016 Elsevier Inc. All rights reserved.

Conservation of pancreatic tissue by combined gastric, biliary, and pancreatic duct drainage for pain from chronic pancreatitis.

PubMed

Warshaw, A L

1985-04-01

In patients with chronic pancreatitis, the sclerosing process of the pancreas may constrict not only the pancreatic duct for also the bile duct and duodenum. This study analyzes the prevalence of these obstructive lesions in 58 consecutive patients with chronic pancreatitis requiring surgery for either pain (57 patients) or for painless jaundice (1 patient). There was significant biliary obstruction in 21, 4 of whom also had symptomatic duodenal obstruction. All 21 patients with biliary and duodenal obstruction were among the 38 with a dilated pancreatic duct suitable for pancreaticojejunostomy (modified Puestow procedure). None of the 20 patients with small duct pancreatitis had biliary or duodenal obstruction. Pseudocysts were distributed evenly between the two groups (9 of 38 patients with a dilated duct versus 4 of 20 patients with small duct pancreatitis). Pancreaticojejunostomy combined with choledochoenterostomy and gastrojejunostomy in appropriately selected patients provided good to excellent long-term (mean 3.6 years) relief of pain in 30 of 36 patients (83 percent). There was no correlation between successful relief of pain and development of pancreatic exocrine or endocrine insufficiency or calcification. Stenosis of the bile duct developed some years subsequent to pancreaticojejunostomy in four patients and required a second operation for choledochoenterostomy in three. Three other patients required secondary pancreatic resections due to failure of the pancreaticojejunostomy to relieve pain. It is often possible to effect excellent relief of symptoms with maximal conservation of remaining pancreatic functions despite sclerotic obstruction of multiple organ systems.

Periorbital burns – a 6 year review of management and outcome.

PubMed

Fitzgerald O'Connor, Edmund; Frew, Q; Din, A; Pleat, J; Ashraff, S; Ghazi-Nouri, S; El-Muttardi, N; Philp, B; Dziewulski, P

2015-05-01

Periorbital burns are an infrequent but potentially devastating injury. This study aimed to elucidate the spectrum of such injuries presenting to a UK burns centre and the outcome achieved in the cases requiring periorbital reconstruction for the restoration of function and form. Patients admitted to a UK regional burns centre between January 2005 and January 2011 with periorbital burns were identified from the Patient Administration System (PAS), theatre logs and the International Burns Injury database (IBID). Multiple parameters were assessed using patient notes, ITU and hospital image databases. Over 6 years, 167 patients with facial burns requiring surgery were treated, including 103 patients with eyelid burns. The mean burn size was 33% total body surface area. The eyelid burn depth varied; 67% superficial partial thickness, 17% deep dermal and 16% full thickness. Two patients lost complete vision in one eye, one patient underwent amniotic membrane grafting. In total 16 patients required periorbital reconstruction to maintain eye closure, with 1.8 operations on average per patient. Acute surgery was required in 11 patients, whilst late intervention (>3 months) was needed in 5, 2 patients had both acute and delayed surgery. Of the 5 late intervention patients 4 were treated with full thickness skin grafts and 1 with a Z plasty. Average time for final reconstruction with delayed surgery was 4.5 months. The goal in management of periorbital burns is preservation of vision, prevention of future complications and restoration of an acceptable aesthetic outcome. Total visual loss is thankfully rare, but early ophthalmology intervention is vital given the evidence of corneal damage as a brief therapeutic window exists. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

Sirolimus and tacrolimus trough concentrations and dose requirements after kidney transplantation in relation to CYP3A5 and MDR1 polymorphisms and steroids.

PubMed

Mourad, Michel; Mourad, Georges; Wallemacq, Pierre; Garrigue, Valérie; Van Bellingen, Christophe; Van Kerckhove, Valérie; De Meyer, Martine; Malaise, Jacques; Eddour, Djamila Chaib; Lison, Dominique; Squifflet, Jean Paul; Haufroid, Vincent

2005-10-15

CYP3A5 and MDR1 polymorphisms have been shown to influence tacrolimus blood concentrations and dose requirements. The aim is to determine whether these polymorphisms also affect sirolimus trough concentrations and dose requirements after kidney transplantation. Eighty-five renal transplant recipients receiving sirolimus were included. Twenty-four were treated with a combined sirolimus-tacrolimus regimen. Eighty-one patients received steroids. Sirolimus and tacrolimus were adjusted to a target therapeutic window. CYP3A5 (intron 3) and MDR1 (exons 12, 21, 26) genotypes were correlated to the adjusted trough concentrations and dose requirements for both sirolimus and tacrolimus. There were no significant correlation between adjusted sirolimus trough concentrations or dose requirements and genetic polymorphisms. In a multiple regression model, adjusted-prednisone dose was involved with a positive or negative effect when considering sirolimus dose requirements or adjusted concentrations, respectively. In the subgroup of patients treated by tacrolimus and sirolimus, adjusted tacrolimus doses were higher in patients carrying at least one CYP3A5 *1 allele (median 0.083 vs. 0.035 mg/kg for CYP3A5*3/*3 patients, P<0.05). Adjusted-prednisolone dose and CYP3A5 polymorphism explained up to 61% of the variability in tacrolimus dose requirements. Unlike tacrolimus, sirolimus adjusted trough concentrations and dose requirements seem not affected by CYP3A5 and MDR1 polymorphisms. Adjusted-prednisone dose has a significant impact on tacrolimus and sirolimus dose requirements.

Two Year Old With Water Bead Ingestion.

PubMed

Jackson, Jami; Randell, Kimberly A; Knapp, Jane F

2015-08-01

Foreign body ingestion is a common pediatric complaint. Two case reports describe intestinal obstruction in children from an ingestion of a single superabsorbent water ball, requiring surgical removal. We describe nonsurgical management of an asymptomatic child who ingested approximately 100 superabsorbent water beads.Because of the risk for subsequent intestinal obstruction, the patient was admitted for whole bowel irrigation. This case report is the first describing use of whole bowel irrigation in the management of an asymptomatic patient with multiple water beads ingestion.

Fournier gangrene associated with hyper IgE syndrome (Job syndrome).

PubMed

Hori, Junichi; Yamaguchi, Satoshi; Watanabe, Masaki; Osanai, Hiroaki; Hori, Masako

2008-04-01

We report a case of a 32-year-old man with hyper IgE syndrome (Job syndrome) who developed Fournier gangrene due to infectious multiple atheromas of the scrotal skin that progressed to the right groin and thigh. The patient required surgical debridement and subsequent skin grafting. This is a rare case of Fournier gangrene associated with hyper IgE syndrome (Job syndrome). When a patient without diabetes mellitus has repeated infections and atopic-like dermatitis, Job syndrome should be considered.

[Diagnosis and management of chronic renal failure in the elderly].

PubMed

Segalen, Isabelle; Le Meur, Yannick

2016-01-01

The incidence of chronic renal failure in the elderly is rising due to the ageing of the general population. Its management, and notably nephroprotective therapies, must be adapted to the elderly person who is often frail and with multiple pathologies. The decision to start extra-renal purification does not depend on the patient's chronological age but on their physiological age and requires dialogue between the patient and their family, the geriatrician and the nephrologist. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Self-expandable CoreValve implantation without contrast media.

PubMed

Bruschi, Giuseppe; Colombo, Paola; De Marco, Federico; Barosi, Alberto; Mauri, Silvia; Klugmann, Silvio

2016-09-01

Transcatheter aortic valve implantation has been designed to treat high-risk surgical patients affected by severe aortic stenosis, many of whom are affected by chronic kidney disease. To perform transcatheter self-expandable valve implantation, multiple contrast injections are required to monitor the procedure, so these patients are at increased risk of acute kidney injury. We described self-expandable transcatheter aortic valve implantation without contrast media in an 80-year-old man affected by severe aortic stenosis and endstage chronic kidney disease. © The Author(s) 2015.

[Is polytrauma affordable these days? G-DRG system vs per diem charge based on 1,030 patients with multiple injuries].

PubMed

Qvick, B; Buehren, V; Woltmann, A

2012-10-01

The introduction of diagnosis-related groups (DRG) in Germany comprises the risk of a non-cost-effective reimbursement in complex medical treatments. The aim of this study was to compare the reimbursement between the DRG system and the system of hospital per diem charge in effect until now. The G-DRG (Version 2004) reimbursement was calculated for 1,030 polytrauma patients (average ISS 26.4) treated at the BGU Murnau from 2000 to 2004, using a base value of 2900 euros, and compared to the reimbursement of hospital per diem charge. Just half of all polytrauma patients are classified as a polytrauma according to the DRG (18.7%) or as requiring artificial respiration based on the DRG (29.1%). The average G-DRG reimbursement was 27,157 euros vs 36,387 euros (74.6%). Patients with minor trauma, increasing age, high GCS, ICU stay without artificial respiration, trauma of the upper extremity and patients who survived show the greatest discrepancy. A revision of the G-DRG definition of polytrauma is necessary to ensure adequate reimbursement for management of patients with multiple injuries. The severity of a trauma has to be considered in the DRG system.

Factors associated with discontinuation of aripiprazole treatment after switching from other antipsychotics in patients with chronic schizophrenia: A prospective observational study.

PubMed

Takaesu, Yoshikazu; Kishimoto, Taishiro; Murakoshi, Akiko; Takahashi, Nobutada; Inoue, Yuichi

2016-02-28

The purpose of the study was to identify factors associated with discontinuation of aripiprazole after switching from other antipsychotics in patients with schizophrenia in real world clinical settings. From January 2011 to December 2012, a prospective, 48-week open-label study was undertaken. Thirty-eight subjects on antipsychotic monotherapy were switched to aripiprazole. Patients who discontinued aripiprazole were compared to those who continued with regards to demographic characteristics as well as treatment factors. Multiple regression analysis was conducted to identify predictors for aripiprazole discontinuation. Thirteen out of 38 patients (34.2%) discontinued aripiprazole during the follow up period. Nine patients (23.7%) discontinued aripiprazole due to worsening of psychotic symptoms. Multiple logistic regression analysis revealed that only the duration of previous antipsychotic treatment was associated with aripiprazole discontinuation after switching to aripiprazole. The receiver operating curve (ROC) analysis identified that the cut-off length for duration of illness to predict aripiprazole discontinuation was 10.5 years. Longer duration of illness was associated with aripiprazole discontinuation. Greater caution may be required when treating such patients with aripiprazole. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Multiple sclerosis: evaluation of purine nucleotide metabolism in central nervous system in association with serum levels of selected fat-soluble antioxidants.

PubMed

Kuračka, Lubomír; Kalnovičová, Terézia; Kucharská, Jarmila; Turčáni, Peter

2014-01-01

In the pathogenesis of demyelinating diseases including multiple sclerosis (MS) an important role is played by oxidative stress. Increased energy requirements during remyelination of axons and mitochondria failure is one of the causes of axonal degeneration and disability in MS. In this context, we analyzed to what extent the increase in purine catabolism is associated with selected blood lipophilic antioxidants and if there is any association with alterations in serum levels of coenzyme Q10. Blood serum and cerebrospinal fluid (CSF) samples from 42 patients with diagnosed MS and 34 noninflammatory neurologic patients (control group) were analyzed. Compared to control group, MS patients had significantly elevated values of all purine nucleotide metabolites, except adenosine. Serum lipophilic antioxidants γ -tocopherol, β -carotene, and coenzyme Q10 for the vast majority of MS patients were deficient or moved within the border of lower physiological values. Serum levels of TBARS, marker of lipid peroxidation, were increased by 81% in the MS patients. The results indicate that the deficit of lipophilic antioxidants in blood of MS patients may have a negative impact on bioenergetics of reparative remyelinating processes and promote neurodegeneration.

Familial Adenomatous Polyposis (FAP)-A Case Study and Review of Literature.

PubMed

Dalavi, Santosh Bhimrao; Vedpalsingh, Tanwar Harshwardhan; Bankar, Sanket Subhash; Ahmed, Mohd Hamid Shafique; Bhosale, Dattatray Nivrutti

2015-03-01

Familial adenomatous polyposis (FAP) is a syndrome characteristically having numerous (hundreds to thousands) polyps in the epithelium of the large intestines with an autosomal dominant inheritance caused by germ line mutations in adenomatous polyposis coli (APC) gene in chromosome 5q21. Most FAP patients have a family history of colorectal polyps and cancer but 25-30% of them are "de novo", without any clinical or genetic evidence of FAP in family members. Prophylactic proctocolectomy is required in almost all patients since all affected patients inevitably develop cancer. We report a case of a 32-year-old man who presented with vague abdominal complaints without any family history, which on evaluation as found to have multiple colorectal polyps and underwent a prophylactic proctocolectomy with end continent ileostomy. Two of his children were evaluated and found to have multiple colorectal polyps on colonoscopy and have been advised regular follow up annually. In conclusion, patients with FAP may present with vague abdominal complaints and without any family history, hence need to be carefully evaluated. Good patient compliance is of prime importance in deciding the treatment and surveillance modality subsequently determining the prognosis of patients with FAP.

NOX2 protects against progressive lung injury and multiple organ dysfunction syndrome.

PubMed

Whitmore, Laura C; Goss, Kelli L; Newell, Elizabeth A; Hilkin, Brieanna M; Hook, Jessica S; Moreland, Jessica G

2014-07-01

Systemic inflammatory response syndrome (SIRS) is a common clinical condition in patients in intensive care units that can lead to complications, including multiple organ dysfunction syndrome (MODS). MODS carries a high mortality rate, and it is unclear why some patients resolve SIRS, whereas others develop MODS. Although oxidant stress has been implicated in the development of MODS, several recent studies have demonstrated a requirement for NADPH oxidase 2 (NOX2)-derived oxidants in limiting inflammation. We recently demonstrated that NOX2 protects against lung injury and mortality in a murine model of SIRS. In the present study, we investigated the role of NOX2-derived oxidants in the progression from SIRS to MODS. Using a murine model of sterile systemic inflammation, we observed significantly greater illness and subacute mortality in gp91(phox-/y) (NOX2-deficient) mice compared with wild-type mice. Cellular analysis revealed continued neutrophil recruitment to the peritoneum and lungs of the NOX2-deficient mice and altered activation states of both neutrophils and macrophages. Histological examination showed multiple organ pathology indicative of MODS in the NOX2-deficient mice, and several inflammatory cytokines were elevated in lungs of the NOX2-deficient mice. Overall, these data suggest that NOX2 function protects against the development of MODS and is required for normal resolution of systemic inflammation. Copyright © 2014 the American Physiological Society.

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.

Surgical treatment of traumatic multiple intracranial hematomas

PubMed Central

Yang, Chaohua; Li, Qiang; Wu, Cong; Zan, Xin; You, Chao

2014-01-01

Objective: To summarize our experience with the surgical treatment of traumatic multiple intracranial hematomas (TMIHs) and discuss the surgical indications. Methods: We analyzed the clinical data of 118 patients with TMIHs who were treated at the West China Hospital in Sichuan University, Chengdu, China between October 2008 and October 2011, including age, gender, cause of injury, diagnosis, treatment, and outcomes. Results: Among the 118 patients, there were 12 patients with different types of hematomas at the same site, 69 with one hematoma type in different compartments, and 37 with different types of hematomas in different compartments. In total, 106 patients had obliteration of basal cisterns, and 34 had a simultaneous midline shift ≥5 mm. Eighty-nine patients underwent single-site surgery, 19 had 2-site surgeries, and 10 patients did not undergo surgery. Based on the Glasgow Outcome Scale 6 months post-injury, 41 patients had favorable outcomes, and 77 had unfavorable outcomes. Basal cisterns obliteration was a strong indicator for surgical treatment. Single- or 2-site surgery was not related to outcome (p=0.234). Conclusion: Obliteration of the basal cisterns is a strong indication for surgical treatment of TMIHs. After evacuation of the major hematomas, the remaining hematomas can be treated conservatively. Most patients only require single-site surgical treatment. PMID:25274591

Implementing Family Meetings Into a Respiratory Care Unit: A Care and Communication Quality Improvement Project.

PubMed

Loeslie, Vicki; Abcejo, Ma Sunnimpha; Anderson, Claudia; Leibenguth, Emily; Mielke, Cathy; Rabatin, Jeffrey

Substantial evidence in critical care literature identifies a lack of quality and quantity of communication between patients, families, and clinicians while in the intensive care unit. Barriers include time, multiple caregivers, communication skills, culture, language, stress, and optimal meeting space. For patients who are chronically critically ill, the need for a structured method of communication is paramount for discussion of goals of care. The objective of this quality improvement project was to identify barriers to communication, then develop, implement, and evaluate a process for semistructured family meetings in a 9-bed respiratory care unit. Using set dates and times, family meetings were offered to patients and families admitted to the respiratory care unit. Multiple avenues of communication were utilized to facilitate attendance. Utilizing evidence-based family meeting literature, a guide for family meetings was developed. Templates were developed for documentation of the family meeting in the electronic medical record. Multiple communication barriers were identified. Frequency of family meeting occurrence rose from 31% to 88%. Staff satisfaction with meeting frequency, meeting length, and discussion of congruent goals of care between patient/family and health care providers improved. Patient/family satisfaction with consistency of message between team members; understanding of medications, tests, and dismissal plan; and efficacy to address their concerns with the medical team improved. This quality improvement project was implemented to address the communication gap in the care of complex patients who require prolonged hospitalizations. By identifying this need, engaging stakeholders, and developing a family meeting plan to meet to address these needs, communication between all members of the patient's care team has improved.

Difficulties with diagnosis and consequential poor outcome due to stigma of acquired immunodeficiency syndrome – a case report

PubMed Central

Vuletic, Vladimira; Nevajda, Branimir; Spero, Martina; Chudy, Darko

2013-01-01

Low incidence of human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) has been detected in Croatia so far. Toxoplasmic encephalitis (TE) is the most common opportunistic cerebral infection in AIDS patients and is highly responsive to antiparasitic chemotherapy, if treated at an early stage. We present the case of the brain biopsy confirmed as TE on a 36-year-old female patient who at admission presented with unconsciousness and a right hemiplegia. A MSCT was performed and two hypodense lesions were diagnosed. The patient’s family initially denied the presence or history of any medical problem or infection. An MRI showed multiple ring-enhanced mass lesions. An infectologist required a brain biopsy to exclude cerebral lymphoma and multiple metastases. Pathohistological analysis suggested TE. Meanwhile, patient’s blood samples were found to be HIV positive. The patient was transferred to University Hospital for Infectious Diseases in Zagreb, where she died 2 days following admission. The patient’s family terminally confessed that the patient had been HIV positive for 10 years and had refused any treatment. Family’s denial of infection as well as ‘hiding information’ concerning patient’s health from physicians involved in her treatment caused a delay in proper on-time patient treatment. We would like to emphasize that TE must be considered as a differential diagnosis in patients presenting with multiple cerebral lesions, including patients without acknowledged past history of HIV infection. A stigma towards HIV infection and ignorance of the disease still exist and therefore hinders proper treatment. PMID:24091082

Validity and reliability of a pilot scale for assessment of multiple system atrophy symptoms.

PubMed

Matsushima, Masaaki; Yabe, Ichiro; Takahashi, Ikuko; Hirotani, Makoto; Kano, Takahiro; Horiuchi, Kazuhiro; Houzen, Hideki; Sasaki, Hidenao

2017-01-01

Multiple system atrophy (MSA) is a rare progressive neurodegenerative disorder for which brief yet sensitive scale is required in order for use in clinical trials and general screening. We previously compared several scales for the assessment of MSA symptoms and devised an eight-item pilot scale with large standardized response mean [handwriting, finger taps, transfers, standing with feet together, turning trunk, turning 360°, gait, body sway]. The aim of the present study is to investigate the validity and reliability of a simple pilot scale for assessment of multiple system atrophy symptoms. Thirty-two patients with MSA (15 male/17 female; 20 cerebellar subtype [MSA-C]/12 parkinsonian subtype [MSA-P]) were prospectively registered between January 1, 2014 and February 28, 2015. Patients were evaluated by two independent raters using the Unified MSA Rating Scale (UMSARS), Scale for Assessment and Rating of Ataxia (SARA), and the pilot scale. Correlations between UMSARS, SARA, pilot scale scores, intraclass correlation coefficients (ICCs), and Cronbach's alpha coefficients were calculated. Pilot scale scores significantly correlated with scores for UMSARS Parts I, II, and IV as well as with SARA scores. Intra-rater and inter-rater ICCs and Cronbach's alpha coefficients remained high (> 0.94) for all measures. The results of the present study indicate the validity and reliability of the eight-item pilot scale, particularly for the assessment of symptoms in patients with early state multiple system atrophy.

Rural patients' knowledge about heart failure.

PubMed

Dracup, Kathleen; Moser, Debra K; Pelter, Michele M; Nesbitt, Thomas; Southard, Jeffrey; Paul, Steven M; Robinson, Susan; Hemsey, Jessica Zègre; Cooper, Lawton

2014-01-01

Heart failure (HF) is a potentially disabling condition requiring significant patient knowledge to manage the requirements of self-care. The need for self-care is important for all patients but particularly for those living in rural areas that are geographically remote from healthcare services. The aim of this study was to identify the level of knowledge of rural patients with HF and the clinical and demographic characteristics associated with low levels of HF knowledge. Baseline data from 612 patients with HF enrolled in the Rural Education to Improve Outcomes in Heart Failure trial were analyzed using the Heart Failure Knowledge Scale, the Short Test of Functional Health Literacy in Adults, and the anxiety subscale of the Brief Symptom Inventory. Multiple linear regression was used to explore the contribution of sociodemographic and clinical variables to levels of HF knowledge. The mean (SD) age was 66 (13) years; 59% were men, and 50.5% had an ejection fraction of less than 40%. The mean (SD) percent correct on the Heart Failure Knowledge Scale was 69.5% (13%; range, 25%-100%), with the most frequent incorrect items related to symptoms of HF and the need for daily weights. The men and the older patients scored significantly lower in HF knowledge than did the women and the younger patients (P = 0.002 and 0.011, respectively). The patients with preserved systolic function also scored significantly lower than those with systolic HF (P = 0.030). Patients who are at risk for poor self-care because of low levels of HF knowledge can be identified. Older patients, men, and, patients with HF with preserved systolic function may require special educational strategies to gain the knowledge required for effective self-care.

Use of whole-exome sequencing to determine the genetic basis of multiple mitochondrial respiratory chain complex deficiencies.

PubMed

Taylor, Robert W; Pyle, Angela; Griffin, Helen; Blakely, Emma L; Duff, Jennifer; He, Langping; Smertenko, Tania; Alston, Charlotte L; Neeve, Vivienne C; Best, Andrew; Yarham, John W; Kirschner, Janbernd; Schara, Ulrike; Talim, Beril; Topaloglu, Haluk; Baric, Ivo; Holinski-Feder, Elke; Abicht, Angela; Czermin, Birgit; Kleinle, Stephanie; Morris, Andrew A M; Vassallo, Grace; Gorman, Grainne S; Ramesh, Venkateswaran; Turnbull, Douglass M; Santibanez-Koref, Mauro; McFarland, Robert; Horvath, Rita; Chinnery, Patrick F

2014-07-02

Mitochondrial disorders have emerged as a common cause of inherited disease, but their diagnosis remains challenging. Multiple respiratory chain complex defects are particularly difficult to diagnose at the molecular level because of the massive number of nuclear genes potentially involved in intramitochondrial protein synthesis, with many not yet linked to human disease. To determine the molecular basis of multiple respiratory chain complex deficiencies. We studied 53 patients referred to 2 national centers in the United Kingdom and Germany between 2005 and 2012. All had biochemical evidence of multiple respiratory chain complex defects but no primary pathogenic mitochondrial DNA mutation. Whole-exome sequencing was performed using 62-Mb exome enrichment, followed by variant prioritization using bioinformatic prediction tools, variant validation by Sanger sequencing, and segregation of the variant with the disease phenotype in the family. Presumptive causal variants were identified in 28 patients (53%; 95% CI, 39%-67%) and possible causal variants were identified in 4 (8%; 95% CI, 2%-18%). Together these accounted for 32 patients (60% 95% CI, 46%-74%) and involved 18 different genes. These included recurrent mutations in RMND1, AARS2, and MTO1, each on a haplotype background consistent with a shared founder allele, and potential novel mutations in 4 possible mitochondrial disease genes (VARS2, GARS, FLAD1, and PTCD1). Distinguishing clinical features included deafness and renal involvement associated with RMND1 and cardiomyopathy with AARS2 and MTO1. However, atypical clinical features were present in some patients, including normal liver function and Leigh syndrome (subacute necrotizing encephalomyelopathy) seen in association with TRMU mutations and no cardiomyopathy with founder SCO2 mutations. It was not possible to confidently identify the underlying genetic basis in 21 patients (40%; 95% CI, 26%-54%). Exome sequencing enhances the ability to identify potential nuclear gene mutations in patients with biochemically defined defects affecting multiple mitochondrial respiratory chain complexes. Additional study is required in independent patient populations to determine the utility of this approach in comparison with traditional diagnostic methods.

Aspiration of breast abscess under ultrasound guidance: outcome obtained and factors affecting success.

PubMed

Elagili, Faisal; Abdullah, Norlia; Fong, Liew; Pei, Tan

2007-01-01

To assess ultrasonographically (US) guided needle aspiration of breast abscesses as an alternative to surgical incision and drainage. In our prospective study, 30 patients with 31 breast abscesses (one patient had bilateral breast abscess) underwent percutaneous breast abscess drainage under US guidance with local anaesthesia and oral antibiotics between 1 January 2004 and 31 March 2005. These patients consisted of 16 (53.3%) non-lactating and 14 (46.7%) lactating women, with ages ranging from 18 to 68 years (median, 28 years). The racial distribution comprised 26 (86.7%) Malays, three (10%) Chinese and one (3.3%) Indian. All patients had the chief complaint of breast swelling and 25 (83.3%) had breast pain. Clinically, 28 (93.3%) were found to have a palpable mass. Nine (30%) lesions were in the upper outer quadrant of the left breast. US diameters ranged from 1 to 15 cm (median, 4 cm). The pus volumes varied from 1 to 200 mL (median, 14 mL). Fifteen (50%) patients required only a single aspiration, 10 required multiple aspirations and five required incision and drainage. Those patients in whom needle aspiration failed had multiloculated lesions irrespective of abscess volume and size. Needle aspiration with ultrasound guidance is an effective treatment for breast abscess irrespective of abscess volume and size.

Risk Factors Associated with Mortality and Increased Drug Costs in Nonvariceal Upper Gastrointestinal Bleeding.

PubMed

Lu, Mingliang; Sun, Gang; Zhang, Xiu-li; Zhang, Xiao-mei; Liu, Qing-sen; Huang, Qi-yang; Lau, James W Y; Yang, Yun-sheng

2015-06-01

To determine risk factors associated with mortality and increased drug costs in patients with nonvariceal upper gastrointestinal bleeding. We retrospectively analyzed data from patients hospitalized with nonvariceal upper gastrointestinal bleeding between January 2001-December 2011. Demographic and clinical characteristics and drug costs were documented. Univariate analysis determined possible risk factors for mortality. Statistically significant variables were analyzed using a logistic regression model. Multiple linear regression analyzed factors influencing drug costs. p < 0.05 was considered statistically significant. The study included data from 627 patients. Risk factors associated with increased mortality were age > 60, systolic blood pressure<100 mmHg, lack of endoscopic examination, comorbidities, blood transfusion, and rebleeding. Drug costs were higher in patients with rebleeding, blood transfusion, and prolonged hospital stay. In this patient cohort, re-bleeding rate is 11.20% and mortality is 5.74%. The mortality risk in patients with comorbidities was higher than in patients without comorbidities, and was higher in patients requiring blood transfusion than in patients not requiring transfusion. Rebleeding was associ-ated with mortality. Rebleeding, blood transfusion, and prolonged hospital stay were associated with increased drug costs, whereas bleeding from lesions in the esophagus and duodenum was associated with lower drug costs.

Timing of intra-aortic balloon pump support and 1-year survival.

PubMed

Ramnarine, Ian R; Grayson, Antony D; Dihmis, Walid C; Mediratta, Neeraj K; Fabri, Brian M; Chalmers, John A C

2005-05-01

The relationship between the timing of intra-aortic balloon pump (IABP) support and surgical outcome remains a subject of debate. Peri-operative mechanical circulatory support is commenced either prophylactically or after increasing inotropic support has proved inadequate. This study evaluates the effect timing of IABP support on the 1-year survival of patients undergoing cardiac surgery. From April 1997 to September 2002, 7698 consecutive cardiac surgical procedures were performed. This included 5678 isolated coronary artery bypasses (CABGs), 1245 isolated valve procedures and 775 simultaneous CABG and valve procedures. IABP support was required in 237 patients (3.1%). Twenty-seven patients (0.35%) were classed as high-risk and received preoperative IABP support, 25 patients (0.32%) were haemodynamically compromised and required preoperative IABP support, 120 patients (1.56%) required intra-operative IABP support, and 65 patients (0.84%) required post-operative IABP support. Multiple variables were offered to a Cox proportional hazards model and significant predictors of 1-year survival were identified. These were used to risk adjust Kaplan-Meier survival curves. 1-year follow-up was complete and 450 deaths (5.8%) were recorded. The significant independent predictors of increased mortality at 1-year (P<0.05, HR=hazard ratio) were post-operative renal failure (HR=3.5), increasing EuroSCORE (HR=1.2), post-operative myocardial infarction (HR=3.7), post-operative IABP (HR=4.1) intra-operative IABP (HR=2.8), post-operative stroke (HR=2.5), increasing number of valves (HR=1.6), ejection fraction <30% (HR=1.3) and triple-vessel disease (HR=1.3). After risk-adjustment, 1-year survival for patients who required intra-operative IABP support was significantly greater than for those patients who required IABP support in the post-operative period. Patients who warrant IABP support in the post-operative setting have a significantly increased mortality at 1-year when compared to any other group. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome.

Reducing Unnecessary Portable Pelvic Radiographs in Trauma Patients: A Resident-Driven Quality Improvement Initiative.

PubMed

Langer, Jessica M; Tsai, Emily B; Luhar, Aarti; McWilliams, Justin; Motamedi, Kambiz

2015-09-01

Quality improvement is increasingly important in the changing health care climate. We aim to establish a methodology and identify critical factors leading to successful implementation of a resident-led radiology quality improvement intervention at the institutional level. Under guidance of faculty mentors, the first-year radiology residents developed a quality improvement initiative to decrease unnecessary STAT pelvic radiographs (PXRs) in hemodynamically stable trauma patients who would additionally receive STAT pelvic CT scans. Development and implementation of this initiative required multiple steps, including: establishing resident and faculty leadership, gathering evidence from published literature, cultivating multidisciplinary support, and developing and implementing an institution-wide ordering algorithm. A visual aid and brief questionnaire were distributed to clinicians for use during treatment of trauma cases to ensure sustainability of the initiative. At multiple time points, pre- and post-intervention, residents performed a retrospective chart review to evaluate changes in imaging-ordering trends for trauma patients. Chart review showed a decline in the number of PXRs for hemodynamically stable trauma patients, as recommended in the ordering algorithm: 78% of trauma patients received both a PXR and a pelvic CT scan in the first 24 hours of the initiative, compared with 26% at 1 month; 24% at 6 months; and 18% at 10 to 12 months postintervention. The resident-led radiology quality improvement initiative created a shift in ordering culture at an institutional level. Development and implementation of this algorithm exemplified the impact of a multidisciplinary collaborative effort involving multiple departments and multiple levels of the medical hierarchy. Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers.

PubMed

Seamon, Mark J; Shiroff, Adam M; Franco, Michael; Stawicki, S Peter; Molina, Ezequiel J; Gaughan, John P; Reilly, Patrick M; Schwab, C William; Pryor, John P; Goldberg, Amy J

2009-12-01

Historically, patients with penetrating cardiac injuries have enjoyed the best survival after emergency department thoracotomy (EDT), but further examination of these series reveals a preponderance of cardiac stab wound (SW) survivors with only sporadic cardiac gunshot wound (GSW) survivors. Our primary study objective was to determine which patients requiring EDT for penetrating cardiac or great vessel (CGV) injury are salvageable. All patients who underwent EDT for penetrating CGV injuries in two urban, level I trauma centers during 2000 to 2007 were retrospectively reviewed. Demographics, injury (mechanism, anatomic injury), prehospital care, and physiology (signs of life [SOL], vital signs, and cardiac rhythm) were analyzed with respect to hospital survival. The study population (n = 283) comprised young (mean age, 27.1 years +/- 10.1 years) men (96.1%) injured by gunshot (GSW, 88.3%) or SWs (11.7%). Patients were compared by injury mechanism and number of CGV wounds with respect to survival (SW, 24.2%; GSW, 2.8%; p < 0.001; single, 9.5%; multiple, 1.4%; p = 0.003). Three predictors-injury mechanism, ED SOL, and number of CGV wounds-were then analyzed alone and in combination with respect to hospital survival. Only one patient (0.8%) with multiple CGV GSW survived EDT. When the cumulative impact of penetrating injury mechanism, ED SOL, and number of CGV wounds was analyzed together, we established that those sustaining multiple CGV GSWs (regardless of ED SOL) were nearly unsalvageable. These results indicate that when multiple CGV GSWs are encountered after EDT, further resuscitative efforts may be terminated without limiting the opportunity for survival.

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

NASA Astrophysics Data System (ADS)

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

2016-10-01

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

Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy.

PubMed

Leung, S M; Chau, W W; Law, S W; Fung, K Y

2015-10-01

To identify the diagnostic, therapeutic, and prognostic values of transforaminal epidural steroid injection as interventional rehabilitation for lumbar radiculopathy. Regional hospital, Hong Kong. A total of 232 Chinese patients with lumbar radiculopathy attributed to disc herniation or spinal stenosis received transforaminal epidural steroid injection between 1 January 2007 and 31 December 2011. Transforaminal epidural steroid injection. Patients' immediate response, response duration, proportion of patients requiring surgery, and risk factors affecting the responses to transforaminal epidural steroid injection for lumbar radiculopathy. Of the 232 patients, 218 (94.0%) had a single level of radiculopathy and 14 (6.0%) had multiple levels. L5 was the most commonly affected level. The immediate response rate to transforaminal epidural steroid injection was 80.2% in 186 patients with clinically diagnosed lumbar radiculopathy and magnetic resonance imaging of the lumbar spine suggesting nerve root compression. Of patients with single-level radiculopathy and multiple-level radiculopathy, 175 (80.3%) and 11 (78.6%) expressed an immediate response to transforaminal epidural steroid injection, respectively. The analgesic effect lasted for 1 to <3 weeks in 35 (15.1%) patients, for 3 to 12 weeks in 37 (15.9%) patients, and for more than 12 weeks in 92 (39.7%) patients. Of the 232 patients, 106 (45.7%) were offered surgery, with 65 (61.3%) undergoing operation, and with 42 (64.6%) requiring spinal fusion in addition to decompression surgery. Symptom chronicity was associated with poor immediate response to transforaminal epidural steroid injection, but not with duration of pain reduction. Poor response to transforaminal epidural steroid injection was not associated with a preceding industrial injury. The immediate response to transforaminal epidural steroid injection was approximately 80%. Transforaminal epidural steroid injection is a useful diagnostic, prognostic, and short-term therapeutic tool for lumbar radiculopathy. Although transforaminal epidural steroid injection cannot alter the need for surgery in the long term, it is a reasonably safe procedure to provide short-term pain relief and as a preoperative assessment tool.

Comparison of quality of life between two clinical conditions with immunosuppressive therapy: liver transplantation and multiple sclerosis.

PubMed

Fernández-Jiménez, E; Pérez-San-Gregorio, M A; Martín-Rodríguez, A; Domínguez-Cabello, E; Navarro-Mascarell, G; Bernardos-Rodríguez, A

2012-11-01

We aimed to compare quality of life in two clinical conditions treated with immunosuppressants: cadaveric liver transplant recipients and multiple sclerosis patients. We also assessed the clinical significance of these results regarding a representative age-adjusted sample of the general Spanish population. Using a cross-sectional design, the SF-36 Health Survey was used to evaluate 62 patients with these chronic conditions (31 in each group) who were matched for gender. An analysis of covariance was performed to control for the influence of time from multiple sclerosis diagnosis and liver transplantation surgery until assessment. Student t test of covariate-adjusted mean values was used as the statistical test and Cohen's d effect size index, to assess the magnitude of intergroup differences and assess clinical significance. Significantly worse scores were observed among the neurological patients compared with transplant recipients regarding role-physical (P = .038), general health (P = .003), vitality (P = .034), and physical functioning (P = .049), with medium effect sizes (Cohen's ds from -0.511 to -0.785). Against normative values, liver transplant recipients displayed relevant differences in all SF-36 subscales (Cohen's ds from -0.569 to -0.974) except for mental health (small effect size). Likewise, multiple sclerosis patients showed much greater differences versus the general population (Cohen's ds from -0.846 to -1.760). Liver transplant recipients showed better quality of life than multiple sclerosis patients (medium effect sizes) in physical quality-of-life dimensions. Interestingly, despite having controlled for time from diagnosis/transplantation, both medical conditions showed clinically significant impairments (large and medium effect sizes) in physical and psychosocial quality-of-life domains. We concluded that transplant recipients belong to a population that still requires special health care because, even after having undergone their treatment of choice, they do not achieve normal levels of biopsychosocial functioning. Copyright © 2012 Elsevier Inc. All rights reserved.

75 FR 82402 - Proposed Consolidated Vaccine Information Materials for Multiple Infant Vaccines

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-30

... number of shots your baby needs by combining several vaccines in one shot. These combination vaccines are... to any patient (or to the parent or legal representative in the case of a child) receiving vaccines... United States who intends to administer one of these covered vaccines is required to provide copies of...

Multiple-, But Not Single-, Dose of Parecoxib Reduces Shoulder Pain after Gynecologic Laparoscopy

PubMed Central

Zhang, Hufei; Shu, Haihua; Yang, Lu; Cao, Minghui; Zhang, Jingjun; Liu, Kexuan; Xiao, Liangcan; Zhang, Xuyu

2012-01-01

Background: The aim of this study was to investigate effect of single- and multiple-dose of parecoxib on shoulder pain after gynecologic laparoscopy. Methods: 126 patients requiring elective gynecologic laparoscopy were randomly allocated to three groups. Group M (multiple-dose): receiving parecoxib 40mg at 30min before the end of surgery, at 8 and 20hr after surgery, respectively; Group S (single-dose): receiving parecoxib 40mg at 30min before the end of surgery and normal saline at the corresponding time points; Group C (control): receiving normal saline at the same three time points. The shoulder pain was evaluated, both at rest and with motion, at postoperative 6, 24 and 48hr. The impact of shoulder pain on patients' recovery (activity, mood, walking and sleep) was also evaluated. Meanwhile, rescue analgesics and complications were recorded. Results: The overall incidence of shoulder pain in group M (37.5%) was lower than that in group C (61.9%) (difference=-24.4%; 95% CI: 3.4~45.4%; P=0.023). Whereas, single-dose regimen (61.0%) showed no significant reduction (difference with control=-0.9%; 95% CI: -21.9~20.0%; P=0.931). Moreover, multiple-dose regimen reduced the maximal intensity of shoulder pain and the impact for activity and mood in comparison to the control. Multiple-dose of parecoxib decreased the consumption of rescue analgesics. The complications were similar among all groups and no severe complications were observed. Conclusions: Multiple-, but not single-, dose of parecoxib may attenuate the incidence and intensity of shoulder pain and thereby improve patients' quality of recovery following gynecologic laparoscopy. PMID:23136538

The influence of parenteral glutamine supplementation on glucose homeostasis in critically ill polytrauma patients--A randomized-controlled clinical study.

PubMed

Grintescu, Ioana Marina; Luca Vasiliu, Irina; Cucereanu Badica, Ioana; Mirea, Liliana; Pavelescu, Daniela; Balanescu, Andreea; Grintescu, Ioana Cristina

2015-06-01

Rapid onset of resistance to insulin is a prominent component of stress metabolism in multiple trauma patients. Recent studies have clarified the role of amino acids (especially glutamine) in glucose transportation and the benefits of parenteral alanyl-glutamine supplementation (0.3-0.6 g/kg/day) in glucose homeostasis. The aims of this study are to evaluate the incidence of hyperglycemic episodes and the need for exogenous insulin to maintain stable glucose levels in critically ill polytrauma patients supplemented with parenteral glutamine dipeptide (Dipeptiven(®)) versus standard nutritional support. This was an open-label randomized-controlled trial of 82 polytrauma patients aged 20-60 years old, randomly assigned into two equal groups independent of sex, age and Injury Severity Score. We excluded patients with diabetes mellitus, or renal or hepatic failure. One group received parenteral Dipeptiven(®) supplementation of 0.5 g/kg/day and the other received standard isocaloric isoproteinic nutritional support. We found that 63% of patients in the glutamine-supplemented group had no hyperglycemic episodes; only 37% required exogenous insulin (mean daily requirement of 44 units/day). In the control group, 51% of patients required insulin (mean daily requirement 63 unit/day; p = 0.0407). The effect of glutamine supplementation on glucose homeostasis is associated with a lower incidence of hyperglycemia among critically ill polytrauma patients, and leads to a lower mean daily dose of insulin. Controlled-trials.com Identifier: ISRCTN71592366 (http://www.controlled-trials.com/ISRCTN71592366/ISRCTN71592366). Copyright © 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Assessment of Depression, Anxiety, Quality of Life, and Coping in Long-Standing Multiple Endocrine Neoplasia Type 2 Patients.

PubMed

Rodrigues, Karine C; Toledo, Rodrigo A; Coutinho, Flavia L; Nunes, Adriana B; Maciel, Rui M B; Hoff, Ana O; Tavares, Marcos C; Toledo, Sergio P A; Lourenço, Delmar M

2017-05-01

Data on psychological harm in multiple endocrine neoplasia type 2 (MEN2) are scarce. The aim of this study was to assess anxiety, depression, quality of life, and coping in long-standing MEN2 patients. Patients were 43 adults (age ≥18 years) with clinical and genetic diagnosis of MEN2 and long-term follow-up (10.6 ± 8.2 years; range 1-33 years). This was a cross-sectional study with qualitative and quantitative psychological assessment using semi-directed interviews and HADS, EORTC QLQ C30, and MINI-MAC scales. Adopting clinical criteria from 2015 ATA Guidelines on MEN2, biochemical cure (39%; 16/41), persistence/recurrence (61%; 25/41), and stable chronic disease (22/41) of medullary thyroid carcinoma (MTC) were scored. Pheochromocytoma affected 19 (44%) patients, with previous adrenalectomy in 17 of them. Overall, anxiety (42%; mean score 11 ± 2.9; range 8-18; anxiety is defined as a score ≥8) and depression (26%; mean score 11 ± 3.8; range 8-20; depression is defined as a score ≥8) symptoms were frequent. Patients who transmitted RET mutations to a child had higher scores for weakness-discouragement/anxious preoccupation and lower scores for cognitive, emotional, and physical functioning (p < 0.05). Feelings of guilt were present in 35% of patients with mutation-positive children. Lower mean score values for depression and anxiety and higher scores for role, cognitive, and emotional functioning were noticed in 33 patients who were well-informed about their disease (p < 0.05). Fighting spirit was more frequently found in patients with multiple surgical procedures (p = 0.019) and controlled chronic adrenal insufficiency (p = 0.024). Patients with MEN2-related stress-inducing factors had lower scores for fighting spirit and cognitive functioning and higher scores for insomnia and dyspnea (p < 0.05). Eleven patients required sustained psychotherapeutic treatment. Mean global health status was relatively good in MEN2 cases (68.1 ± 22.3), and the cured group had higher physical functioning (p = 0.021). Psychological distress is likely chronic in MEN2 patients. This study identified diverse MEN2-related factors (degree of information on disease, mutation-positive children, number of surgeries, comorbidities, stress-inducing factors, and cure) interfering positively or negatively with the results of the psychometrics scales. The active investigation of these factors and the applied psychological assessment protocol are useful to identify MEN2 patients requiring psychological assistance.

Middle ear findings and need for ventilation tubes among pediatric cleft lip and palate patients in northern Finland.

PubMed

Lehtonen, Ville; Lithovius, Riitta H; Autio, Timo J; Sándor, George K; Ylikontiola, Leena P; Harila, Virpi; Pesonen, Paula; Koskinen, Sari; Anttonen, Vuokko

2016-04-01

Middle ear problems are common in cleft patients. This study aimed to determine the need for ventilation tubes (VTs) and complications such as tympanic perforation and cholesteatoma. Data of 156 children with clefts managed in northern Finland spanning 15 years from 1997 to 2011 were collected from 6 hospitals. The following were recorded: birth date, gender, cleft type, surgery timing, surgery type, number of tube insertions, tube material, middle ear findings, and tube placement timing. Clefts were divided into 4 groups: cleft palate (CP), cleft lip and palate (CLP), cleft lip (CL), and submucous cleft palate. The prevalence of middle ear findings was reported. Mucous secretion was noted in 96.8% of CLP patients, 69.2% of CP patients, and 13.0% of CL patients. In all, 82.7% of study group had 1 or more VTs placed during follow-up. All CLP patients required more than 1 VT placement. A total of 94.5% of CP patients required VTs compared to 13.0% of CL patients. In the presence of residual oral nasal fistula, the mean number of tube insertions was 5.3. The prevalence of tympanic perforations in clefts was 35.9% and cholesteatoma in 2.6% of patients. CLP and isolated CP patients have frequent middle ear infections requiring multiple VT placements. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Feasibility of Image-Guided Transthoracic Core Needle Biopsy in the BATTLE Lung Trial

PubMed Central

Tam, Alda L.; Kim, Edward S.; Lee, J. Jack; Ensor, Joe E.; Hicks, Marshall E.; Tang, Ximing; Blumenschein, George R.; Alden, Christine M.; Erasmus, Jeremy J.; Tsao, Anne; Lippman, Scott M.; Hong, Waun K.; Wistuba, Ignacio I.; Gupta, Sanjay

2013-01-01

Purpose As therapy for non-small cell lung cancer (NSCLC) patients becomes more personalized, additional tissue in the form of core needle biopsies (CNBs) for biomarker analysis is increasingly required for determining appropriate treatment and for enrollment into clinical trials. We report our experience with small-caliber percutaneous transthoracic (PT) CNBs for the evaluation of multiple molecular biomarkers in BATTLE (Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination), a personalized, targeted therapy NSCLC clinical trial. Methods The medical records of patients who underwent PTCNB for consideration of enrollment in BATTLE, were reviewed for diagnostic yield of 11 predetermined molecular markers, and procedural complications. Univariate and multivariate analyses of factors related to patient and lesion characteristics were performed to determine possible influences on diagnostic yield. Results One hundred and seventy PTCNBs were performed using 20-gauge biopsy needles in 151 NSCLC patients screened for the trial. 82.9% of the biopsy specimens were found to have adequate tumor tissue for analysis of the required biomarkers. On multivariate analysis, metastatic lesions were 5.4 times more likely to yield diagnostic tissue as compared to primary tumors (p = 0.0079). Pneumothorax and chest tube insertion rates were 15.3% and 9.4%, respectively. Conclusions Image-guided 20-gauge PTCNB is safe and provides adequate tissue for analysis of multiple biomarkers in the majority of patients being considered for enrollment into a personalized, targeted therapy NSCLC clinical trial. Metastatic lesions are more likely to yield diagnostic tissue as compared to primary tumors. PMID:23442309

Establishment of a definitive protocol for the diagnosis and management of body packers (drug mules).

PubMed

Mandava, Nageswara; Chang, Richard S; Wang, John H; Bertocchi, Michael; Yrad, Jonathan; Allamaneni, Shyam; Aboian, Edouard; Lall, Malini H; Mariano, Rosalind; Richards, Neil

2011-02-01

'Mules' or body packers are people who transport illegal drugs by packet ingestion into the gastrointestinal tract. These people are otherwise healthy and their management should maintain minimal morbidity. In this study, experience with body packers is presented and an algorithm for conservative and surgical management is provided. The clinical patient database for all body packer admissions at Mary Immaculate Hospital of the Caritas Health Care Inc. from 1993 to 2005 was interrogated. 56 patients (4.5%) required admission out of a total of 1250 subjects confirmed to be body packers and apprehended by United State Customs officials at JFK International Airport, New York. The retrieved patient data were analysed retrospectively. 70% of the body packers were men, with a male to female ratio of 2.8 to 1. The mean age was 33 years and 52% were from Columbia. Heroin was the most common illegally transported substance (73%). 25 patients (45%) required surgical intervention, whereas 31 patients (55%) were successfully managed conservatively. Indications for intervention included: bowel obstruction, packet rupture/toxicity, and delayed progression of packet transit on conservative management. Multiple intraoperative manoeuvres were used to remove the foreign bodies: gastrotomy, enterotomy and colotomy. Wound infection was the most common complication and is associated with distal enterotomy and colotomy. Men were more likely to present as body packers than women. Proximal enterotomies are preferred and multiple enterotomies should be avoided. A confirmatory radiological study is needed to demonstrate complete clearance of packets. A systematic protocol for the management of body packers results in minimal morbidity and no mortality.

Continuous subcutaneous insulin infusion in diabetes: patient populations, safety, efficacy, and pharmacoeconomics.

PubMed

Pozzilli, Paolo; Battelino, Tadej; Danne, Thomas; Hovorka, Roman; Jarosz-Chobot, Przemyslawa; Renard, Eric

2016-01-01

The level of glycaemic control necessary to achieve optimal short-term and long-term outcomes in subjects with type 1 diabetes mellitus (T1DM) typically requires intensified insulin therapy using multiple daily injections or continuous subcutaneous insulin infusion. For continuous subcutaneous insulin infusion, the insulins of choice are the rapid-acting insulin analogues, insulin aspart, insulin lispro and insulin glulisine. The advantages of continuous subcutaneous insulin infusion over multiple daily injections in adult and paediatric populations with T1DM include superior glycaemic control, lower insulin requirements and better health-related quality of life/patient satisfaction. An association between continuous subcutaneous insulin infusion and reduced hypoglycaemic risk is more consistent in children/adolescents than in adults. The use of continuous subcutaneous insulin infusion is widely recommended in both adult and paediatric T1DM populations but is limited in pregnant patients and those with type 2 diabetes mellitus. All available rapid-acting insulin analogues are approved for use in adult, paediatric and pregnant populations. However, minimum patient age varies (insulin lispro: no minimum; insulin aspart: ≥2 years; insulin glulisine: ≥6 years) and experience in pregnancy ranges from extensive (insulin aspart, insulin lispro) to limited (insulin glulisine). Although more expensive than multiple daily injections, continuous subcutaneous insulin infusion is cost-effective in selected patient groups. This comprehensive review focuses on the European situation and summarises evidence for the efficacy and safety of continuous subcutaneous insulin infusion, particularly when used with rapid-acting insulin analogues, in adult, paediatric and pregnant populations. The review also discusses relevant European guidelines; reviews issues that surround use of this technology; summarises the effects of continuous subcutaneous insulin infusion on patients' health-related quality of life; reviews relevant pharmacoeconomic data; and discusses recent advances in pump technology, including the development of closed-loop 'artificial pancreas' systems. © 2015 The Authors. Diabetes/Metabolism Research and Reviews Published by John Wiley & Sons Ltd. © 2015 The Authors. Diabetes/Metabolism Research and Reviews Published by John Wiley & Sons Ltd.

Narcotic Use and Postoperative Doctor Shopping by Patients with Nephrolithiasis Requiring Operative Intervention: Implications for Patient Safety.

PubMed

Kappa, Stephen F; Green, Elizabeth A; Miller, Nicole L; Herrell, Stanley D; Mitchell, Christopher R; Mir, Hassan R; Resnick, Matthew J

2016-09-01

We sought to determine perioperative patterns of narcotic use and the prevalence of postoperative doctor shopping among patients with nephrolithiasis requiring operative management. We retrospectively reviewed the records of consecutive patients residing in Tennessee who required ureteroscopy with laser lithotripsy for nephrolithiasis at a single institution from January to December 2013. Using the Tennessee CSMD (Controlled Substances Medication Database) patients were categorized by the number of postoperative narcotic providers. Doctor shopping behavior was identified as any patient seeking more than 1 narcotic provider within 3 months of surgery. Demographic and clinical characteristics associated with doctor shopping behavior were identified. During the study period 200 eligible patients underwent ureteroscopy with laser lithotripsy for nephrolithiasis, of whom 48 (24%) were prescribed narcotics by more than 1 provider after surgery. Compared to those receiving narcotics from a single provider, patients with multiple narcotic providers were younger (48.1 vs 54.2 years, p <0.001), less educated (high school education or less in 83.3% vs 58.7%, p = 0.014), more likely to have a history of mental illness (37.5% vs 16%, p <0.01) and more likely to have undergone prior stone procedures (66% vs 42%, p <0.01). Additionally, these patients demonstrated more frequent preoperative narcotic use (87.5% vs 63.2%), longer postoperative narcotic use (39.1 vs 6.0 days) and a higher morphine equivalent dose per prescription (44.7 vs 35.2 dose per day, each p <0.001). Postoperative doctor shopping is common among patients with nephrolithiasis who require operative management. Urologists should be aware of available registry data to decrease the likelihood of redundant narcotic prescribing. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

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.

Tumefactive multiple sclerosis requiring emergency craniotomy: case report and literature review.

PubMed

Munarriz, Pablo M; Castaño-Leon, Ana M; Martinez-Perez, Rafael; Hernandez-Lain, Aurelio; Ramos, Ana; Lagares, Alfonso

2013-01-01

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system, characterized by focal neurological dysfunction with a relapsing and remitting course. Tumor-like presentation of MS (or "tumefactive"/"pseudotumoral" presentation) has been described before with a certain frequency; it consists of a large single plaque (>2cm) with presence of edema and mass effect and it is hard to distinguish from a brain tumor. However, we present a very rare case of a 53-year-old woman with a right temporal mass that turned out to be a MS plaque, who deteriorated within hours (brain herniation with loss of consciousness and unilateral mydriasis) and required an emergency craniotomy. We also present a review of the literature. It appears that only 4 cases of emergency craniotomy/craniectomy required in a patient with a tumor-like MS plaque have been reported before. Copyright © 2012 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Advanced 3-D analysis, client-server systems, and cloud computing-Integration of cardiovascular imaging data into clinical workflows of transcatheter aortic valve replacement.

PubMed

Schoenhagen, Paul; Zimmermann, Mathis; Falkner, Juergen

2013-06-01

Degenerative aortic stenosis is highly prevalent in the aging populations of industrialized countries and is associated with poor prognosis. Surgical valve replacement has been the only established treatment with documented improvement of long-term outcome. However, many of the older patients with aortic stenosis (AS) are high-risk or ineligible for surgery. For these patients, transcatheter aortic valve replacement (TAVR) has emerged as a treatment alternative. The TAVR procedure is characterized by a lack of visualization of the operative field. Therefore, pre- and intra-procedural imaging is critical for patient selection, pre-procedural planning, and intra-operative decision-making. Incremental to conventional angiography and 2-D echocardiography, multidetector computed tomography (CT) has assumed an important role before TAVR. The analysis of 3-D CT data requires extensive post-processing during direct interaction with the dataset, using advance analysis software. Organization and storage of the data according to complex clinical workflows and sharing of image information have become a critical part of these novel treatment approaches. Optimally, the data are integrated into a comprehensive image data file accessible to multiple groups of practitioners across the hospital. This creates new challenges for data management requiring a complex IT infrastructure, spanning across multiple locations, but is increasingly achieved with client-server solutions and private cloud technology. This article describes the challenges and opportunities created by the increased amount of patient-specific imaging data in the context of TAVR.

The introduction and evaluation of mobile devices to improve access to patient records: a catalyst for innovation and collaboration at BCCA.

PubMed

Wu, Jonn; Waldron, John; Hood, Shaina; Kahnamelli, Adam; Khan, Mohamed; Barnett, Jeff; French, John; Slager, Stacey; Melhem, Shadi; Shabestari, Omid

2013-01-01

Prompt and efficient access to patient records is vital in providing optimal patient care. The Cancer Agency Information System (CAIS) is the primary patient record repository for the British Columbia Cancer Agency (BCCA) but is only accessible on traditional computer workstations. The BCCA clinics have significant space limitations resulting in multiple health care professionals sharing each workstation. Furthermore, workstations are not available in examination rooms. A novel and cost efficient solution is necessary to improve clinician access to CAIS. This prompted the BCCA and IMITS to embark on an innovative provincial collaboration to introduce and evaluate the impact of a mobile device to improve access to CAIS. The project consisted of 2 phases with over 50 participants from multiple clinical disciplines across BCCA sites. Phase I evaluated the adoptability, effectiveness and costs associated with providing access to CAIS using a generic viewer (Citrix). Phase II incorporated the feedback and findings from Phase I to make available a customized mobile device-specific application. Phase II also addressed privacy and security requirements.

[Usefulness of electronic drug registers: Spanish register of patients treated with fingolimod (Gilenya ®)].

PubMed

Fernández, Óscar; Rodríguez-Antigüedad, Alfredo; Oreja-Guevara, Celia; Garcia-Garcia, Margarida; Montalban, Xavier

2014-01-16

This study outlines the design of an electronic register of patients with multiple sclerosis who began treatment with fingolimod in Spain. The system is intended to serve as a tool to monitor its utilisation in daily clinical practice and thus allow optimisation of the way it is used. To establish the profile of patients with multiple sclerosis undergoing treatment with fingolimod and to determine the effectiveness and safety of this treatment in daily clinical practice. An observation-based, retrospective and prospective, multi-centre registry is set up, which will be active for five years. Forty neurologists working in Spain will participate in the project. Patients treated with fingolimod who fulfil the selection criteria will be included in the study. The effectiveness variables that will be evaluated are: disability measured by means of the Expanded Disability Status Scale, the rate of attacks, T1 gadolinium-enhancing lesions and new lesions in T2, and the percentage of patients who were free of activity and those who require concomitant treatments. The tolerability variables that will be evaluated are: the rate of patients who present events and adverse reactions, respectively, with a separate analysis of those presenting after the first dose or that are related to the fingolimod risk management plan and the treatment dropout rate. New pharmaceuticals that have only recently been commercialised require more information about their effectiveness and safety, beyond the controlled environment of a clinical trial. Initiatives involving electronic registries such as the Gilenya register are a solution that can respond to such needs by providing information in the shortest possible time about the most suitable management in order to be able to make the best and most efficient use of it.

Addressing the regulatory and scientific challenges in multiple sclerosis--a statement from the EU regulators.

PubMed

Balabanov, Pavel; Haas, Manuel; Elferink, Andre; Bakchine, Serge; Broich, Karl

2014-09-01

Improving and facilitating the process of making new drugs available to patients with multiple sclerosis (MS) requires cooperation among the regulators and other stakeholders. This cooperation will also positively contribute towards developing guidelines of the highest quality in medical, regulatory and scientific aspects. This would be beneficial both in areas that require further guideline development, but also in fields where existing guidance should be adapted to take into account evolution in science. Considering the input from all stakeholders, the European Medicines Agency confirmed its intention to update the relevant guideline and apply a flexible approach towards new drug development strategies in MS. This article is the first official position from the EU regulators, presenting the main changes to be expected in the guidance document. © The Author(s) 2014.

Treatment of neonatal abstinence syndrome.

PubMed

Johnson, K; Gerada, C; Greenough, A

2003-01-01

Neonatal abstinence syndrome (NAS) is suffered by infants withdrawing from substances on which they have become physically dependent after in utero exposure. They may require prolonged treatment and spend weeks or even months in hospital. A wide range of drugs have been used to treat NAS. The efficacy of few, however, have been adequately investigated. Evidence suggests that opioids are the most appropriate, at least in infants exposed to diamorphine or methadone. In all "head to head" trials, diazepam has been shown to be ineffective. Morphine and methadone are currently the most commonly prescribed opioids to treat NAS, but randomised trials have not been undertaken to determine which is the more beneficial. Many infants with NAS have been exposed to multiple substances in utero. Further research is required into whether a single opiate or a multiple drug regimen is the best option for such patients.

Multiple sclerosis.

PubMed

Files, Daniel Kane; Jausurawong, Tani; Katrajian, Ruba; Danoff, Robert

2015-06-01

Multiple sclerosis (MS) is a chronic, debilitating disease that can have devastating effects. Presentation varies widely in symptoms, pace, and progression. In addition to a thorough history and physical examination, diagnostic tools required to diagnose MS and exclude other diagnoses include MRI, evoked potential testing, and cerebrospinal fluid analysis. Although the disease is not curable presently, quality of life can be improved by minimizing the frequency and severity of disease burden. Disease modification, symptom management, preservation of function, and treatment of psychosocial issues are paramount to enhance the quality of life for the patient affected with MS. Copyright © 2015 Elsevier Inc. All rights reserved.

The SmartOR: a distributed sensor network to improve operating room efficiency.

PubMed

Huang, Albert Y; Joerger, Guillaume; Fikfak, Vid; Salmon, Remi; Dunkin, Brian J; Bass, Barbara L; Garbey, Marc

2017-09-01

Despite the significant expense of OR time, best practice achieves only 70% efficiency. Compounding this problem is a lack of real-time data. Most current OR utilization programs require manual data entry. Automated systems require installation and maintenance of expensive tracking hardware throughout the institution. This study developed an inexpensive, automated OR utilization system and analyzed data from multiple operating rooms. OR activity was deconstructed into four room states. A sensor network was then developed to automatically capture these states using only three sensors, a local wireless network, and a data capture computer. Two systems were then installed into two ORs, recordings captured 24/7. The SmartOR recorded the following events: any room activity, patient entry/exit time, anesthesia time, laparoscopy time, room turnover time, and time of preoperative patient identification by the surgeon. From November 2014 to December 2015, data on 1003 cases were collected. The mean turnover time was 36 min, and 38% of cases met the institutional goal of ≤30 min. Data analysis also identified outlier cases (>1 SD from mean) in the domains of time from patient entry into the OR to intubation (11% of cases) and time from extubation to patient exiting the OR (11% of cases). Time from surgeon identification of patient to scheduled procedure start time was 11 min (institution bylaws require 20 min before scheduled start time), yet OR teams required 22 min on average to bring a patient into the room after surgeon identification. The SmartOR automatically and reliably captures data on OR room state and, in real time, identifies outlier cases that may be examined closer to improve efficiency. As no manual entry is required, the data are indisputable and allow OR teams to maintain a patient-centric focus.

The Changing Landscape of Smoldering Multiple Myeloma: A European Perspective

PubMed Central

Fernández de Larrea, Carlos; Leleu, Xavier; Heusschen, Roy; Zojer, Niklas; Decaux, Olivier; Kastritis, Efstathios; Minnema, Monique; Jurczyszyn, Artur; Beguin, Yves; Wäsch, Ralph; Palumbo, Antonio; Dimopoulos, Meletios; Mateos, Maria Victoria; Ludwig, Heinz; Engelhardt, Monika

2016-01-01

Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder and bridges monoclonal gammopathy of undetermined significance to multiple myeloma (MM), based on higher levels of circulating monoclonal immunoglobulin and bone marrow plasmocytosis without end-organ damage. Until a Spanish study reported fewer MM-related events and better overall survival among patients with high-risk SMM treated with lenalidomide and dexamethasone, prior studies had failed to show improved survival with earlier intervention, although a reduction in skeletal-related events (without any impact on disease progression) has been described with bisphosphonate use. Risk factors have now been defined, and a subset of ultra-high-risk patients have been reclassified by the International Myeloma Working Group as MM, and thus will require optimal MM treatment, based on biomarkers that identify patients with a >80% risk of progression. The number of these redefined patients is small (∼10%), but important to unravel, because their risk of progression to overt MM is substantial (≥80% within 2 years). Patients with a high-risk cytogenetic profile are not yet considered for early treatment, because groups are heterogeneous and risk factors other than cytogenetics are deemed to weight higher. Because patients with ultra-high-risk SMM are now considered as MM and may be treated as such, concerns exist that earlier therapy may increase the risk of selecting resistant clones and induce side effects and costs. Therefore, an even more accurate identification of patients who would benefit from interventions needs to be performed, and clinical judgment and careful discussion of pros and cons of treatment initiation need to be undertaken. For the majority of SMM patients, the standard of care remains observation until development of symptomatic MM occurs, encouraging participation in ongoing and upcoming SMM/early MM clinical trials, as well as consideration of bisphosphonate use in patients with early bone loss. Implications for Practice: Smoldering multiple myeloma is an early stage of myeloma disease and is diagnosed before any symptoms occur. Recent research has redefined the diagnostic criteria for multiple myeloma, offering new insights into testing and classification of this malignancy. Risk factors have now been defined and three biomarkers have been validated that are able to identify patients presenting a high risk of progression toward a symptomatic disease. These biomarkers will help physicians to identify high-risk patients who may benefit from optimal treatment. This article summarizes the views of a European panel of hematologists on the implicated changes in patient care. PMID:26921288

Fibular lengthening for the management of translational talus instability in hereditary multiple exostoses patients.

PubMed

Lee, Dong Yeon; Kim, Joong Il; Song, Mi Hyun; Choi, Eun Seok; Park, Moon Seok; Yoo, Won Joon; Chung, Chin Youb; Choi, In Ho; Cho, Tae-Joon

2014-01-01

Hereditary multiple exostoses (HME) patients frequently present with ankle valgus deformity and marked fibular shortening. Loss of the lateral buttress may cause translational talus instability (TTI) that manifests as ankle pain after physical exercise, medial clear space widening on plain radiographs, and gross translational movement of the talus within the mortise. Among 123 HME patients examined and/or surgically treated, 10 patients (14 ankles) with symptomatic TTI underwent fibular lengthening with osteochondroma excision. Twelve ankles of 9 patients were followed for >1 year after surgery. Total fibular length gain averaged 15.3 mm and distal migration of the distal fibular fragment averaged 5.5 mm. The mean medial clear space decreased from preoperative 6.7 mm to postlengthening 3.5 mm. Gross instability of the talus within the ankle mortise disappeared in all cases. AOFAS ankle-hindfoot score improved from preoperative 80.3 to 97.3 at the latest follow-up. The current study showed the fibular lengthening improved lateral ankle stability by providing lateral buttress on the talus and providing favorable short-term result by ameliorating exercise-induced ankle pain in TTI of HME. The authors carefully conclude that TTI is a rare but potentially disabling condition in HME patients, requiring special attention during follow-up of HME patients. Level IV.

Urinary incontinence in multiple sclerosis: prevalence, severity and impact on patients' quality of life.

PubMed

Zecca, C; Riccitelli, G C; Disanto, G; Singh, A; Digesu, G A; Panicari, L; Puccini, F; Mattioli, M; Tubaro, A; Gobbi, C

2016-07-01

Lower urinary tract symptoms (LUTS) including frequent urination, nocturia and urge urinary incontinence negatively impact quality of life. This project aimed at characterizing the prevalence and severity of urinary incontinence in multiple sclerosis (MS) patients and its association with demographic and clinical features. In all, 403 consecutive clinically stable MS patients answered the International Consultation on Incontinence Questionnaire (ICIQ) and the Patient Perception of Bladder Condition (PPBC) questionnaire. Demographic and clinical parameters including the Expanded Disability Status Scale (EDSS) were collected. Statistical analyses were performed using univariate and multivariate linear regression models. Females represented 72%, relapsing-remitting patients 82%. The mean (SD) disease duration and EDSS were 11.8 (8.6) years and 3.1 (1.9) respectively. Approximately 35% of patients reported urine incontinence. ICIQ scores were positively associated with EDSS, female gender, presence of LUTS therapies and absence of disease modifying treatments (P < 0.001). PPBC scores were positively associated with EDSS and the presence of LUTS therapies (P < 0.001). Urinary incontinence is frequent in MS, prevailing in more disabled and female patients. Currently available LUTS therapies appear insufficient in the treatment of this symptom. The negative impact of urinary incontinence on quality of life is high and requires more attention in clinical management and research. © 2016 EAN.

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.

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

PubMed Central

2015-01-01

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

Ambulatory rehabilitation in multiple sclerosis.

PubMed

Kelleher, Kevin John; Spence, William; Solomonidis, Stephan; Apatsidis, Dimitrios

2009-01-01

Multiple sclerosis (MS) is an autoimmunogenic disease involving demyelination within the central nervous system. Many of the typical impairments associated with MS can affect gait patterns. With walking ability being one of the most decisive factors when assessing quality of life and independent living, this review focuses on matters, which are considered of significance for maintaining and supporting ambulation. This article is an attempt to describe current research and available interventions that the caring healthcare professional can avail of and to review the present trends in research to further these available options. Evidence-based rehabilitation techniques are of interest in the care of patients with MS, given the various existing modalities of treatment. In this review, we summarise the primary factors affecting ambulation and highlight available treatment methods. We review studies that have attempted to characterise gait deficits within this patient population. Finally, as ambulatory rehabilitation requires multidisciplinary interventions, we examine approaches, which may serve to support and maintain ambulation within this patient group for as long as possible.

Anaesthetic management of patients with severe sepsis.

PubMed

Eissa, D; Carton, E G; Buggy, D J

2010-12-01

Severe sepsis, a syndrome characterized by systemic inflammation and acute organ dysfunction in response to infection, is a major healthcare problem affecting all age groups throughout the world. Anaesthetists play a central role in the multidisciplinary management of patients with severe sepsis from their initial deterioration at ward level, transfer to the diagnostic imaging suite, and intraoperative management for emergency surgery. The timely administration of appropriate i.v. antimicrobial therapy is a crucial step in the care of patients with severe sepsis who may require surgery to control the source of sepsis. Preoperative resuscitation, aimed at optimizing major organ perfusion, is based on judicious use of fluids, vasopressors, and inotropes. Intraoperative anaesthesia management requires careful induction and maintenance of anaesthesia, optimizing intravascular volume status, avoidance of lung injury during mechanical ventilation, and ongoing monitoring of arterial blood gases, lactate concentration, haematological and renal indices, and electrolyte levels. Postoperative care overlaps with ongoing management of the severe sepsis syndrome patient in the intensive care unit. These patients are by definition, high risk, already requiring multiple supports, and require experienced and skilful decision-making to optimize their chances of a favourable outcome. Similar to acute myocardial infarction, stroke, or acute trauma, the initial hours (golden hours) of clinical management of severe sepsis represent an important opportunity to reduce morbidity and mortality. Rapid clinical assessment, resuscitation and surgical management by a focused multidisciplinary team, and early effective antimicrobial therapy are the key components to improved patient outcome.

A Knowledge-Modeling Approach to Integrate Multiple Clinical Practice Guidelines to Provide Evidence-Based Clinical Decision Support for Managing Comorbid Conditions.

PubMed

Abidi, Samina

2017-10-26

Clinical management of comorbidities is a challenge, especially in a clinical decision support setting, as it requires the safe and efficient reconciliation of multiple disease-specific clinical procedures to formulate a comorbid therapeutic plan that is both effective and safe for the patient. In this paper we pursue the integration of multiple disease-specific Clinical Practice Guidelines (CPG) in order to manage co-morbidities within a computerized Clinical Decision Support System (CDSS). We present a CPG integration framework-termed as COMET (Comorbidity Ontological Modeling & ExecuTion) that manifests a knowledge management approach to model, computerize and integrate multiple CPG to yield a comorbid CPG knowledge model that upon execution can provide evidence-based recommendations for handling comorbid patients. COMET exploits semantic web technologies to achieve (a) CPG knowledge synthesis to translate a paper-based CPG to disease-specific clinical pathways (CP) that include specialized co-morbidity management procedures based on input from domain experts; (b) CPG knowledge modeling to computerize the disease-specific CP using a Comorbidity CPG ontology; (c) CPG knowledge integration by aligning multiple ontologically-modeled CP to develop a unified comorbid CPG knowledge model; and (e) CPG knowledge execution using reasoning engines to derive CPG-mediated recommendations for managing patients with comorbidities. We present a web-accessible COMET CDSS that provides family physicians with CPG-mediated comorbidity decision support to manage Atrial Fibrillation and Chronic Heart Failure. We present our qualitative and quantitative analysis of the knowledge content and usability of COMET CDSS.

Virtual reality in multiple sclerosis - A systematic review.

PubMed

Massetti, Thais; Trevizan, Isabela Lopes; Arab, Claudia; Favero, Francis Meire; Ribeiro-Papa, Denise Cardoso; de Mello Monteiro, Carlos Bandeira

2016-07-01

Multiple sclerosis (MS) is an inflammatory disease in which the insulating cover of nerve cells in the brain and spinal cord are damaged. The methods used for motor rehabilitation of patients with neurological problems require the performance of several rehabilitation exercises. Recently, studies related to the use of video game consoles have proliferated in the field of motor rehabilitation. Virtual reality (VR) has been proposed as a potentially useful tool for motoring assessment and rehabilitation. The purpose of this study was to investigate the results shown in previous studies on "Multiple Sclerosis" and "Virtual Reality". A bibliographic review was performed without time limitations. The research was carried out using PubMed and BVS databases. Considering keywords, we included articles that showed the terms "Multiple Sclerosis" and "Virtual Reality". The review was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines The initial search yielded 41 articles. After the duplicates were removed, two authors independently evaluated the title and abstract of each of the articles with the study inclusion criteria. From these, 31 articles were excluded based on the title and abstract. Finally, 10 articles were isolated that met the inclusion criteria. VR represents a motivational and effective alternative to traditional motor rehabilitation for MS patients. The results showed that VR programs could be an effective method of patients with MS rehabilitation in multiple cognitive and / or motor deficits. Additional research is needed to support the rehabilitation protocols with VR and increase the effects of treatment. Copyright © 2016 Elsevier B.V. All rights reserved.

Recommendations for the Treatment of Patients With Parkinson Disease During Ramadan.

PubMed

Damier, Philippe; Al-Hashel, Jasem

2017-02-01

Every year, Ramadan fasting is practiced by many Muslim individuals. In cases of chronic disease, religious texts allow fasting to be broken. However, many believers still want to fast even at the risk of damaging their health. To our knowledge, there are no published recommendations on the medical management of Parkinson disease (PD) during Ramadan. Effective treatments exist in PD and usually require several daily drug intakes. Apart from worsening symptoms, interrupting PD treatment might lead to a severe withdrawal syndrome. Although no specific studies on this topic have led to formal recommendations, we suggest some options for adapting the treatment for patients who fast during Ramadan. The general principle is based on switching the patient's treatment to an equivalent dosage of a dopamine agonist that can be administered once daily or by transdermal patch. However, such an option is only feasible for patients who require a moderate amount of PD treatment and can tolerate dopamine agonist therapy. Because many patients with PD require regular multiple daily administration of dopamine-replacement medication, the management of Ramadan fasting is not easy. Switching the patient's treatment to an equivalent dosage of a dopamine agonist that can be administered once daily or by transdermal patch seems to be a reasonable option to consider for patients treated with a low-to-moderate amount of PD medication.

Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

PubMed

Buck, J R; Sorensen, V J; Fath, J J; Horst, H M; Obeid, F N

1992-09-01

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.

Practices of US health insurance companies concerning MS therapies interfere with shared decision-making and harm patients.

PubMed

Bourdette, Dennis N; Hartung, Daniel M; Whitham, Ruth H

2016-04-01

The US Food and Drug Administration has registered 13 multiple sclerosis (MS) disease-modifying therapies (DMTs). The medications are not interchangeable as they vary in route of administration, efficacy, and safety profile. Selecting the appropriate MS DMT for individual patients requires shared decision-making between patients and neurologists. To reduce costs, insurance companies acting through pharmacy benefit companies restrict access to MS DMTs through tiered coverage and other regulations. We discuss how policies established by insurance companies that limit access to MS DMTs interfere with the process of shared decision-making and harm patients. We present potential actions that neurologists can take to change how insurance companies manage MS DMTs.

Sustained Erythroid Response in a Patient with Myelofibrosis Receiving Concomitant Treatment with Ruxolitinib and Deferasirox.

PubMed

Piro, Eugenio; Lentini, Maria; Levato, Luciano; Russo, Antonio; Molica, Stefano

2018-04-25

Iron overload (IOL) due to transfusion-dependent anemia is a serious adverse effect in patients with myelofibrosis (MF). Recent studies have shown that the oral iron chelator deferasirox may prevent multiple organ damage due to IOL in MF. However, it is not clear whether deferasirox may contribute to revert transfusion-dependent anemia. Here, we present a patient with transfusion-dependent intermediate-2 MF according to the International Prognostic Scoring System treated with ruxolitinib in combination with deferasirox. In addition to a reduced serum ferritin level, the patient required less blood transfusions, ultimately resulting in long-lasting transfusion-free survival. © 2018 S. Karger AG, Basel.

Measuring Patient Preferences: An Overview of Methods with a Focus on Discrete Choice Experiments.

PubMed

Hazlewood, Glen S

2018-05-01

There is increasing recognition of the importance of patient preferences and methodologies to measure them. In this article, methods to quantify patient preferences are reviewed, with a focus on discrete choice experiments. In a discrete choice experiment, patients are asked to choose between 2 or more treatments. The results can be used to quantify the relative importance of treatment outcomes and/or other considerations relevant to medical decision making. Conducting and interpreting a discrete choice experiment requires multiple steps and an understanding of the potential biases that can arise, which we review in this article with examples in rheumatic diseases. Copyright © 2018 Elsevier Inc. All rights reserved.

Emergent biomarker derived from next-generation sequencing to identify pain patients requiring uncommonly high opioid doses

PubMed Central

Kringel, D; Ultsch, A; Zimmermann, M; Jansen, J-P; Ilias, W; Freynhagen, R; Griessinger, N; Kopf, A; Stein, C; Doehring, A; Resch, E; Lötsch, J

2017-01-01

Next-generation sequencing (NGS) provides unrestricted access to the genome, but it produces ‘big data’ exceeding in amount and complexity the classical analytical approaches. We introduce a bioinformatics-based classifying biomarker that uses emergent properties in genetics to separate pain patients requiring extremely high opioid doses from controls. Following precisely calculated selection of the 34 most informative markers in the OPRM1, OPRK1, OPRD1 and SIGMAR1 genes, pattern of genotypes belonging to either patient group could be derived using a k-nearest neighbor (kNN) classifier that provided a diagnostic accuracy of 80.6±4%. This outperformed alternative classifiers such as reportedly functional opioid receptor gene variants or complex biomarkers obtained via multiple regression or decision tree analysis. The accumulation of several genetic variants with only minor functional influences may result in a qualitative consequence affecting complex phenotypes, pointing at emergent properties in genetics. PMID:27139154

Emergent biomarker derived from next-generation sequencing to identify pain patients requiring uncommonly high opioid doses.

PubMed

Kringel, D; Ultsch, A; Zimmermann, M; Jansen, J-P; Ilias, W; Freynhagen, R; Griessinger, N; Kopf, A; Stein, C; Doehring, A; Resch, E; Lötsch, J

2017-10-01

Next-generation sequencing (NGS) provides unrestricted access to the genome, but it produces 'big data' exceeding in amount and complexity the classical analytical approaches. We introduce a bioinformatics-based classifying biomarker that uses emergent properties in genetics to separate pain patients requiring extremely high opioid doses from controls. Following precisely calculated selection of the 34 most informative markers in the OPRM1, OPRK1, OPRD1 and SIGMAR1 genes, pattern of genotypes belonging to either patient group could be derived using a k-nearest neighbor (kNN) classifier that provided a diagnostic accuracy of 80.6±4%. This outperformed alternative classifiers such as reportedly functional opioid receptor gene variants or complex biomarkers obtained via multiple regression or decision tree analysis. The accumulation of several genetic variants with only minor functional influences may result in a qualitative consequence affecting complex phenotypes, pointing at emergent properties in genetics.

Remote Respiration Monitoring Using Ultra-wideband Microwave Sensor

NASA Astrophysics Data System (ADS)

Higashikatsuragi, Kenji; Nakahata, Youichiro; Matsunami, Isamu; Kajiwara, Akihiro

Impulse based ultra-wideband radio has lately attracted considerable attention as medical monitoring sensor since it is expected to measure bio-signals of a patient on a bed such as respiration rate and heartbeat with a remote non-contact approach. It is also friendly to the environment including the human body due to the very low electromagnetic energy emission. Using conventional ranging scheme, however, high speed A/D device should be required in order to detect the small respiratory displacement. This paper suggests a respiratory monitoring scheme where the respiration rate is measured by observing the variation of the path strength from the patient. Therefore, it does not require high speed A/D. It also makes possible to design the simultaneous monitoring of multiple patients in hospital beds, for example. In this paper the measurements were conducted for various scenarios and the feasibility is discussed.

Biomedical Use of Aerospace Personal Cooling Garments

NASA Technical Reports Server (NTRS)

Webbon, Bruce W.; Montgomery, Leslie D.; Callaway, Robert K.

1994-01-01

Personal thermoregulatory systems are required during extravehicular activity (EVA) to remove the metabolic heat generated by the suited astronaut. The Extravehicular and Protective Systems (STE) Branch of NASA Ames Research Center has developed advanced concepts or liquid cooling garments for both industrial and biomedical applications for the past 25 years. Examples of this work include: (1) liquid cooled helmets for helicopter pilots and race car drivers; (2) vests for fire and mine rescue personnel; (3) bras to increase the definition of tumors during thermography; (4) lower body garments for young women with erythomelaigia; and (5) whole body garments used by patients with multiple sclerosis (MS). The benefits of the biomedical application of artificial thermoregulation received national attention through two recent events: (1) the liquid-cooled garment technology was inducted into the United States Space Foundation's Space Technology Hall of Fame (1993); and (2) NASA has signed a joint Memorandum of Understanding with the Multiple Sclerosis Association (1994) to share this technology for use with MS patient treatment. The STE Branch is currently pursuing a program to refine thermoregulatory design in light of recent technology developments that might be applicable for use by several medical patient populations. Projects have been initiated to apply thermoregulatory technology for the treatment and/or rehabilitation of patients with spinal cord injuries, multiple sclerosis, migraine headaches, and to help prevent the loss of hair during chemotherapy.

Opioid Overdose Outbreak - West Virginia, August 2016.

PubMed

Massey, Joel; Kilkenny, Michael; Batdorf, Samantha; Sanders, Sarah K; Ellison, Debra; Halpin, John; Gladden, R Matthew; Bixler, Danae; Haddy, Loretta; Gupta, Rahul

2017-09-22

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil, † which had been used by patients who overdosed in Huntington. Results of these two investigations highlight the importance of collaboration between public health and public safety agencies to provide in-depth surveillance data from opioid overdose outbreaks that involve high-potency fentanyl analogs. These data facilitated a public health response through increased awareness of powerful opioid substances requiring multiple naloxone doses for reversal, and improved patient linkage to recovery support services and a harm reduction program from the ED after opioid overdose.

Pharmacological treatments for fatigue in patients with multiple sclerosis: A systematic review and meta-analysis.

PubMed

Yang, Ting-Ting; Wang, Li; Deng, Xiao-Yang; Yu, Gang

2017-09-15

Multiple sclerosis (MS) is a chronic immune-mediated inflammatory disease. Fatigue is the most common symptom of MS patients, affecting >80% subjects. Medical treatment is an important method for managing fatigue. Currently, although many drugs have been tested in treatment of MS fatigue, the efficacy of these drugs remain largely unclear. We researched available literatures in PubMed, Embase, Medline, Google Scholar, Cochrane Library (August 31, 2016). Search terms included multiple sclerosis, fatigue, medication treatments, amantadine, modafinil, aspirin, acetyl-l-carnitine, pemoline, 4-aminopyridine and randomized controlled trial (RCT). Two researchers were required to independently assess the quality of literatures, and finish data extraction. Meta-analysis was conducted using RevMan 5.3 software. A total of 11 RCTs involving 723 patients were included. The therapeutic effects were quantified by different scales, such as Modified Fatigue Impact Scale (MFIS) or Fatigue Severity Scale (FSS). Here, meta-analysis suggested that amantadine, not modafinil, was effective for treating the fatigue in MS. Moreover, two studies implied that l-carnitine might have similar therapeutic effect with amantadine. However, the reliability of this finding was greatly weakened by the limited sample sizes. Additionally, current data could not answer whether treatment of MS fatigue using aspirin or 4-aminopyridine was beneficial. Finally, we found that all drugs except pemoline were relatively safe for treating MS fatigue. Current limited data suggest that amantadine may be the only drug that has relatively sufficient evidences in treatment of fatigue symptoms in MS. Further RCT studies recruiting larger samples sizes are required to validate the therapeutic effect of these candidate drugs. Copyright © 2017. Published by Elsevier B.V.

Current management of sarcoidosis I: pulmonary, cardiac, and neurologic manifestations.

PubMed

West, Sterling G

2018-05-01

Sarcoidosis is a systemic disease characterized by noncaseating granulomatous inflammation of multiple organ systems. Pulmonary, cardiac, and neurologic involvements have the worst prognosis. Current recommendations for the therapeutic management and follow-up of sarcoidosis involving these critical organs will be reviewed. In those sarcoidosis patients requiring immunosuppressive therapy, corticosteroids are used first at varying doses depending on the presenting manifestation. Patients with symptomatic pulmonary, cardiac, or neurologic involvement will be maintained on corticosteroids for at least a year. Many require a second immunosuppressive agent with methotrexate used most commonly. Anti-tumor necrosis factor agents, especially infliximab, are effective and recommendations for their use have been proposed. Evidence-based treatment guidelines do not exist for most sarcoidosis clinical manifestations. Therefore, clinical care of these patients must rely on expert opinion. Patients are best served by a multidisciplinary approach to their care. Future research to identify environmental triggers, genetic associations, biomarkers for treatment response, and where to position new steroid-sparing immunosuppressive agents is warranted.

Dental anesthesia for patients with special needs.

PubMed

Wang, Yi-Chia; Lin, I-Hua; Huang, Chi-Hsiang; Fan, Shou-Zen

2012-09-01

To offer individualized dental treatment to certain patients who cannot tolerate dental treatment, sedation or general anesthesia is required. The needs could be either medical, mental, or psychological. The most common indications for sedation or general anesthesia are lack of cooperation, multiple morbidities, and pediatric autism. In adults, cognitive impairment and multiple morbidities are most commonly encountered indications. Because of suboptimal home care, incomplete medical history, poor preoperative management, lack of cooperation, and developmental abnormalities, it is a challenge to prepare anesthesia for patients with special needs. The American Society of Anesthesiology (ASA) has proposed guidelines for office-based anesthesia for ambulatory surgery. In patients with ASA physical status IV and V, sedation or general anesthesia for treatment in the dental office is not recommended. The distinction between sedation levels and general anesthesia is not clear. If intravenous general anesthesia without tracheal intubation is chosen for dental procedures, full cooperation between the dentist, dental assistant, and anesthesiologist is needed. Teamwork between the dentist and healthcare provider is key to achieve safe and successful dental treatment under sedation or general anesthesia in the patient with special needs. Copyright © 2012. Published by Elsevier B.V.

Lacosamide-Induced Recurrent Ventricular Tachycardia in the Acute Care Setting.

PubMed

Berei, Theodore J; Lillyblad, Matthew P; Almquist, Adrian K

2018-04-01

Lacosamide is a new-generation antiepileptic drug (AED) most commonly used adjunctively in the setting of partial-onset seizures refractory to traditional therapy. We describe the first case report, to our knowledge, of a patient who developed recurrent, sustained ventricular tachycardia with multiple administrations of lacosamide in an acute setting. A 70-year-old woman with a history significant for valvular heart disease was admitted to the inpatient cardiology service for worsening heart failure. On hospital day 7, she received a bioprosthetic aortic valve. Prior to surgery and immediately after, the patient's electrocardiogram (ECG) was normal. After developing multiple generalized tonic-clonic seizures refractory to levetiracetam, fosphenytoin, and valproic acid, the decision was made to initiate lacosamide. Two hours following the second lacosamide dose, the patient developed a wide complex QRS that transitioned into sustained ventricular tachycardia requiring electrical cardioversion. Sustained ventricular tachycardia occurred again, just hours after the third dose of lacosamide was given. Following cessation of lacosamide, the patient's QRS interval normalized and has since had no documented episodes of ventricular tachycardia. Clinicians should be aware of the potential for life-threatening rhythmic disturbances in patients initiated on lacosamide and the need for vigilant ECG, electrolyte, and drug-drug monitoring.

Valsartan combination therapy in the management of hypertension – patient perspectives and clinical utility

PubMed Central

Nash, David T; McNamara, Michael S

2009-01-01

The morbidity and mortality benefits of lowering blood pressure (BP) in hypertensive patients are well established, with most individuals requiring multiple agents to achieve BP control. Considering the important role of the renin-angiotensin-aldosterone system (RAAS) in the pathophysiology of hypertension, a key component of combination therapy should include a RAAS inhibitor. Angiotensin receptor blockers (ARBs) lower BP, reduce cardiovascular risk, provide organ protection, and are among the best tolerated class of antihypertensive therapy. In this article, we discuss two ARB combinations (valsartan/hydrochlorothiazide [HCTZ] and amlodipine/valsartan), both of which are indicated for the treatment of hypertension in patients not adequately controlled on monotherapy and as initial therapy in patients likely to need multiple drugs to achieve BP goals. Randomized, double-blind studies that have assessed the antihypertensive efficacy and safety of these combinations in the first-line treatment of hypertensive patients are reviewed. Both valsartan/HCTZ and amlodipine/valsartan effectively lower BP and are well tolerated in a broad range of patients with hypertension, including difficult-to-treat populations such as those with severe BP elevations, prediabetes and diabetes, patients with the cardiometabolic syndrome, and individuals who are obese, elderly, or black. Also discussed herein are patient-focused perspectives related to the use of valsartan/HCTZ and amlodipine/valsartan, and the rationale for use of single-pill combinations as one approach to enhance patient compliance with antihypertensive therapy. PMID:21949614

Baveno VI Recommendation on Avoidance of Screening Endoscopy in Cirrhotic Patients: Are We There Yet?

PubMed Central

Silva, Mário Jorge; Bernardes, Carlos; Pinto, João; Loureiro, Rafaela; Duarte, Pedro; Mendes, Milena; Calinas, Filipe

2017-01-01

Introduction Recent studies assessed the predictive value of liver transient elastography, combined or not with platelet count, for the presence of esophageal varices in patients with liver cirrhosis, and multiple cutoffs have been proposed. The Baveno VI consensus states that patients with compensated advanced chronic liver disease, liver stiffness <20 kPa, and a platelet count >150,000 have a very low risk of having varices requiring treatment and can avoid screening endoscopy. We aimed to validate this recommendation in a cohort of cirrhotic patients. Methods Retrospective analysis of all patients evaluated at the Gastroenterology Department (Centro Hospitalar de Lisboa Central) between September 2009 and October 2015 with a liver stiffness (FibroScan®) compatible with liver cirrhosis as well as upper endoscopy and blood tests within 12 months from elastography. Patients on propranolol ≥80 mg/day or carvedilol ≥12.5 mg/day, as well as those with previous variceal bleeding, variceal endoscopic treatments, or cirrhosis decompensations were excluded. We validated the new Baveno VI recommendation and explored alternative cutoffs. Results Ninety-seven patients were analyzed, 76.3% (74/97) male, mean age 54.3 ± 11.2 years. Most patients (55.7%) had no varices and 14.4% had varices requiring treatment. Most patients (78.4%) had cirrhosis related to chronic hepatitis C. If the new Baveno VI recommendation had been applied to this cohort, upper endoscopy would have been avoided in 11.3% (11/97) of patients, none of them with esophageal varices requiring treatment: specificity 100%, sensitivity 13.3%, positive predictive value 100%, and negative predictive value 16.3% for absence of varices requiring treatment. If screening endoscopy had been avoided in those patients with liver stiffness <30 kPa and platelet count ≥120,000, endoscopy would have been avoided in 27.8% (27/97) of patients, none of whom with esophageal varices requiring treatment: specificity 100%, sensitivity 32.5%, positive predictive value 100%, and negative predictive value 20% for absence of varices requiring treatment. Conclusions The new Baveno VI criteria identified compensated cirrhotic patients without varices requiring treatment in whom screening endoscopy could have been avoided safely. Further studies are needed to confirm these findings and potentially explore more ambitious but still safe cutoffs for those criteria. PMID:28848787

Irradiation induced kyphosis

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

Riseborough, E.J.

1977-10-01

Eighty-one patients with Wilms tumor treated by irradiation and chemotherapy were studied. Despite the fact that multiple portals for irradiation were used, each crossing the midline, the amount of irradiation delivered to different parts of the vertebral body varied and it was this variation in delivered dose which produced axial skeletal deformities in 70% of the patients. Of the 57 patients with these deformities, 32 had scoliosis, 22 kyphoscoliosis and 3 patients pure kyphosis; 12 patients had a kyphotic deformity of over 25 degrees, 7 patients requiring surgical correction. A high incidence of pseudarthrosis following posterior fusion has led tomore » the preference of a 2-stage procedure, anterior interbody fusion followed by a posterior fusion with Harrington rods after 2 weeks of correction in halo femoral traction.« less

SO MUCH TO DO, SO LITTLE TIME: CARE FOR THE SOCIALLY DISADVANTAGED AND THE 15-MINUTE VISIT

PubMed Central

Fiscella, Kevin; Epstein, Ronald M

2008-01-01

There is much to do in primary care and little time to do it. Currently, primary care delivery is organized around visits, often 15 minutes or less, during which much is expected of clinicians. This includes establishing partnerships with patient and families; addressing acute and chronic biomedical and psychosocial problems; prevention, care coordination; and ensuring informed decision-making that respects patients’ needs and preferences. Visit-based care discriminates against socially disadvantaged patients, who often require more time due to complex health care needs and the challenge of establishing partnerships and communicating across chasms of race, ethnicity, education, language, and culture. Rushed visits exacerbate disparities in health car due to competing demands, miscommunications and activation of unconscious physician stereotypes. Addressing health care disparities requires radical transformation in the structure and financing of primary care and the roles of the health care team members and patients. One such innovation, the patient-centered medical home, organizes care around patients’ needs, not visits. Thus, face-to-face visits and physician-centered care are supplanted by team-based care that relies on multiple communication modalities, expanded health information technology, population management, culturally-sensitive outreach and follow-up, and coaching patients to assume more active roles in care. Implementation requires payment reform that allocates resources based on the true costs of providing high quality care to socially disadvantaged patients. Ensuring success will require physician leadership and training in new care models, transformation in primary care culture, and redesign of care around the needs of patients, particularly those needing care the most. PMID:18809810

Erosive lichen planus: a therapeutic challenge.

PubMed

Romero, Williams; Giesen, Laura; Navajas-Galimany, Lucas; Gonzalez, Sergio

2016-01-01

Erosive lichen planus is an uncommon variant of lichen planus. Chronic erosions of the soles, accompanied by intense and disabling pain, are some of its most characteristic manifestations. We present the case of a woman who developed oral and plantar erosive lichen planus associated with lichen planus pigmentosus and ungueal lichen planus that were diagnosed after several years. The patient failed to respond to multiple therapies requiring longstanding medication but remained refractory. Knowledge of the treatment options for erosive lichen planus is insufficient. Further research is required to clarify their effectiveness, ideally adopting an evidence-based methodology.

Abnormal pain perception in patients with Multiple System Atrophy.

PubMed

Ory-Magne, F; Pellaprat, J; Harroch, E; Galitzsky, M; Rousseau, V; Pavy-Le Traon, A; Rascol, O; Gerdelat, A; Brefel-Courbon, C

2018-03-01

Patients with Parkinson's disease or Multiple System Atrophy frequently experience painful sensations. The few studies investigating pain mechanisms in Multiple System Atrophy patients have reported contradictory results. In our study, we compared pain thresholds in Multiple System Atrophy and Parkinson's disease patients and healthy controls and evaluated the effect of l-DOPA on pain thresholds. We assessed subjective and objective pain thresholds (using a thermotest and RIII reflex), and pain tolerance in OFF and ON conditions, clinical pain, motor and psychological evaluation. Pain was reported in 78.6% of Multiple System Atrophy patients and in 37.5% of Parkinson's disease patients. In the OFF condition, subjective and objective pain thresholds were significantly lower in Multiple System Atrophy patients than in healthy controls (43.8 °C ± 1.3 vs 45.7 °C ± 0.8; p = 0.0005 and 7.4 mA ± 3.8 vs 13.7 mA ± 2.8; p = 0.002, respectively). They were also significantly reduced in Multiple System Atrophy compared to Parkinson's disease patients. No significant difference was found in pain tolerance for the 3 groups and in the effect of l-DOPA on pain thresholds in Multiple System Atrophy and Parkinson's disease patients. In the ON condition, pain tolerance tended to be reduced in Multiple System Atrophy versus Parkinson's disease patients (p = 0.05). Multiple System Atrophy patients had an increase in pain perception compared to Parkinson's disease patients and healthy controls. The l-DOPA effect was similar for pain thresholds in Multiple System Atrophy and Parkinson's disease patients, but tended to worsen pain tolerance in Multiple System Atrophy. Copyright © 2017 Elsevier Ltd. All rights reserved.

TIPS treatment in a patient with severe lower gastrointestinal bleeding with a misdiagnosis of cirrhotic portal hypertension.

PubMed

Laborda, Alicia; Guirola, José Andrés; Medrano, Joaquín; Simón, Miguel Ángel; Ioakeim, Ignatios; de-Gregorio, Miguel Ángel

2015-12-01

Abernethy malformation is a rare abnormal embryological development of splanchnic venous system characterised by the presence of a congenital extrahepatic portosystemic shunt. We present a rare case of an adult male patient that was admitted with severe lower gastrointestinal bleeding, requiring multiple blood transfusions. The patient's medical history and the laboratory tests performed led to the misdiagnosis of a congenital Abernethy malformation. We present a rare case, discussing the reasons for the misdiagnosis and we conclude that management of clinical data and imaging are highly important to discard these types of congenital malformations that can mimic a portal hypertension condition.

Confidentiality in Sports Medicine.

PubMed

Malcolm, Dominic

2016-04-01

This article synthesizes existing literature to provide a summary of the ethical issues concerning patient confidentiality in sport. It outlines the medical principle of confidentiality and identifies cross-cultural ethicolegal variations that shape its implementation. Clinicians' multiple obligations, physical environments, and practice and policy contexts are discussed, and research detailing experiences of maintaining patient confidentiality in sport is reviewed. Policy recommendations for enhancing compliance with this ethical principle are summarized. It is argued that the context of sport exacerbates pressures on clinicians to break patient confidentiality, breaches occur regularly, and interventions are required to enhance ethical compliance in sports medicine. Copyright © 2016 Elsevier Inc. All rights reserved.

Duodenal perforation following esophagogastroduodenoscopy (EGD) with cautery and epinephrine injection for peptic ulcer disease: An interesting case of nonoperative management in the medical intensive care unit (MICU).

PubMed

Chertoff, Jason; Khullar, Vikas; Burke, Lucas

2015-01-01

The utilization of esophagogastroduodenoscopy (EGD) and related procedures continues to rise. Due to this increase in utilization is an inevitable rise in serious complications such as hemorrhage and perforation. One understudied and dreaded complication of EGD causing significant morbidity and mortality is duodenal perforation. We present the case of a 63-year-old male who presented to our institution's emergency room with dyspepsia, melanic stools, tachycardia, and hypotension. Initial laboratory evaluation was significant for severe anemia, lactic acidosis, and acute kidney injury, while CT scan of the abdomen pelvis did not suggest retroperitoneal hematoma or bowel perforation. An emergent EGD was performed which showed multiple bleeding duodenal ulcers that were cauterized and injected with epinephrine. Post-procedure the patient developed worsening abdominal pain, distension, diaphoresis, and tachypnea, requiring emergent intubation. A CT scan of the abdomen and pelvis with oral contrast confirmed pneumoperitoneum and duodenal perforation. Due to the patient's hemodynamic instability and multiple comorbidities, he was treated non-operatively with strict bowel rest and intravenous antibiotics. The patient ultimately had a 19-day hospital course complicated by renal failure requiring hemodialysis and an ischemic limb necessitating above knee amputation. This case describes an unsuccessful attempt at nonoperative management of duodenal perforation following EGD. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

The relational database model and multiple multicenter clinical trials.

PubMed

Blumenstein, B A

1989-12-01

The Southwest Oncology Group (SWOG) chose to use a relational database management system (RDBMS) for the management of data from multiple clinical trials because of the underlying relational model's inherent flexibility and the natural way multiple entity types (patients, studies, and participants) can be accommodated. The tradeoffs to using the relational model as compared to using the hierarchical model include added computing cycles due to deferred data linkages and added procedural complexity due to the necessity of implementing protections against referential integrity violations. The SWOG uses its RDBMS as a platform on which to build data operations software. This data operations software, which is written in a compiled computer language, allows multiple users to simultaneously update the database and is interactive with respect to the detection of conditions requiring action and the presentation of options for dealing with those conditions. The relational model facilitates the development and maintenance of data operations software.

A conditional approach for modelling patient readmissions to hospital using a mixture of Coxian phase-type distributions incorporating Bayes' theorem.

PubMed

Gordon, Andrew S; Marshall, Adele H; Cairns, Karen J

2016-09-20

The number of elderly patients requiring hospitalisation in Europe is rising. With a greater proportion of elderly people in the population comes a greater demand for health services and, in particular, hospital care. Thus, with a growing number of elderly patients requiring hospitalisation competing with non-elderly patients for a fixed (and in some cases, decreasing) number of hospital beds, this results in much longer waiting times for patients, often with a less satisfactory hospital experience. However, if a better understanding of the recurring nature of elderly patient movements between the community and hospital can be developed, then it may be possible for alternative provisions of care in the community to be put in place and thus prevent readmission to hospital. The research in this paper aims to model the multiple patient transitions between hospital and community by utilising a mixture of conditional Coxian phase-type distributions that incorporates Bayes' theorem. For the purpose of demonstration, the results of a simulation study are presented and the model is applied to hospital readmission data from the Lombardy region of Italy. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Development of a Microcomputer-Based Adaptive Testing System. Phase I. Specification of Requirements and Preliminary Design.

DTIC Science & Technology

1982-06-30

treatments, and cure (or kill ) a patient. Administratively, the items were in a multiple-choice format and the simulation proceeded by branching...Discs: dual 5 1/4 inch floppies (IM) Bus: N/A Operating System: CP/M, MmmOST Price: $3,495 -14 ~-174- - ’i~ Model 820 Xerox 1341 West Mockingbird Lane

High prevalence of normal tests assessing hypercortisolism in subjects with mild and episodic Cushing's syndrome suggests that the paradigm for diagnosis and exclusion of Cushing's syndrome requires multiple testing.

PubMed

Friedman, T C; Ghods, D E; Shahinian, H K; Zachery, L; Shayesteh, N; Seasholtz, S; Zuckerbraun, E; Lee, M L; McCutcheon, I E

2010-11-01

Many Endocrinologists believe that a single determination of eucortisolism or a single demonstration of appropriate suppression to dexamethasone excluded Cushing's syndrome, except in what was previously thought to be the rare patient with episodic or periodic Cushing's syndrome. We hypothesize that episodic Cushing's syndrome is relatively common and a single test assessing hypercortisolism may not be sufficient to accurately rule out or diagnose Cushing's syndrome and retrospectively examined the number of normal and abnormal tests assessing hypercortisolism performed on multiple occasions in 66 patients found to have mild and/or episodic Cushing's syndrome compared to a similar group of 54 patients evaluated for, but determined not to have Cushing's syndrome. We found that 65 of the 66 patients with Cushing's syndrome had at least one normal test of cortisol status and most patients had several normal tests. The probability of having Cushing's syndrome when one test was negative was 92% for 23:00 h salivary cortisol, 88% for 24-h UFC, 86% for 24-h 17OHS, and 54% for nighttime plasma cortisol. These results demonstrated that episodic hypercortisolism is highly prevalent in subjects with mild Cushing's syndrome and no single test was effective in conclusively diagnosing or excluding the condition. Rather, the paradigm for the diagnosis should be a careful history and physical examination and in those patients in whom mild Cushing's syndrome/disease is strongly suspected, multiple tests assessing hypercortisolism should be performed on subsequent occasions, especially when the patient is experiencing signs and symptoms of short-term hypercortisolism. © Georg Thieme Verlag KG Stuttgart · New York.

Dramatic response to levetiracetam in post-ischaemic Holmes’ tremor

PubMed Central

Striano, P; Elefante, Andrea; Coppola, Antonietta; Tortora, Fabio; Zara, Federico; Minetti, Carlo

2009-01-01

Holmes’ tremor refers to an unusual combination of rest, postural and kinetic tremor of extremities. Common causes of Holmes’ tremor include stroke, trauma, vascular malformations and multiple sclerosis, with lesions involving the thalamus, brain stem or cerebellum. Although some drugs (eg, levodopa and dopaminergic drugs, clonazepam and propranolol) have been occasionally reported to give some benefit, medical treatment of Holmes’ tremor is unsatisfactory, and many patients require thalamic surgery to achieve satisfactory control. We report a patient in whom post-ischaemic Holmes’ tremor dramatically responded to levetiracetam treatment. PMID:21686707

The development of an MRI lesion quantifying system for multiple sclerosis patients undergoing treatment

NASA Astrophysics Data System (ADS)

Moin, Paymann; Ma, Kevin; Amezcua, Lilyana; Gertych, Arkadiusz; Liu, Brent

2009-02-01

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system that affects approximately 2.5 million people worldwide. Magnetic resonance imaging (MRI) is an established tool for the assessment of disease activity, progression and response to treatment. The progression of the disease is variable and requires routine follow-up imaging studies. Currently, MRI quantification of multiple sclerosis requires a manual approach to lesion measurement and yields an estimate of lesion volume and interval change. In the setting of several prior studies and a long treatment history, trends related to treatment change quickly become difficult to extrapolate. Our efforts seek to develop an imaging informatics based MS lesion computer aided detection (CAD) package to quantify and track MS lesions including lesion load, volume, and location. Together, with select clinical parameters, this data will be incorporated into an MS specific e- Folder to provide decision support to evaluate and assess treatment options for MS in a manner tailored specifically to an individual based on trends in MS presentation and progression.

[A review of multiple sclerosis (2). Diagnosis and treatment].

PubMed

Martinez-Altarriba, M C; Ramos-Campoy, O; Luna-Calcaño, I M; Arrieta-Antón, E

2015-09-01

Multiple sclerosis is a major demyelinating disease of the central nervous system. It has a significant economic and social impact. Its etiology is unclear, although there are several hypotheses, such as infections or genetics. In its pathophysiology, it seems that immune activation attacks the myelin sheath, causing a progressive and irreversible axonal degeneration. The disease produces a variety of symptoms, and diagnosis requires fulfilling a number of criteria and the exclusion of other possible causes. The role of neuroimaging is very important, especially Magnetic Resonance Imaging. Despite the availability of disease-modifying drugs, none of them are able to halt its progress, and the most useful drugs are those designed to alleviate the symptoms of outbreaks. Overall, multiple sclerosis requires a significant effort in research to clarify not only why and how it occurs, as well as the development of new measures to improve quality of life of affected patients. Copyright © 2013 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

[A review of multiple sclerosis (1). Presentation of a case].

PubMed

Martinez-Altarriba, M C; Ramos-Campoy, O; Luna-Calcaño, I M; Arrieta-Antón, E

2015-01-01

Multiple sclerosis is a major demyelinating disease of the central nervous system. It has a significant economic and social impact. Its etiology is unclear, although there are several hypotheses, such as infections or genetics. In its pathophysiology, it seems that immune activation attacks the myelin sheath, causing a progressive and irreversible axonal degeneration. The disease produces a variety of symptoms, and diagnosis requires fulfilling a number of criteria and the exclusion of other possible causes. The role of neuroimaging, especially MRI, is very important. Despite the availability of disease-modifying drugs, none of them are able to halt its progress, and the most useful drugs are those designed to alleviate the symptoms of outbreaks. Overall, multiple sclerosis requires a significant effort in research to clarify not only why and how it occurs, but also to develop of new measures to improve the life of affected patients. Copyright © 2013 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

Three-Dimensional Echocardiographic Assessment of Left Heart Chamber Size and Function with Fully Automated Quantification Software in Patients with Atrial Fibrillation.

PubMed

Otani, Kyoko; Nakazono, Akemi; Salgo, Ivan S; Lang, Roberto M; Takeuchi, Masaaki

2016-10-01

Echocardiographic determination of left heart chamber volumetric parameters by using manual tracings during multiple beats is tedious in atrial fibrillation (AF). The aim of this study was to determine the usefulness of fully automated left chamber quantification software with single-beat three-dimensional transthoracic echocardiographic data sets in patients with AF. Single-beat full-volume three-dimensional transthoracic echocardiographic data sets were prospectively acquired during consecutive multiple cardiac beats (≥10 beats) in 88 patients with AF. In protocol 1, left ventricular volumes, left ventricular ejection fraction, and maximal left atrial volume were validated using automated quantification against the manual tracing method in identical beats in 10 patients. In protocol 2, automated quantification-derived averaged values from multiple beats were compared with the corresponding values obtained from the indexed beat in all patients. Excellent correlations of left chamber parameters between automated quantification and the manual method were observed (r = 0.88-0.98) in protocol 1. The time required for the analysis with the automated quantification method (5 min) was significantly less compared with the manual method (27 min) (P < .0001). In protocol 2, there were excellent linear correlations between the averaged left chamber parameters and the corresponding values obtained from the indexed beat (r = 0.94-0.99), and test-retest variability of left chamber parameters was low (3.5%-4.8%). Three-dimensional transthoracic echocardiography with fully automated quantification software is a rapid and reliable way to measure averaged values of left heart chamber parameters during multiple consecutive beats. Thus, it is a potential new approach for left chamber quantification in patients with AF in daily routine practice. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

A Systematic Analysis of 2 Monoisocentric Techniques for the Treatment of Multiple Brain Metastases.

PubMed

Narayanasamy, Ganesh; Stathakis, Sotirios; Gutierrez, Alonso N; Pappas, Evangelos; Crownover, Richard; Floyd, John R; Papanikolaou, Niko

2017-10-01

In this treatment planning study, we compare the plan quality and delivery parameters for the treatment of multiple brain metastases using 2 monoisocentric techniques: the Multiple Metastases Element from Brainlab and the RapidArc volumetric-modulated arc therapy from Varian Medical Systems. Eight patients who were treated in our institution for multiple metastases (3-7 lesions) were replanned with Multiple Metastases Element using noncoplanar dynamic conformal arcs. The same patients were replanned with the RapidArc technique in Eclipse using 4 noncoplanar arcs. Both techniques were designed using a single isocenter. Plan quality metrics (conformity index, homogeneity index, gradient index, and R 50% ), monitor unit, and the planning time were recorded. Comparison of the Multiple Metastases Element and RapidArc plans was performed using Shapiro-Wilk test, paired Student t test, and Wilcoxon signed rank test. A paired Wilcoxon signed rank test between Multiple Metastases Element and RapidArc showed comparable plan quality metrics and dose to brain. Mean ± standard deviation values of conformity index were 1.8 ± 0.7 and 1.7 ± 0.6, homogeneity index were 1.3 ± 0.1 and 1.3 ± 0.1, gradient index were 5.0 ± 1.8 and 5.1 ± 1.9, and R 50% were 4.9 ± 1.8 and 5.0 ± 1.9 for Multiple Metastases Element and RapidArc plans, respectively. Mean brain dose was 2.3 and 2.7 Gy for Multiple Metastases Element and RapidArc plans, respectively. The mean value of monitor units in Multiple Metastases Element plan was 7286 ± 1065, which is significantly lower than the RapidArc monitor units of 9966 ± 1533 ( P < .05). For the planning of multiple brain lesions to be treated with stereotactic radiosurgery, Multiple Metastases Element planning software produced equivalent conformity, homogeneity, dose falloff, and brain V 12 Gy but required significantly lower monitor units, when compared to RapidArc plans.

A Systematic Analysis of 2 Monoisocentric Techniques for the Treatment of Multiple Brain Metastases

PubMed Central

Stathakis, Sotirios; Gutierrez, Alonso N.; Pappas, Evangelos; Crownover, Richard; Floyd, John R.; Papanikolaou, Niko

2016-01-01

Background: In this treatment planning study, we compare the plan quality and delivery parameters for the treatment of multiple brain metastases using 2 monoisocentric techniques: the Multiple Metastases Element from Brainlab and the RapidArc volumetric-modulated arc therapy from Varian Medical Systems. Methods: Eight patients who were treated in our institution for multiple metastases (3-7 lesions) were replanned with Multiple Metastases Element using noncoplanar dynamic conformal arcs. The same patients were replanned with the RapidArc technique in Eclipse using 4 noncoplanar arcs. Both techniques were designed using a single isocenter. Plan quality metrics (conformity index, homogeneity index, gradient index, and R50%), monitor unit, and the planning time were recorded. Comparison of the Multiple Metastases Element and RapidArc plans was performed using Shapiro-Wilk test, paired Student t test, and Wilcoxon signed rank test. Results: A paired Wilcoxon signed rank test between Multiple Metastases Element and RapidArc showed comparable plan quality metrics and dose to brain. Mean ± standard deviation values of conformity index were 1.8 ± 0.7 and 1.7 ± 0.6, homogeneity index were 1.3 ± 0.1 and 1.3 ± 0.1, gradient index were 5.0 ± 1.8 and 5.1 ± 1.9, and R50% were 4.9 ± 1.8 and 5.0 ± 1.9 for Multiple Metastases Element and RapidArc plans, respectively. Mean brain dose was 2.3 and 2.7 Gy for Multiple Metastases Element and RapidArc plans, respectively. The mean value of monitor units in Multiple Metastases Element plan was 7286 ± 1065, which is significantly lower than the RapidArc monitor units of 9966 ± 1533 (P < .05). Conclusion: For the planning of multiple brain lesions to be treated with stereotactic radiosurgery, Multiple Metastases Element planning software produced equivalent conformity, homogeneity, dose falloff, and brain V12 Gy but required significantly lower monitor units, when compared to RapidArc plans. PMID:27612917

Cardiac surgery-associated acute kidney injury.

PubMed

Vives, Marc; Wijeysundera, Duminda; Marczin, Nandor; Monedero, Pablo; Rao, Vivek

2014-05-01

Acute kidney injury develops in up to 30% of patients who undergo cardiac surgery, with up to 3% of patients requiring dialysis. The requirement for dialysis after cardiac surgery is associated with an increased risk of infection, prolonged stay in critical care units and long-term need for dialysis. The development of acute kidney injury is independently associated with substantial short- and long-term morbidity and mortality. Its pathogenesis involves multiple pathways. Haemodynamic, inflammatory, metabolic and nephrotoxic factors are involved and overlap each other leading to kidney injury. Clinical studies have identified predictors for cardiac surgery-associated acute kidney injury that can be used effectively to determine the risk for acute kidney injury in patients undergoing cardiac surgery. High-risk patients can be targeted for renal protective strategies. Nonetheless, there is little compelling evidence from randomized trials supporting specific interventions to protect or prevent acute kidney injury in cardiac surgery patients. Several strategies have shown some promise, including less invasive procedures in those at greatest risk, natriuretic peptide, fenoldopam, preoperative hydration, preoperative optimization of anaemia and postoperative early use of renal replacement therapy. The efficacy of larger-scale trials remains to be confirmed.

Intrinsic and extrinsic factors affecting patient engagement in diabetes self-management: perspectives of a certified diabetes educator.

PubMed

Rodriguez, Kellie M

2013-02-01

Patients with diabetes are responsible for the vast majority of management requirements of their condition. However, their ability and motivation to engage in required self-management behaviors may be mitigated by multiple intrinsic and extrinsic factors. Intrinsic barriers include attitudes and health beliefs, limited diabetes knowledge and technical skill, reduced functional health literacy, and inadequate self-efficacy to promote positive behavior change. Extrinsic barriers include financial considerations, inadequate family and community support systems, ineffective clinical relationships, and limited access to effective diabetes health care delivery. Diabetes providers have opportunities for enhancing patient engagement with clinical recommendations and diabetes self-management through effective communication, including efforts to contextually assess patients' perceptions of diabetes and how the condition fits within the context of their changing lives. This article provides a conceptual framework for establishing and building an effective clinical alliance with patients with the goal of empowering them to take more control of their diabetes and reduce their risks for poor diabetes outcomes. Copyright © 2013 Elsevier HS Journals, Inc. All rights reserved.

[Waist-hip ratio and perioperative bleeding in patients who underwent radical prostatectomy].

PubMed

León-Ramírez, Víctor; Santiago-López, Janaí; Reyes-Rivera, Juan Gabriel; Miguel-Soto, Edgar

2016-01-01

Radical prostatectomy is associated with perioperative bleeding and multiple transfusions. Abdominal obesity is a perioperative risk factor. We suggest that the adipocytes have a protective effect in oncological patients undergoing radical prostatectomy. The aim was to evaluate the effect of waist-hip ratio (WHR) on the amount of bleeding and perioperative transfusion requirements in oncological patients undergoing radical prostatectomy. We performed a cohort study in 156 patients. We had two groups: the control group (WHR<0.95) and the problem group (WHR≥0.95). Blood loss and fractions transfused during surgery and in the postoperative period were recorded. In the analysis of variables, for descriptive statistics we used measures of central tendency and dispersion. Inferential statistics was obtained by chi square, Student's t test, Mann-Whitney U and ANOVA. A p<0.05 was significant. We found significant differences in weight, body mass index, waist, WHR, perioperative bleeding, fractions transfused, permanence of the catheter, and hospital days. Patients who underwent radical prostatectomy with a WHR≥0.95 had a magnitude of perioperative bleeding and transfusion requirements with a WHR<0.95.

Using normalisation process theory to understand barriers and facilitators to implementing mindfulness-based stress reduction for people with multiple sclerosis.

PubMed

Simpson, Robert; Simpson, Sharon; Wood, Karen; Mercer, Stewart W; Mair, Frances S

2018-01-01

Objectives To study barriers and facilitators to implementation of mindfulness-based stress reduction for people with multiple sclerosis. Methods Qualitative interviews were used to explore barriers and facilitators to implementation of mindfulness-based stress reduction, including 33 people with multiple sclerosis, 6 multiple sclerosis clinicians and 2 course instructors. Normalisation process theory provided the underpinning conceptual framework. Data were analysed deductively using normalisation process theory constructs (coherence, cognitive participation, collective action and reflexive monitoring). Results Key barriers included mismatched stakeholder expectations, lack of knowledge about mindfulness-based stress reduction, high levels of comorbidity and disability and skepticism about embedding mindfulness-based stress reduction in routine multiple sclerosis care. Facilitators to implementation included introducing a pre-course orientation session; adaptations to mindfulness-based stress reduction to accommodate comorbidity and disability and participants suggested smaller, shorter classes, shortened practices, exclusion of mindful-walking and more time with peers. Post-mindfulness-based stress reduction booster sessions may be required, and objective and subjective reports of benefit would increase clinician confidence in mindfulness-based stress reduction. Discussion Multiple sclerosis patients and clinicians know little about mindfulness-based stress reduction. Mismatched expectations are a barrier to participation, as is rigid application of mindfulness-based stress reduction in the context of disability. Course adaptations in response to patient needs would facilitate uptake and utilisation. Rendering access to mindfulness-based stress reduction rapid and flexible could facilitate implementation. Embedded outcome assessment is desirable.

Systemic Sunitinib Malate Treatment for Advanced Juxtapapillary Retinal Hemangioblastomas Associated with von Hippel-Lindau Disease.

PubMed

Knickelbein, Jared E; Jacobs-El, Naima; Wong, Wai T; Wiley, Henry E; Cukras, Catherine A; Meyerle, Catherine B; Chew, Emily Y

2017-01-01

To describe the clinical course of advanced juxtapapillary retinal capillary hemangioblastomas (RCH) associated with von Hippel-Lindau (VHL) disease treated with systemic sunitinib malate, an agent that inhibits both anti-vascular endothelial growth factor and anti-platelet-derived growth factor signaling. Observational case review. Three patients with advanced VHL-related juxtapapillary RCH treated with systemic sunitinib malate. Patient 1 was followed routinely every 4 months while on systemic sunitinib prescribed by her oncologist for metastatic pancreatic neuroendocrine and kidney tumors. Patients 2 and 3 were part of a prospective clinical trial evaluating the use of systemic sunitinib for ocular VHL lesions during a period of 9 months. Visual acuity, size of RCH, and degree of exudation were recorded at each visit. Optical coherence tomography (OCT) and fluorescein angiography were also obtained at some visits. Visual acuity, size of RCH, and degree of exudation. Three patients with advanced VHL-associated juxtapapillary RCH were treated with systemic sunitinib malate. While none of the patients lost vision during therapy, treatment with sunitinib malate did not improve visual acuity or reduce the size of RCH. Improvements in RCH-associated retinal edema were observed in two patients. All patients experienced multiple adverse effects, including thyroid toxicity, thrombocytopenia, nausea, fatigue, jaundice, and muscle aches. Two of the three patients had to discontinue treatment prematurely and the third required dose reduction. Systemic sunitinib malate may be useful in slowing progression of ocular disease from VHL-associated RCH. However, significant systemic adverse effects limited its use in this small series, and systemic sunitinib malate may not be safe for treatment of RCH when used at the doses described in this report. Further studies are required to determine if this medication used at lower doses with different treatment strategies, other medications in the same class or drugs directed at multiple targets in the tumor, may be safer and more effective for the treatment of advanced VHL-associated RCH.

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

So you think you've designed an effective recruitment protocol?

PubMed

Green, Cara; Vandall-Walker, Virginia

2017-03-22

Background Recruiting acutely ill patients to participate in research can be challenging. This paper outlines the difficulties the first author encountered in a study and the steps she took to overcome problems with research ethics, gain access to participants and implement a recruitment protocol in multiple hospitals. It also compares these steps with literature related to recruitment. Aim To inform and inspire neophyte researchers about the need for planning and resilience when dealing with recruitment challenges in multiple hospitals. Discussion The multiple enablers and barriers to the successful implementation of a hospital-based study recruitment protocol are explored based on a neophyte researcher's optimistic assumptions about this stage of the study. Conclusions Perseverance, adequately planning for contingencies, and accepting the barriers and challenges to recruitment are essential for completing one's research study and ensuring fulfilment as a researcher. Implications for practice Healthcare students carrying out research require adequate knowledge about conducting hospital-based, patient research to inform their recruitment plan. Maximising control over recruitment, allowing for adequate time to conduct data collection, and maintaining a good work ethic will help to ensure success.

The number of 131I therapy courses needed to achieve complete remission is an indicator of prognosis in patients with differentiated thyroid carcinoma.

PubMed

Thies, Elena-Daphne; Tanase, Karina; Maeder, Uwe; Luster, Markus; Buck, Andreas K; Hänscheid, Heribert; Reiners, Christoph; Verburg, Frederik A

2014-12-01

To assess the risk of differentiated thyroid cancer (DTC) recurrence, DTC-related mortality and life expectancy in relation to the number of courses of (131)I therapy (RIT) and cumulative (131)I activities required to achieve complete remission (CR). The study was a database review of 1,229 patients with DTC, 333 without and 896 with CR (negative TSH-stimulated thyroglobulin and negative (131)I diagnostic whole-body scintigraphy) after one or more courses of RIT. The median follow-up was 9.0 years (range 0.1 - 31.8 years) after CR. Recurrence rates at 5 years, 10 years and the end of follow-up were 1.0 ± 0.3%, 4.0 ± 0.7 % and 6.2 ± 1.1 %, and DTC-related mortality was 0.1 ± 0.1%, 0.5 ± 0.3% and 3.4 ± 1.1%, respectively. Recurrence rates also increased with an increasing number of RIT courses required (p = 0.001). DTC-related mortality increased from four RIT courses. In patients with CR after one RIT course, there were no differences in recurrence or DTC-related mortality rates between low-risk and high-risk patients. In patients requiring two RIT courses these rates remain elevated in high-risk patients. Recurrence and DTC-related mortality rates were only significantly elevated in those requiring a cumulative activity over 22.2 GBq (600 mCi) from multiple RIT courses for CR. Regardless of the number of RIT courses or activity needed, life expectancy was not significantly lowered. If more than one RIT course is needed to achieve CR, higher recurrence and DTC-related mortality rates are observed, especially in high-risk patients. Patients requiring >22.2 GBq (131)I for CR should be followed in the same way as patients in whom CR is never reached as long-term mortality rates are similar.

The patient's perspective: How to create awareness for improving access to care and treatment of MS patients?

PubMed

Vermersch, Patrick; Faller, Andreas; Czarnota-Szałkowska, Dominika; Meesen, Bianca; Thalheim, Christoph

2016-08-01

There is currently no known cure for multiple sclerosis (MS). Four stakeholders play a major role in MS: healthcare professionals, regulators, payers and patients. In Europe, patients are represented by the European Multiple Sclerosis Platform (EMSP), which aims to improve MS management and patients' quality of life. The EMSP has recently shown that there are major disparities in Europe in terms of access to care and treatment. Implementing the Code of Good Practice and a standardised MS nurse training may be useful in harmonising MS management across Europe. Additionally, the burden for novel therapeutic options to be approved by regulatory agencies has to decrease in order to provide faster access of treatment to patients. Data collection (e.g. national registers) also appears crucial to help research and shape the most effective policy in each country. Finally, people with MS should get appropriate (financial) support in order to complete their studies and find a job, as their active participation in society requires proper access to education and employment. Moreover, as they are the ones affected by MS, they seem to be best placed to represent themselves and their needs and should be consulted more often during decision-making processes by policy makers, regulators and payers. © The Author(s), 2016.

[Evaluation and perioperative management of patients with diabetes mellitus. A challenge for the anesthesiologist].

PubMed

Pontes, João Paulo Jordão; Mendes, Florentino Fernandes; Vasconcelos, Mateus Meira; Batista, Nubia Rodrigues

Diabetes mellitus (DM) is characterized by alteration in carbohydrate metabolism, leading to hyperglycemia and increased perioperative morbidity and mortality. It evolves with diverse and progressive physiological changes, and the anesthetic management requires attention regarding this disease interference in multiple organ systems and their respective complications. Patient's history, physical examination, and complementary exams are important in the preoperative management, particularly glycosylated hemoglobin (HbA1c), which has a strong predictive value for complications associated with diabetes. The goal of surgical planning is to reduce the fasting time and maintain the patient's routine. Patients with Type 1 DM must receive insulin (even during the preoperative fast) to meet the basal physiological demands and avoid ketoacidosis. Whereas patients with Type 2 DM treated with multiple injectable and/or oral drugs are susceptible to develop a hyperglycemic hyperosmolar state (HHS). Therefore, the management of hypoglycemic agents and different types of insulin is fundamental, as well as determining the surgical schedule and, consequently, the number of lost meals for dose adjustment and drug suspension. Current evidence suggests the safe target to maintain glycemic control in surgical patients, but does not conclude whether it should be obtained with either moderate or severe glycemic control. Copyright © 2017 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Effectiveness of CO2 laser with subcision in patients with acne scars.

PubMed

Anupama, Y G; Wahab, Afthab Jameela

2016-11-01

Post-acne facial scarring has always been a challenge to treat. It requires multiple therapeutic modalities as single modality is not hundred percent effective. Therefore, we have combined CO 2 laser resurfacing with subcision in patients with acne scars for better results. The aim is to study the effectiveness and side effects of CO 2 laser with subcision in patients with atrophic acne scars. Fifty patients were selected for the study. Baseline grading was done with Goodman and Baron grading system. Twenty-five patients were randomly selected for subcision followed by CO 2 laser and the remaining patients were selected for CO 2 laser alone. The treatment was done for four sessions at 4-week interval. Clinical photographs were obtained for evaluation. CO 2 laser with subcision showed excellent response in grade-2 and -3 acne scars. Statistically there is a significant difference between CO 2 laser following subcision and CO 2 laser alone at 5% level (p < 0.05). Both procedures were well tolerated with minimal side effects. The highly versatile CO 2 laser is useful for treating acne scars. Subcision prior to the CO 2 laser procedure showed better improvement when compared to CO 2 laser alone. Thus, in acne scars, multiple therapeutic modalities achieve better results.

Surgery for "body packers"--a 15-year experience.

PubMed

Silverberg, Daniel; Menes, Tehillah; Kim, Unsup

2006-04-01

"Body packing" of illegal drugs has increased in the last decades, and with it our experience in treating these patients, yet no clear guidelines for surgical treatment are available. We examined the characteristics and outcomes of patients who required surgical intervention. Charts of all patients who underwent surgery at our institution for ingested drug packets between January 1990 and January 2005 were reviewed. Patients were identified by a pre-existing list of names collected prospectively and by admission codes. Reviewed parameters included presentation, method of diagnosis, indication for surgery, procedure, and patient outcome. Twenty-five patients were identified, for whom charts were available for review. Main indications for surgery were drug toxicity and small bowel obstruction. Most packets were retrieved using a combination of milking and multiple enterotomies. A high rate (40%) of postoperative wound infection was found. The incidence of wound infection correlated significantly with the number of enterotomies. Surgical intervention for body packing remains the treatment for a minority of these patients. Patients should be placed in lithotomy to facilitate the exposure of the entire gastrointestinal tract, and to allow milking of the packets and their possible retrieval through the anus. The number of enterotomies should be minimized in order to reduce the risk of wound infection. If multiple enterotomies are used, the surgeon should consider leaving the wound open for delayed closure.

A Multicenter, Randomized, Open-Label, Pharmacokinetics and Safety Study of Pantoprazole Tablets in Children and Adolescents Aged 6 Through 16 Years With GERD

PubMed Central

Ward, Robert M.; Kearns, Gregory L.; Tammara, Brinda; Bishop, Phyllis; O’Gorman, Molly A.; James, Laura P.; Katz, Mitchell H.; Maguire, Mary K.; Rath, Natalie; Meng, Xu; Comer, Gail M.

2011-01-01

SUMMARY Children with GERD may benefit from gastric acid suppression with proton pump inhibitors such as pantoprazole. Effective treatment with pantoprazole requires correct dosing and understanding of the drug’s kinetic profile in children. The aim of these studies was to characterize the pharmacokinetic (PK) profile of single and multiple doses of pantoprazole delayed-release tablets in pediatric patients with GERD aged ≥6 through 11 years (study 1) and 12 through 16 years (study 2). Patients were randomly assigned to receive pantoprazole 20 or 40 mg once daily. Plasma pantoprazole concentrations were obtained at intervals through 12 hours after the single dose, and at 2 and 4 hours after multiple doses for PK evaluation. PK parameters were derived by standard noncompartmental methods and examined as a function of both drug dose and patient age. Safety was also monitored. Pantoprazole PK was dose independent (when dose normalized) and similar toPK reported from adult studies. There was no evidence of accumulation with multiple dosing or reports of serious drug-associated adverse events. In children aged 6 to 16 years with GERD, currently available pantoprazole delayed-release tablets can be used to provide systemic exposure similar to that in adults. PMID:20852004

Meningiomatosis restricted to the left cerebral hemisphere with acute clinical deterioration: Case presentation and discussion of treatment options.

PubMed

Ohla, Victoria; Scheiwe, Christian

2015-01-01

True multiple meningiomas are defined as meningiomas occurring at several intracranial locations simultaneously without the presence of neurofibromatosis. Though the prognosis does not differ from benign solitary meningiomas, the simultaneous occurrence of different grades of malignancy has been reported in one-third of patients with multiple meningiomas. Due to its rarity, unclear etiology, and questions related to proper management, we are presenting our case of meningiomatosis and discuss possible pathophysiological mechanisms. We illustrate the case of a 55-year-old female with multiple meningothelial meningeomas exclusively located in the left cerebral hemisphere. The patient presented with acute vigilance decrement, aphasia, and vomiting. Further deterioration with sopor and nondirectional movements required oral intubation. Emergent magnetic resonance imaging (MRI) with MR-angiography disclosed a massive midline shift to the right due to widespread, plaque-like lesions suspicious for meningeomatosis, purely restricted to the left cerebral hemisphere. Emergency partial tumor resection was performed. Postoperative computed tomography (CT) scan showed markedly reduction of cerebral edema and midline shift. After tapering the sedation a right-sided hemiparesis resolved within 2 weeks, leaving the patient neurologically intact. Although multiple meningeomas are reported frequently, the presence of meningeomatosis purely restricted to one cerebral hemisphere is very rare. As with other accessible and symptomatic lesions, the treatment of choice is complete resection with clean margins to avoid local recurrence. In case of widespread distribution a step-by-step resection with the option of postoperative radiation of tumor remnants may be an option.

Multiple-digit resurfacing using a thin latissimus dorsi perforator flap.

PubMed

Kim, Sang Wha; Lee, Ho Jun; Kim, Jeong Tae; Kim, Youn Hwan

2014-01-01

Traumatic digit defects of high complexity and with inadequate local tissue represent challenging surgical problems. Recently, perforator flaps have been proposed for reconstructing large defects of the hand because of their thinness and pliability and minimal donor site morbidity. Here, we illustrate the use of thin latissimus dorsi perforator flaps for resurfacing multiple defects of distal digits. We describe the cases of seven patients with large defects, including digits, circumferential defects and multiple-digit defects, who underwent reconstruction with thin latissimus dorsi perforator flaps between January 2008 and March 2012. Single-digit resurfacing procedures were excluded. The mean age was 56.3 years and the mean flap size was 160.4 cm(2). All the flaps survived completely. Two patients had minor complications including partial flap loss and scar contracture. The mean follow-up period was 11.7 months. The ideal flap for digit resurfacing should be thin and amenable to moulding, have a long pedicle for microanastomosis and have minimal donor site morbidity. Thin flaps can be harvested by excluding the deep adipose layer, and their high pliability enables resurfacing without multiple debulking procedures. The latissimus dorsi perforator flap may be the best flap for reconstructing complex defects of the digits, such as large, multiple-digit or circumferential defects, which require complete wrapping of volar and dorsal surfaces. Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Strategies to reduce hyperthermia in ambulatory multiple sclerosis patients.

PubMed

Edlich, Richard F; Buschbacher, Ralph M; Cox, Mary Jude; Long, William B; Winters, Kathryne L; Becker, Daniel G

2004-01-01

Approximately 400,000 Americans have multiple sclerosis. Worldwide, multiple sclerosis affects 2.5 million individuals. Multiple sclerosis affects two to three times as many women as men. The adverse effects of hyperthermia in patients with multiple sclerosis have been known since 1890. While most patients with multiple sclerosis experience reversible worsening of their neurologic deficits, some patients experience irreversible neurologic deficits. In fact, heat-induced fatalities have been encountered in multiple sclerosis patients subjected to hyperthermia. Hyperthermia can be caused through sun exposure, exercise, and infection. During the last 50 years, numerous strategies have evolved to reduce hyperthermia in individuals with multiple sclerosis, such as photoprotective clothing, sunglasses, sunscreens, hydrotherapy, and prevention of urinary tract infections. Hydrotherapy has become an essential component of rehabilitation for multiple sclerosis patients in hospitals throughout the world. On the basis of this positive hospital experience, hydrotherapy has been expanded through the use of compact aquatic exercise pools at home along with personal cooling devices that promote local and systemic hypothermia in multiple sclerosis patients. The Multiple Sclerosis Association of America and NASA have played leadership roles in developing and recommending technology that will prevent hyperthermia in multiple sclerosis patients and should be consulted for new technological advances that will benefit the multiple sclerosis patient. In addition, products recommended for photoprotection by The Skin Cancer Foundation may also be helpful to the multiple sclerosis patient's defense against hyperthermia. Infections in the urinary tract, especially detrusor-external sphincter dyssynergia, are initially managed conservatively with intermittent self-catheterization and pharmacologic therapy. In those cases, refractory to conservative therapy, transurethral external sphincterotomy followed by condom catheter drainage is recommended. However, if external urethral sphincterotomy fails to reduce residual urine and detrusor pressure, urinary diversion or bladder reconstruction may be necessary.

Management patterns of medicare patients undergoing treatment for upper urinary tract calculi.

PubMed

Matlaga, Brian R; Meckley, Lisa M; Kim, Micheline; Byrne, Thomas W

2014-06-01

We conducted this study to identify differences in the re-treatment rates and ancillary procedures for the two most commonly utilized stone treatment procedures in the Medicare population: ureteroscopy (URS) and shock wave lithotripsy (SWL). A retrospective claims analysis of the Medicare standard analytical file 5% sample was conducted to identify patients with a new diagnosis of urolithiasis undergoing treatment with URS or SWL from 2009-2010. Outcomes evaluated: (1) repeat stone removal procedures within 120 days post index procedure, (2) stent placement procedures on the index date, 30 days prior to and 120 days post index date, and (3) use of general anesthesia. We identified 3885 eligible patients, of which 2165 (56%) underwent SWL and 1720 (44%) underwent URS. Overall, SWL patients were 1.73 times more likely to undergo at least one repeat procedure than URS patients, and twice as likely to require multiple re-treatments compared to URS. Among those with ureteral stones, SWL patients were 2.27 times more likely to undergo repeat procedures. The difference was not statistically significant in renal stone patients. Overall, SWL patients were 1.41 times more likely than URS patients to have a stent placed prior to index procedure, and 1.33 times more likely to have a stent placed subsequent to the index procedure. The majority of URS patients (77.8%) had a stent placed at the time of index procedure. There was no significant difference in anesthetic approaches between SWL and URS. Patients undergoing SWL are significantly more likely to require re-treatments than URS patients. SWL patients are also significantly more likely to require ureteral stent placement as a separate event. SWL and URS patients have similar rates of general anesthesia.

Septic Pulmonary Embolism Requiring Critical Care: Clinicoradiological Spectrum, Causative Pathogens and Outcomes

PubMed Central

Chou, Deng-Wei; Wu, Shu-Ling; Chung, Kuo-Mou; Han, Shu-Chen; Cheung, Bruno Man-Hon

2016-01-01

OBJECTIVES: Septic pulmonary embolism is an uncommon but life-threatening disorder. However, data on patients with septic pulmonary embolism who require critical care have not been well reported. This study elucidated the clinicoradiological spectrum, causative pathogens and outcomes of septic pulmonary embolism in patients requiring critical care. METHODS: The electronic medical records of 20 patients with septic pulmonary embolism who required intensive care unit admission between January 2005 and December 2013 were reviewed. RESULTS: Multiple organ dysfunction syndrome developed in 85% of the patients, and acute respiratory failure was the most common organ failure (75%). The most common computed tomographic findings included a feeding vessel sign (90%), peripheral nodules without cavities (80%) or with cavities (65%), and peripheral wedge-shaped opacities (75%). The most common primary source of infection was liver abscess (40%), followed by pneumonia (25%). The two most frequent causative pathogens were Klebsiella pneumoniae (50%) and Staphylococcus aureus (35%). Compared with survivors, nonsurvivors had significantly higher serum creatinine, arterial partial pressure of carbon dioxide, and Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores, and they were significantly more likely to have acute kidney injury, disseminated intravascular coagulation and lung abscesses. The in-hospital mortality rate was 30%. Pneumonia was the most common cause of death, followed by liver abscess. CONCLUSIONS: Patients with septic pulmonary embolism who require critical care, especially those with pneumonia and liver abscess, are associated with high mortality. Early diagnosis, appropriate antibiotic therapy, surgical intervention and respiratory support are essential. PMID:27759843

Survey on Monitoring and Quality Controlling of the Mobile Biosignal Delivery.

PubMed

Pawar, Pravin A; Edla, Damodar R; Edoh, Thierry; Shinde, Vijay; van Beijnum, Bert-Jan

2017-10-31

A Mobile Patient Monitoring System (MPMS) acquires patient's biosignals and transmits them using wireless network connection to the decision-making module or healthcare professional for the assessment of patient's condition. A variety of wireless network technologies such as wireless personal area networks (e.g., Bluetooth), mobile ad-hoc networks (MANET), and infrastructure-based networks (e.g., WLAN and cellular networks) are in practice for biosignals delivery. The wireless network quality-of-service (QoS) requirements of biosignals delivery are mainly specified in terms of required bandwidth, acceptable delay, and tolerable error rate. An important research challenge in the MPMS is how to satisfy QoS requirements of biosignals delivery in the environment characterized by patient mobility, deployment of multiple wireless network technologies, and variable QoS characteristics of the wireless networks. QoS requirements are mainly application specific, while available QoS is largely dependent on QoS provided by wireless network in use. QoS provisioning refers to providing support for improving QoS experience of networked applications. In resource poor conditions, application adaptation may also be required to make maximum use of available wireless network QoS. This survey paper presents a survey of recent developments in the area of QoS provisioning for MPMS. In particular, our contributions are as follows: (1) overview of wireless networks and network QoS requirements of biosignals delivery; (2) survey of wireless networks' QoS performance evaluation for the transmission of biosignals; and (3) survey of QoS provisioning mechanisms for biosignals delivery in MPMS. We also propose integrating end-to-end QoS monitoring and QoS provisioning strategies in a mobile patient monitoring system infrastructure to support optimal delivery of biosignals to the healthcare professionals.

Use and efficacy of a nutrition protocol for patients with burns in intensive care.

PubMed

Lown, D

1991-01-01

The University of Michigan Burn Center uses a protocol to standardize the assessment, initiation, and monitoring of nutritional support for patients with burns of greater than 30% total body surface area (TBSA). Six patients with 20% to 80% TBSA burns were followed for 3 weeks to determine the effect of the protocol on the assessment, initiation, monitoring, and adequacy of nutritional support. The protocol calls for resting energy expenditure (REE) measurement within 24 hours of injury, to be repeated 3 times per week, for assessment of caloric requirements. Patients experienced an average delay before first REE measurement of 3 days after burn injury because measurements were unavailable on weekends and surgical days. REE measurements were used to determine caloric requirements and to tailor nutritional support to fluctuating metabolic needs. In four of the six patients a Dobhoff feeding tube (Biosearch Medical Products, Inc., Somerville, N.J.) was placed in the small bowel and enteral nutrition was initiated within 24 hours of admission, as outlined in the protocol. Two patients received concurrent parenteral nutrition because of difficulty in placing the Dobhoff feeding tube when fluoroscopy was not available. The three patients receiving nutrition solely through enteral feeding had achieved 100% of their caloric requirements by day 2, 4, and greater than 7 days after injury, respectively. Overall, the six patients received enterally an average of 75% of their caloric requirements. The major reason for inadequate enteral support was interruption of tube feedings because of tube dislodgment or multiple surgical procedures. The protocol used weekly measurements of total iron-binding capacity and prealbumin level s parameters of nutritional support.(ABSTRACT TRUNCATED AT 250 WORDS)

Symptom profile and short term outcome of catatonia: an exploratory clinical study.

PubMed

Worku, Benyam; Fekadu, Abebaw

2015-07-22

Catatonia is a potentially life-threatening but treatable neuropsychiatric condition. Although considered more common in low income countries, data is particularly sparse in these settings. In this study we explore the symptomatology, treatment, and short-term outcome of catatonia in Ethiopia, a low income country. The study was a prospective evaluation of patients admitted with a DSM-IV diagnosis of catatonia. Diagnosis of Catatonia and its severity were further assessed with the Bush-Francis Catatonia Rating Scale (BFCRS). Twenty participants, 5 male and 15 female, were included in the study: 15 patients (75 %) had underlying mood disorders, 4 patients (20 %) had schizophrenia and 1 patient (5 %) had general medical condition. The most common catatonic symptoms, occurring in over two-thirds of participants, were mutism, negativism, staring and immobility (stupor). Eighteen (90 %) of the twenty patients were on multiple medications. Antipsychotics were the most commonly prescribed medications. ECT was required in seven patients (35.0 %). Dehydration, requiring IV rehydration, and infections were the most important complications ascribed to the catatonia. These occurred in seven patients (25 %). Almost all patients (n = 19/20) were discharged with significant improvement. This study supports the growing consensus that catatonia is most often associated with mood disorders. Overall prognosis appears very good although the occurrence of life-threatening complications underlines the serious nature of catatonia. This has implication for "task-shifted" service scale up plans, which aim to improve treatment coverage by training non-specialist health workers to provide mental health care in low income countries. Further larger scale studies are required to clarify the nature and management, as well as, service requirements for catatonia.

Treatment of gallbladder stone with common bile duct stones in the laparoscopic era.

PubMed

Zhang, Wei-jie; Xu, Gui-fang; Huang, Qin; Luo, Kun-lun; Dong, Zhi-tao; Li, Jie-ming; Wu, Guo-zhong; Guan, Wen-xian

2015-01-26

Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients. From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed. Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs. In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.

Needle aspiration of calcific deposits (NACD) for calcific tendinitis is safe and effective: Six months follow-up of clinical results and complications in a series of 431 patients.

PubMed

Oudelaar, Bart W; Schepers-Bok, Relinde; Ooms, Edwin M; Huis In 't Veld, Rianne; Vochteloo, Anne J H

2016-04-01

Although needle aspiration of calcific deposits (NACD) has proven to be an effective treatment for calcific tendinitis of the rotator cuff (CTRC) in patients who are resistant to conservative treatment, little is known about the effectiveness of NACD in terms of complete relief of symptoms and the effectiveness of repeated NACD procedures. Furthermore, analyses of complications of the procedure in large series are scarce. 431 consecutive patients with symptomatic CTRC treated by NACD were included in this retrospective cohort study. Short-term effects were assessed at two weeks post-treatment by using an 11-point numeric rating scale (NRS). The six months outcome was determined on a dichotomous symptom scale (symptom free or persistence of symptoms). NACD procedures performed within six months of a previous NACD procedure were considered repeated procedures. All complications that occurred within six months of the NACD procedure were registered. At two weeks post-treatment, a significant improvement of pain scores was noted (mean reduction of NRS: 4.4 points; p<0.001). 74% of patients had complete relief of symptoms at six months post-treatment. 143 (33.2%) patients required multiple treatments. These repeated procedures were equally effective as the primary procedure. Complications of the NACD procedure were seen in 31 (7.2%) patients: 21 patients (4.9%) developed a subacromial bursitis, seven patients (1.6%) a frozen shoulder and three patients (0.7%) developed a septic bursitis. Needle aspiration of calcific deposits (NACD) is an effective treatment for calcific tendinitis of the rotator cuff in the majority of patients. Approximately one third of the patients will require multiple treatments, which were equally effective as the primary procedure. Based on this, patients should not be withheld a second or even a third treatment in case of persistent symptoms. Furthermore, NACD has a low complication rate, the risk of infection should, however, always be accounted for. Retrospective study, level IV. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

An update on MS Nurse PROfessional, an ongoing project of the European Multiple Sclerosis Platform.

PubMed

Winslow, Anne

2016-12-01

Within the multidisciplinary team required to manage people with multiple sclerosis (MS) effectively, the nurse is the central component of coordinated care and support. A 2009 survey led by the European Multiple Sclerosis Platform, an umbrella organization of national MS associations, identified variance and disparity across Europe in the nursing care of MS patients. This led to development of MS Nurse PROfessional, a continuing medical education-accredited modular online learning program endorsed and approved by leading international nursing and professional groups, and people with MS, as a tool to support the evolving role of the European MS nurse. Analysis of participant experience and nurse practice to date has been overwhelmingly positive. Expansion of MS Nurse PRO is underway or planned for future.

Management of chronic lymphocytic leukemia.

PubMed

Stilgenbauer, Stephan; Furman, Richard R; Zent, Clive S

2015-01-01

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is usually diagnosed in asymptomatic patients with early-stage disease. The standard management approach is careful observation, irrespective of risk factors unless patients meet the International Workshop on CLL (IWCLL) criteria for "active disease," which requires treatment. The initial standard therapy for most patients combines an anti-CD20 antibody (such as rituximab, ofatumumab, or obinutuzumab) with chemotherapy (fludarabine/cyclophosphamide [FC], bendamustine, or chlorambucil) depending on multiple factors including the physical fitness of the patient. However, patients with very high-risk CLL because of a 17p13 deletion (17p-) with or without mutation of TP53 (17p-/TP53mut) have poor responses to chemoimmunotherapy and require alternative treatment regimens containing B-cell receptor (BCR) signaling pathway inhibitors. The BCR signaling pathway inhibitors (ibrutinib targeting Bruton's tyrosine kinase [BTK] and idelalisib targeting phosphatidyl-inositol 3-kinase delta [PI3K-delta], respectively) are currently approved for the treatment of relapsed/refractory CLL and all patients with 17p- (ibrutinib), and in combination with rituximab for relapsed/refractory patients (idelalisib). These agents offer great efficacy, even in chemotherapy refractory CLL, with increased tolerability, safety, and survival. Ongoing studies aim to determine the best therapy combinations with the goal of achieving long-term disease control and the possibility of developing a curative regimen for some patients. CLL is associated with a wide range of infectious, autoimmune, and malignant complications. These complications result in considerable morbidity and mortality that can be minimized by early detection and aggressive management. This active monitoring requires ongoing patient education, provider vigilance, and a team approach to patient care.

Use of giant-sized flow-through venous flap for simultaneous reconstruction of dual or multiple major arteries in salvage therapy for complex upper limb traumatic injury.

PubMed

Zheng, Da-Wei; Li, Zhang-Can; Shi, Rong-Jian; Sun, Feng; Xu, Li; Shou, Kui-Shui

2016-02-01

Salvage repair after complex upper limb traumatic injury is surgically challenging due to underlying major arterial impairment with complicating a large-sized soft tissue defect. The purpose of this study was to evaluate the effectiveness and safety of using a giant-sized (≥100 cm(2)) flow-through venous flap for reconstruction of dual or multiple forearm, metacarpal, or digital arteries after complex upper limb traumatic injury. Seven patients were consecutively hospitalized for emergency salvage repair after complex upper limb traumatic injury between March 2012 and May 2014. The forearm and palmar artery defects were repaired using the calf great saphenous vein flap and the volar forearm venous flap, respectively. The flow-through venous flap ranged from 9.5 cm × 12.0 cm to 12.0 cm × 20.0 cm (mean, 158.4 cm(2)) in size. The flaps and affected limbs survived uneventfully in five patients, with one patient experiencing distal flap marginal necrosis and a second patient requiring amputation of the affected limb. Computed tomography angiography showed patent vessels in all patients. The mean total active motion of the repaired fingers was 199.5° versus 258.8° for the contralateral counterpart (77.1%). The sensory return was determined to be S2 in 2 patients, S3 in 3 patients and S3+ in 1 patient. The disability scores for the arm, shoulder, and hand ranged from 4.6-18.2 (mean, 11.3), and the mean Michigan hand outcomes questionnaire score was 7.8 ± 0.9. The flow-through venous flap is an effective and safe treatment alternative for salvage therapy of a ≥100-cm(2) complex upper limb traumatic injury with dual or multiple major arterial impairment. This technique allows simultaneous reconstruction of dual or multiple artery injuries and an extensive soft tissue defect. Serious surgical site infection remains a major safety concern and necessitates radical debridement in complicating cases. Copyright © 2015 Elsevier Ltd. All rights reserved.

No longer waiting for an accident to happen: Simulation in emergency medicine.

PubMed

Ellison, Stefanie; Sullivan, Christine; McCullough, Robert

2013-01-01

The practice of emergency medicine (EM) requires proficient and expert skills in multiple high risk procedures. The emergency physician in-training needs a safe and realistic environment in which to practice and perfect the skills necessary to care for patients ranging from the critically ill to the patient with difficult intravenous access. Undergraduate medical, education overall has a need for training that enables students to develop the knowledge, skills and attitudes to practice in a variety of specialties. This article provides an overview of simulation in a three-year emergency medicine residency at Truman Medical Center, in a required final year clerkship for all medical students at the University of Missouri-Kansas City, and discusses national trends for the use of simulation in emergency medicine.

Air-fluidized therapy: physical properties and clinical uses.

PubMed

VanGilder, Catherine; Lachenbruch, Charlie A

2010-09-01

Since the late 1960s, air-fluidized therapy (AFT) has been effectively used to treat patients with pressure ulcers, burns, and many other clinical problems. Much of the demonstrated efficacy is believed to be associated with the unique fluid environment provided by AFT that is fundamentally different from the support provided by surfaces made up of conventional solid materials. Fluid support maximizes the envelopment of the body while significantly reducing shear, friction, and pressure, and mechanical stress applied to the skin and subcutaneous tissue. Additionally, the variable temperature airflow allows the microclimate to be controlled according to needs for both therapy and patient comfort. Clinical benefits of AFT include faster and more cost-effective healing of pressure ulcers, a decreased rate of hospitalizations and emergency room visits for long-term care pressure ulcer patients, decreased mortality of patients with extensive burns and inhalation injury and rapid healing and increased comfort in burn patients. The fluid support also results in a substantial decrease in the amount of caregiver effort required for repositioning patients and increased patient comfort in patients with multiple trauma and external fixation devices or deformities that require a conforming bed, and patients with cancer and bony metastasis. This article seeks to evaluate the physical differences in AFT over other mattress types and to review the published literature for this therapy modality.

The most important psychological and psychosocial needs of Polish multiple sclerosis patients and their significant others.

PubMed

Potemkowski, Andrzej; Brola, Waldemar; Ratajczak, Anna; Ratajczak, Marcin; Kowalewski, Mariusz; Lewita, Małgorzata; Kapica-Topczewska, Katarzyna; Tarasiuk, Joanna; Stępień, Adam; Gocyła-Dudar, Katarzyna; Zaborski, Jacek; Bartosik-Psujek, Halina

2017-01-01

People with multiple sclerosis (MS) and their relatives often have multiple, complex needs which require support from a wide range of services. The aim of the study, the first of its kind in Poland, was to identify the most important needs of patients with MS and their significant others (SO). A questionnaire developed from focus groups consisting of 20 needs-related statements was administered in seven MS centers to 573 MS patients and 220 SO. The mean age of the patients was 42.61 years old; the mean MS duration was 9.43 years. The respondents were asked to rate the needs statements according to their importance on an 11-point scale. The questionnaire was similar for the MS patients and their SO. The most important needs in the patient group were: to feel needed and efficient in life; to have easy access to professional rehabilitation; and to be sure that doctors are interested in my condition. The three most important needs in the SO group were: to know that relatives/friends feel needed and efficient in life; to have good living conditions; and to be sure that doctors are interested in my relative's/friend's condition. Correlation analysis revealed that in the patients group, there was a positive correlation between patient's age and the importance of factors such as the need for support and interest in their disease from the family doctor ( P <0.004), receiving educational materials from an MS clinic ( P <0.011), interest from the clinic in life issues of the patient ( P <0.001), and the need for access to self-rehabilitation ( P <0.003); while the need to continue working part-time was inversely correlated with age ( P <0.009). The needs of the MS patients and SO were similar. The data validate the importance of interdisciplinary care for the MS population.

Increased patient communication using a process supplementing an electronic medical record.

PubMed

Garvey, Thomas D; Evensen, Ann E

2015-02-01

Importance: Patients with cervical cytology abnormalities may require surveillance for many years, which increases the risk of management error, especially in clinics with multiple managing clinicians. National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) certification requires tracking of abnormal results and communicating effectively with patients. The purpose of this study was to determine whether a computer-based tracking system that is not embedded in the electronic medical record improves (1) accurate and timely communication of results and (2) patient adherence to follow-up recommendations. Design: Pre/post study using data from 2005-2012. Intervention implemented in 2008. Data collected via chart review for at least 18 months after index result. Participants: Pre-intervention: all women (N = 72) with first abnormal cytology result from 2005-2007. Post-intervention: all women (N = 128) with first abnormal cytology result from 2008-2010. Patients were seen at a suburban, university-affiliated, family medicine residency clinic. Intervention: Tracking spreadsheet reviewed monthly with reminders generated for patients not in compliance with recommendations. Main Outcome and Measures: (1) rates of accurate and timely communication of results and (2) rates of patient adherence to follow-up recommendations. Intervention decreased absent or erroneous communication from clinician to patient (6.4% pre- vs 1.6% post-intervention [P = 0.04]), but did not increase patient adherence to follow-up recommendations (76.1% pre- vs 78.0% post-intervention [ P= 0.78]). Use of a spreadsheet tracking system improved communication of abnormal results to patients, but did not significantly improve patient adherence to recommended care. Although the tracking system complies with NCQA PCMH requirements, it was insufficient to make meaningful improvements in patient-oriented outcomes.

A radiobiological model of metastatic burden reduction for molecular radiotherapy: application to patients with bone metastases

NASA Astrophysics Data System (ADS)

Denis-Bacelar, Ana M.; Chittenden, Sarah J.; Murray, Iain; Divoli, Antigoni; McCready, V. Ralph; Dearnaley, David P.; O'Sullivan, Joe M.; Johnson, Bernadette; Flux, Glenn D.

2017-04-01

Skeletal tumour burden is a biomarker of prognosis and survival in cancer patients. This study proposes a novel method based on the linear quadratic model to predict the reduction in metastatic tumour burden as a function of the absorbed doses delivered from molecular radiotherapy treatments. The range of absorbed doses necessary to eradicate all the bone lesions and to reduce the metastatic burden was investigated in a cohort of 22 patients with bone metastases from castration-resistant prostate cancer. A metastatic burden reduction curve was generated for each patient, which predicts the reduction in metastatic burden as a function of the patient mean absorbed dose, defined as the mean of all the lesion absorbed doses in any given patient. In the patient cohort studied, the median of the patient mean absorbed dose predicted to reduce the metastatic burden by 50% was 89 Gy (interquartile range: 83-105 Gy), whilst a median of 183 Gy (interquartile range: 107-247 Gy) was found necessary to eradicate all metastases in a given patient. The absorbed dose required to eradicate all the lesions was strongly correlated with the variability of the absorbed doses delivered to multiple lesions in a given patient (r  =  0.98, P  <  0.0001). The metastatic burden reduction curves showed a potential large reduction in metastatic burden for a small increase in absorbed dose in 91% of patients. The results indicate the range of absorbed doses required to potentially obtain a significant survival benefit. The metastatic burden reduction method provides a simple tool that could be used in routine clinical practice for patient selection and to indicate the required administered activity to achieve a predicted patient mean absorbed dose and reduction in metastatic tumour burden.

Advanced technical skills are required for microsurgical clipping of posterior communicating artery aneurysms in the endovascular era.

PubMed

Sanai, Nader; Caldwell, Nolan; Englot, Dario J; Lawton, Michael T

2012-08-01

Many neurosurgeons feel competent clipping posterior communicating artery (PCoA) aneurysms and include this lesion in their practice. However, endovascular therapy removes simple aneurysms that would have been easiest to clip with the best results. What remains are aneurysms with complex anatomy and technical challenges that are not well described. A contemporary surgical series with PCoA aneurysms is reviewed to define the patients, microsurgical techniques, and outcomes in current practice. A total of 218 patients had 218 PCoA aneurysms that were treated microsurgically during an 11-year period. Complexities influencing aneurysm management included (1) large/giant size; (2) fetal posterior cerebral artery; (3) previous coiling; (4) anterior clinoidectomy; (5) adherence of the anterior choroidal artery (AChA); (6) intraoperative aneurysm rupture; (7) complex clipping; and (8) atherosclerotic calcification. Simple PCoA aneurysms were encountered in 113 patients (51.8%) and complex aneurysms in 105 (48.2%). Adherent AChA (13.8%) and intraoperative rupture (11.5%) were the most common complexities. Simple aneurysms had favorable outcomes in 86.6% of patients, whereas aneurysms with 1 or multiple complexities had favorable outcomes in 78.2% and 75.0%, respectively. Intraoperative rupture (P < .01), large/giant size (P = .04), and complex clipping (P = .05) were associated with increased neurological worsening. Because endovascular therapy alters the surgical population, neurosurgeons should recalibrate their expectations with this once straightforward aneurysm. The current mix of PCoA aneurysms requires advanced techniques including clinoidectomy, AChA microdissection, complex clipping, and facility with intraoperative rupture. Microsurgery is recommended for recurrent aneurysms after coiling, complex branches, aneurysms causing oculomotor nerve palsy, multiple aneurysms, and patients with hematomas.

Early-Onset Multiple Sclerosis in Isfahan, Iran: Report of the Demographic and Clinical Features of 221 Patients.

PubMed

Etemadifar, Masoud; Nourian, Sayed-Mohammadamin; Nourian, Niloofaralsadat; Abtahi, Seyed-Hossein; Sayahi, Farnaz; Saraf, Zahra; Fereidan-Esfahani, Mahboobeh

2016-06-01

It is estimated that early-onset multiple sclerosis multiple sclerosis (early-onset multiple sclerosis) approximately incorporates 3-5% of the multiple sclerosis population. In this report on early-onset multiple sclerosis, the authors aimed to define demographic, clinical and imaging features in a case-series of true-childhood multiple sclerosis and to compare its characteristics with juvenile multiple sclerosis. The authors inspected the records of multiple sclerosis patients who were registered by Isfahan MS Society. Clinical and demographic data of children with less than 16 years of age were reviewed retrospectively. Out of 4536 multiple sclerosis patients referred to the authors' center, 221 patients (4.8%) had multiple sclerosis starting at the age of 16 or less (11 true-childhood multiple sclerosis vs 210 juvenile-onset multiple sclerosis); the female to male ratio was 4.81:1. In the mean follow-up period of 6.2 years, 22 patients (10.5%) had positive family history of multiple sclerosis, 196 (88.6%) patients were classified as relapsing-remitting multiple sclerosis, the mean (± SD Expanded Disability Status Scale) was 1.5 ± 1.1 at the last evaluation. The most common initial presentation was optic nerve involvement (36.1%) and cerebellar sign and symptoms (14.6%). In all, 13 patients (5.8%) had experienced seizure in the course of multiple sclerosis. This study indicated that early-onset multiple sclerosis is not rare condition and overwhelmingly affects girls even at prepubertal onset. Physicians should consider multiple sclerosis in suspicious pediatric cases. © The Author(s) 2016.

Data integration: Combined imaging and electrophysiology data in the cloud.

PubMed

Kini, Lohith G; Davis, Kathryn A; Wagenaar, Joost B

2016-01-01

There has been an increasing effort to correlate electrophysiology data with imaging in patients with refractory epilepsy over recent years. IEEG.org provides a free-access, rapidly growing archive of imaging data combined with electrophysiology data and patient metadata. It currently contains over 1200 human and animal datasets, with multiple data modalities associated with each dataset (neuroimaging, EEG, EKG, de-identified clinical and experimental data, etc.). The platform is developed around the concept that scientific data sharing requires a flexible platform that allows sharing of data from multiple file formats. IEEG.org provides high- and low-level access to the data in addition to providing an environment in which domain experts can find, visualize, and analyze data in an intuitive manner. Here, we present a summary of the current infrastructure of the platform, available datasets and goals for the near future. Copyright © 2015 Elsevier Inc. All rights reserved.

Data integration: Combined Imaging and Electrophysiology data in the cloud

PubMed Central

Kini, Lohith G.; Davis, Kathryn A.; Wagenaar, Joost B.

2015-01-01

There has been an increasing effort to correlate electrophysiology data with imaging in patients with refractory epilepsy over recent years. IEEG.org provides a free-access, rapidly growing archive of imaging data combined with electrophysiology data and patient metadata. It currently contains over 1200 human and animal datasets, with multiple data modalities associated with each dataset (neuroimaging, EEG, EKG, de-identified clinical and experimental data, etc.). The platform is developed around the concept that scientific data sharing requires a flexible platform that allows sharing of data from multiple file-formats. IEEG.org provides high and low-level access to the data in addition to providing an environment in which domain experts can find, visualize, and analyze data in an intuitive manner. Here, we present a summary of the current infrastructure of the platform, available datasets and goals for the near future. PMID:26044858

How does measurement of platelet P-selectin compare with other methods of measuring platelet function as a means of determining the effectiveness of antiplatelet therapy?

PubMed

Fox, Susan C; May, Jane A; Dovlatova, Natalia; Glenn, Jackie R; Johnson, Andrew; White, Ann E; Radhakrishnan, Ashwin; Heptinstall, Stan

2018-02-20

Measurement of P-selectin on activated platelets as a means of measuring platelet function utilizing the technology described here has the advantage of not requiring immediate access to specialist equipment and expertise. Blood samples are activated, fixed, stored, and transported to a central laboratory for flow cytometric analysis. Here we have compared P-selectin with other more traditional approaches to measuring platelet function in blood and/or platelet-rich plasma (PRP) from patients with acute coronary syndromes on treatment for at least 1 month with either aspirin and clopidogrel or aspirin with prasugrel. The comparators were light transmission aggregometry (LTA), VerifyNow and Multiplate aggregometry (for determining the effects of aspirin) and LTA, VerifyNow and Multiplate together with the BioCytex VASP phosphorylation assay (for the P2Y 12 antagonists). The P-selectin Aspirin Test revealed substantial inhibition of platelet function in all but three of 96 patients receiving aspirin with clopidogrel and in none of 51 patients receiving aspirin and prasugrel. The results were very similar to those obtained using LTA. There was only one patient with high residual platelet aggregation and low P-selectin expression. The same patients identified as "non-responders" to aspirin also presented with the highest residual platelet activity as measured using the VerifyNow system, although not quite as well separated from the other values. With the Multiplate test only one of these patients clearly stood out from the others. The results obtained using the P-selectin P2Y 12 Test in 102 patients taking aspirin and clopidogrel were similar to the more traditional approaches in that a wide scatter of results was obtained. Generally, high values seen with the P-selectin P2Y 12 Test were also high with the LTA, VerifyNow, Multiplate, and BioCytex VASP P2Y 12 Tests. Similarly, low residual platelet function using the P2Y 12 test was seen irrespective of the testing procedure used. However, there were differences in some patients. Prasugrel was always more effective than clopidogrel in inhibiting platelet function with none of 56 patients (P-selectin and VerifyNow), only 2 of 56 patients (Multiplate) and only 3 of 56 patients (Biocytex VASP) demonstrating high on-treatment residual platelet reactivity (HRPR) defined using previously published cut-off values. The exception was LTA where there were 11 of 56 patients with HRPR. It remains to be seen which experimental approach provides the most useful information regarding outcomes after adjusting therapies in treated patients.

Intrathecal Baclofen Dosing Regimens: A Retrospective Chart Review.

PubMed

Clearfield, Jacob S; Nelson, Mary Elizabeth S; McGuire, John; Rein, Lisa E; Tarima, Sergey

2016-08-01

To examine dosing patterns in patients receiving baclofen via intrathecal baclofen pumps to assess for common patterns by diagnosis, ambulation ability, and affected limbs distribution. This trial study included 25 patients with baclofen pumps selected from the 356 patients enrolled in our center's baclofen pump program. Selection was done by splitting all patients into diagnostic categories of stroke, multiple sclerosis, traumatic/anoxic brain injury, cerebral palsy, and spinal cord injury, and then, five patients were randomly selected from each diagnosis.A systematic chart review was then conducted for each patient from Jan 1, 2008, through September 16, 2013, to look at factors including mean daily dose at end of study, and among those implanted during the study mean initial stable dose and time to initial stable dose. Analysis of mean daily dose across diagnoses found significant differences, with brain injury, cerebral palsy, and spinal cord injury patients having higher doses while multiple sclerosis and stroke patients required lower doses. Nonambulatory patients strongly trended to have higher daily doses than ambulatory patients. Similar trends of mean initial stable dose being higher in a similar pattern as that of end mean daily dose were seen according to diagnoses and ambulatory status, although statistical significance could not be achieved with the small sample size. Significant differences in dosing were found between diagnoses and trended to differ by ambulatory status at the end of the study, and similar trends could be observed in achieving initial stable dose. © 2015 International Neuromodulation Society.

Antineutrophil Cytoplasmic Antibodies Associated With Infective Endocarditis

PubMed Central

Langlois, Vincent; Lesourd, Anais; Girszyn, Nicolas; Ménard, Jean-Francois; Levesque, Hervé; Caron, Francois; Marie, Isabelle

2016-01-01

Abstract To determine the prevalence of antineutrophil cytoplasmic antibodies (ANCA) in patients with infective endocarditis (IE) in internal medicine; and to compare clinical and biochemical features and outcome between patients exhibiting IE with and without ANCA. Fifty consecutive patients with IE underwent ANCA testing. The medical records of these patients were reviewed. Of the 50 patients with IE, 12 exhibited ANCA (24%). ANCA-positive patients with IE exhibited: longer duration between the onset of first symptoms and IE diagnosis (P = 0.02); and more frequently: weight loss (P = 0.017) and renal impairment (P = 0.08), lower levels of C-reactive protein (P = 0.0009) and serum albumin (P = 0.0032), involvement of both aortic and mitral valves (P = 0.009), and longer hospital stay (P = 0.016). Under multivariate analysis, significant factors for ANCA-associated IE were: longer hospital stay (P = 0.004), lower level of serum albumin (P = 0.02), and multiple valve involvement (P = 0.04). Mortality rate was 25% in ANCA patients; death was because of IE complications in all these patients. Our study identifies a high prevalence of ANCA in unselected patients with IE in internal medicine (24%). Our findings further underscore that ANCA may be associated with a subacute form of IE leading to multiple valve involvement and more frequent renal impairment. Because death was due to IE complications in all patients, our data suggest that aggressive therapy may be required to improve such patients’ outcome. PMID:26817911

Clinical characteristics of patients who overdose on multiple psychotropic drugs in Tokyo.

PubMed

Hori, Satoshi; Kinoshita, Kosaku

2016-01-01

The purpose of this study was to identify the clinical aspects leading to overdose of multiple psychotropic drugs, in order to determine areas which need attention in the proper treatment of overdose patients. Patients who were treated for overdose of psychotropic drugs at our emergency and critical center over two years were targeted. The clinical data was gathered from the medical records and database of all patients, including age, gender, vital signs, and laboratory data, drugs, and medical complications during hospital stay. In addition primary patient care at the emergency department was examined. Among the 277 patients treated during this study period, 255 (74.0%) used two or more types of psychotropic drugs. Risk factors associated with endotracheal intubation and aspiration pneumonitis included the use of antipsychotics and/or barbiturates as types of overdose drugs. The mean number of days in the ICU was 3.4 days. Seventy-four patients (26.7%) stayed 4 days or more in the ICU of which 16 patients (5.8%) still had suicidal thoughts. A significantly higher incidence of extended ICU stay or endotracheal intubation and aspiration pneumonitis was observed in the group who overdosed on more than 50 or 60 tablets of psychotropic drugs, respectively. Patients who ingested an overdose of more than 60 tablets of psychotropic drugs should be considered a high-risk group requiring intensive care with extended ICU stay. In case of including antipsychotics and/or barbiturates, the patient should be observed carefully due to a higher risk of medical complications.

Hypercoagulable states in patients with multiple myeloma can affect the thalidomide-associated venous thromboembolism.

PubMed

Talamo, Giampaolo P; Ibrahim, Sulfi; Claxton, David; Tricot, Guido J; Fink, Louis M; Zangari, Maurizio

2009-07-01

The therapeutic use of thalidomide in patients with multiple myeloma is often complicated by the development of venous thromboembolism. The objective of the present study was to identify hypercoagulable states associated with development of venous thromboembolism in thalidomide-treated multiple myeloma patients. We screened 49 consecutive multiple myeloma patients treated with thalidomide at baseline for hypercoagulability. With a median follow-up of 11 months, 10 of 49 multiple myeloma patients developed a thrombotic episode. Laboratory assays revealed an underlying abnormality in nine of the 10 patients; hypercoagulable screenings were normal in 36 of the 39 patients who did not develop venous thromboembolism (P < 0.0001). Our retrospective study results suggest that the multiple myeloma patients with thromboembolic complications during treatment with thalidomide have a frequent concomitant underlying thrombophilic state.

Intraoperative 3D Navigation for Single or Multiple 125I-Seed Localization in Breast-Preserving Cancer Surgery.

PubMed

Pouw, Bas; de Wit-van der Veen, Linda J; van Duijnhoven, Frederieke; Rutgers, Emiel J Th; Stokkel, Marcel P M; Valdés Olmos, Renato A; Vrancken Peeters, Marie-Jeanne T F D

2016-05-01

Mammographic screening has led to the identification of more women with nonpalpable breast cancer, many of them to be treated with breast-preserving surgery. To accomplish radical tumor excision, adequate localization techniques such as radioactive seed localization (RSL) are required. For RSL, a radioactive I-seed is implanted central in the tumor to enable intraoperative localization using a γ-probe. In case of extensive tumor or multifocal carcinoma, multiple I-seeds can be used to delineate the involved area. Preoperative imaging is performed different from surgical positioning; therefore, exact I-seed depth remains unknown during surgery. Twenty patients (mean age, 56.8 years) with 25 implanted I-seeds scheduled for RSL were included. Sixteen patients had 1 I-seed implanted in the primary lesion, 3 patients had 2 I-seeds, and 1 patient had 3 I-seeds. Freehand SPECT localized I-seeds by measuring γ-counts from different directions, all registered by an optical tracking system. A reconstruction and visualization algorithm enabled 3-dimensional (3D) navigation toward the I-seeds. Freehand SPECT visualized all I-seeds in primary tumors and provided preincision depth information. The deviation, mean (SD), between the freehand SPECT depth and the surgical depth estimation was 1.9 (2.1) mm (range, 0-7 mm). Three-dimensional freehand SPECT was especially useful identifying multiple implanted I-seeds because the conventional γ-probe has more difficulty discriminating I-seeds transcutaneous. Freehand SPECT with 3D navigation is a valuable tool in RSL for both single and multiple implanted I-seeds in breast-preserving cancer surgery. Freehand SPECT provides continuous updating 3D imaging with information about depth and location of the I-seeds contributing to adequate excision of nonpalpable breast cancer.

Quality of life and patients' expectations in soft tissue sarcoma.

PubMed

Jones, Robin L; Cesne, Axel Le

2018-05-01

Assessment of health-related quality of life (HRQoL) is essential for holistic care. Greater efforts are required to incorporate HRQoL measures into clinical trials and daily practice. Considerable HRQoL data are available for localized soft tissue sarcomas (STS), particularly in the orthopedic setting. In future, HRQoL is expected to become increasingly important in the evaluation of palliative therapy in advanced STS. A patient-centric approach is advocated for STS management. Greater awareness of STS by nonspecialist clinicians, and timely referral to specialized sarcoma reference centers, is crucial for patient welfare. The patient is central to shared decision-making during consultations and during case review in tumor boards. The management approach to STS should be collaborative, involving a multidisciplinary team, multiple centers and patient advocacy groups.

Acute suppurative parotitis: a dreadful complication in elderly surgical patients.

PubMed

Lampropoulos, Pavlos; Rizos, Spyros; Marinis, Athanasios

2012-08-01

Acute suppurative parotitis (ASP) is a severe infection seen particularly in elderly surgical patients. Factors that increase the risk of ASP include post-operative dehydration, debilitating conditions, and immunosuppressed states. Case report and literature review. An 82-year-old female patient was admitted because of paralytic ileus, dehydration, and poor oral hygiene, and was in distress. After two days of hospitalization, the patient developed a progressive painful swelling of her right parotid gland and fever up to 39.0°C. Computed tomography scanning showed an abscess in the parotid gland. Because of her progressive clinical deterioration, the patient underwent operative drainage of the abscess and removal of the necrotic material. Unfortunately, she suffered multiple organ dysfunction syndrome and died. Acute suppurative parotitis requires prompt aggressive treatment that nevertheless may fail.

Navigating complex patients using an innovative tool: the MTM Spider Web.

PubMed

Morello, Candis M; Hirsch, Jan D; Lee, Kelly C

2013-01-01

To introduce a teaching tool that can be used to assess the complexity of medication therapy management (MTM) patients, prioritize appropriate interventions, and design patient-centered care plans for each encounter. MTM patients are complex as a result of multiple comorbidities, medications, and socioeconomic and behavioral issues. Pharmacists who provide MTM services are required to synthesize a plethora of information (medical and nonmedical), evaluate and prioritize the clinical problems, and design a comprehensive patient-centered care plan. The MTM Spider Web is a visual tool to facilitate this process. A description is provided regarding how to build the MTM Spider Web using case-based scenarios. This model can be used to teach pharmacists, health professional students, and patients. The MTM Spider Web is an innovative teaching tool that can be used to teach pharmacists and students how to assess complex patients and design a patient-centered care plan to deliver the most appropriate medication therapy.

Propofol Frenzy: Clinical Spectrum in 3 Patients.

PubMed

Carvalho, Diego Z; Townley, Ryan A; Burkle, Christopher M; Rabinstein, Alejandro A; Wijdicks, Eelco F M

2017-11-01

Postsedation neuroexcitation is sometimes attributed to intravenous injection of the sedative-hypnotic drug propofol. The movements associated with these events have strongly suggested convulsive activity, but they rarely have been comprehensively evaluated. We present video recordings of 3 healthy young patients who underwent elective surgery under conscious sedation and emerged from sedation with transient but repetitive violent motor activity and impaired consciousness. These manifestations required considerable mobilization of multiple health care workers to protect the patient from inflicting harm. All patients received propofol, and all fully recovered without adverse sequelae. We postulate that these movements are propofol related. Importantly, we found no evidence of seizures clinically or electrographically. Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Nontraditional or noncentralized models of diabetes care: models in which other HCPs take on a leading role in managing patients' diabetes.

PubMed

Arnold, K C

2011-11-01

Nurse practitioners (NPs) are advanced practice nurses who have increased responsibility,such as prescribing authority. In the NP-led model, the NP is the primary care provider for clinic patients and takes on an autonomous role in patient management. In some states, NP-led clinics are required to have a supervising or collaborating physician. There is evidence that NP-led and physician-led primary care is comparable for multiple health outcomes. The NP-led model emphasizes the strong interaction between health care provider and patient. Challenges of NP-led care include physician resistance, legal restrictions, inaccessibility and cost of malpractice insurance, and limited payouts from insurance companies

Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers.

PubMed

Taylor, Erin Fries; Machta, Rachel M; Meyers, David S; Genevro, Janice; Peikes, Deborah N

2013-01-01

Efforts to redesign primary care require multiple supports. Two potential members of the primary care team-practice facilitator and care manager-can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities-reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.

Performing Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease.

PubMed

Waldram, Jeremy D; Simon, Ronald A

2016-11-01

Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic rhinosinusitis with nasal polyps, asthma, and reactions to cyclooxygenase-1-inhibiting drugs. This condition is often refractory to standard medical treatments and results in aggressive nasal polyposis that often requires multiple sinus surgeries. Aspirin desensitization followed by daily aspirin therapy is an important treatment option, and its efficacy has been validated in multiple research studies. Aspirin desensitization is not without risk, but specific protocols and recommendations exist to mitigate the risk. Most patients with AERD can undergo aspirin desensitization in an outpatient setting under the supervision of an allergist. Copyright © 2016 Elsevier Inc. All rights reserved.

Patient Litter System Response in a Full-Scale CH-46 Crash Test.

PubMed

Weisenbach, Charles A; Rooks, Tyler; Bowman, Troy; Fralish, Vince; McEntire, B Joseph

2017-03-01

U.S. Military aeromedical patient litter systems are currently required to meet minimal static strength performance requirements at the component level. Operationally, these components must function as a system and are subjected to the dynamics of turbulent flight and potentially crash events. The first of two full-scale CH-46 crash tests was conducted at NASA's Langley Research Center and included an experiment to assess patient and litter system response during a severe but survivable crash event. A three-tiered strap and pole litter system was mounted into the airframe and occupied by three anthropomorphic test devices (ATDs). During the crash event, the litter system failed to maintain structural integrity and collapsed. Component structural failures were recorded from the litter support system and the litters. The upper ATD was displaced laterally into the cabin, while the middle ATD was displaced longitudinally into the cabin. Acceleration, force, and bending moment data from the instrumented middle ATD were analyzed using available injury criteria. Results indicated that a patient might sustain a neck injury. The current test illustrates that a litter system, with components designed and tested to static requirements only, experiences multiple component structural failures during a dynamic crash event and does not maintain restraint control of its patients. It is unknown if a modern litter system, with components tested to the same static criteria, would perform differently. A systems level dynamic performance requirement needs to be developed so that patients can be provided with protection levels equivalent to that provided to seated aircraft occupants. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Fibrin Sheath Angioplasty: A Technique to Prevent Superior Vena Cava Stenosis Secondary to Dialysis Catheters

PubMed Central

Hacker, Robert I.; Garcia, Lorena De Marco; Chawla, Ankur; Panetta, Thomas F.

2012-01-01

Fibrin sheaths are a heterogeneous matrix of cells and debris that form around catheters and are a known cause of central venous stenosis and catheter failure. A total of 50 cases of central venous catheter fibrin sheath angioplasty (FSA) after catheter removal or exchange are presented. A retrospective review of an outpatient office database identified 70 eligible patients over a 19-month period. After informed consent was obtained, the dialysis catheter exiting the skin was clamped, amputated, and a wire was inserted. The catheter was then removed and a 9-French sheath was inserted into the superior vena cava, a venogram was performed. If a fibrin sheath was present, angioplasty was performed using an 8 × 4 or 10 × 4 balloon along the entire length of the fibrin sheath. A completion venogram was performed to document obliteration of the sheath. During the study, 50 patients were diagnosed with a fibrin sheath, and 43 had no pre-existing central venous stenosis. After FSA, 39 of the 43 patient's (91%) central systems remained patent without the need for subsequent interventions; 3 patients (7%) developed subclavian stenoses requiring repeat angioplasty and stenting; 1 patent (2.3%) developed an occlusion requiring a reintervention. Seven patients with prior central stenosis required multiple angioplasties; five required stenting of their central lesions. Every patient had follow-up fistulograms to document long-term patency. We propose that FSA is a prudent and safe procedure that may help reduce the risk of central venous stenosis from fibrin sheaths due to central venous catheters. PMID:23997555

[Retrospective, descriptive, observational study of treatment of multiple actinic keratoses with topical methyl aminolevulinate and red light: results in clinical practice and correlation with fluorescence imaging].

PubMed

Fernández-Guarino, M; Harto, A; Sánchez-Ronco, M; Pérez-García, B; Marquet, A; Jaén, P

2008-12-01

Actinic keratosis (AK) is one of the most common skin diseases seen in clinical practice. In the last 5 years, several studies assessing the efficacy of photodynamic therapy in the treatment of multiple AKs have been published. We aimed to assess the clinical outcomes of photodynamic therapy in patients with multiple AKs and the correlation of those outcomes with fluorescence imaging. In this retrospective, descriptive, observational study of 57 patients treated in our hospital with photodynamic therapy for multiple AKs, we recorded age, sex, and lesion site (face, scalp, and dorsum of the hands). All patients were treated in the same way: methyl aminolevulinic acid (Metvix) was applied for 3 hours and the skin then irradiated with red light at 630 nm, 37 J/cm(2), for 7.5 minutes (Aktilite). The response, remission duration, tolerance, number of sessions, and fluorescence images were recorded by site. The chi(2) test was used to assess between-site differences and the correlation between fluorescence imaging and clinical response. The greatest improvements were obtained for facial lesions; these required fewer sessions and remission lasted longer than lesions at other sites. The treatment was best tolerated on the dorsum of the hands. The fluorescence area and the reduction in intensity on applying treatment were found to be strongly and significantly correlated with the extent of clinical response. Overall, the outcomes of treatment of multiple AKs with photodynamic therapy are better for the face than for the scalp and dorsum of the hands. Fluorescence imaging may be an effective tool for predicting response to treatment.

[Occupational exposure to blood in multiple trauma care].

PubMed

Wicker, S; Wutzler, S; Schachtrupp, A; Zacharowski, K; Scheller, B

2015-01-01

Trauma care personnel are at risk of occupational exposure to blood-borne pathogens. Little is known regarding compliance with standard precautions or occupational exposure to blood and body fluids among multiple trauma care personnel in Germany. Compliance rates of multiple trauma care personnel in applying standard precautions, knowledge about transmission risks of blood-borne pathogens, perceived risks of acquiring hepatitis B, hepatitis C and human immunodeficiency virus (HIV) and the personal attitude towards testing of the index patient for blood-borne pathogens after a needlestick injury were evaluated. In the context of an advanced multiple trauma training an anonymous questionnaire was administered to the participants. Almost half of the interviewees had sustained a needlestick injury within the last 12 months. Approximately three quarters of the participants were concerned about the risk of HIV and hepatitis. Trauma care personnel had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of hepatitis C infection and underused standard precautionary measures. Although there was excellent compliance for using gloves, there was poor compliance in using double gloves (26.4 %), eye protectors (19.7 %) and face masks (15.8 %). The overwhelming majority of multiple trauma care personnel believed it is appropriate to test an index patient for blood-borne pathogens following a needlestick injury. The process of treatment in prehospital settings is less predictable than in other settings in which invasive procedures are performed. Periodic training and awareness programs for trauma care personnel are required to increase the knowledge of occupational infections and the compliance with standard precautions. The legal and ethical aspects of testing an index patient for blood-borne pathogens after a needlestick injury of a healthcare worker have to be clarified in Germany.

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

PubMed Central

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

2013-01-01

Multiple myeloma remains largely incurable. However, a few patients experience more than 10 years of relapse-free survival and can be considered as operationally cured. Interestingly, long-term disease control in multiple myeloma is not restricted to patients with a complete response, since some patients revert to having a profile of monoclonal gammopathy of undetermined significance. We compared the distribution of multiple compartments of lymphocytes and dendritic cells in the bone marrow and peripheral blood of multiple myeloma patients with long-term disease control (n=28), patients with newly diagnosed monoclonal gammopathy of undetermined significance (n=23), patients with symptomatic multiple myeloma (n=23), and age-matched healthy adults (n=10). Similarly to the patients with monoclonal gammopathy of undetermined significance and symptomatic multiple myeloma, patients with long-term disease control showed an expansion of cytotoxic CD8+ T cells and natural killer cells. However, the numbers of bone marrow T-regulatory cells were lower in patients with long-term disease control than in those with symptomatic multiple myeloma. It is noteworthy that B cells were depleted in patients with monoclonal gammopathy of undetermined significance and in those with symptomatic multiple myeloma, but recovered in both the bone marrow and peripheral blood of patients with long-term disease control, due to an increase in normal bone marrow B-cell precursors and plasma cells, as well as pre-germinal center peripheral blood B cells. The number of bone marrow dendritic cells and tissue macrophages differed significantly between patients with long-term disease control and those with symptomatic multiple myeloma, with a trend to cell count recovering in the former group of patients towards levels similar to those found in healthy adults. In summary, our results indicate that multiple myeloma patients with long-term disease control have a constellation of unique immune changes favoring both immune cytotoxicity and recovery of B-cell production and homing, suggesting improved immune surveillance. PMID:22773604

The art and science of choosing efficacy endpoints for rare disease clinical trials.

PubMed

Cox, Gerald F

2018-04-01

An important challenge in rare disease clinical trials is to demonstrate a clinically meaningful and statistically significant response to treatment. Selecting the most appropriate and sensitive efficacy endpoints for a treatment trial is part art and part science. The types of endpoints should align with the stage of development (e.g., proof of concept vs. confirmation of clinical efficacy). The patient characteristics and disease stage should reflect the treatment goal of improving disease manifestations or preventing disease progression. For rare diseases, regulatory approval requires demonstration of clinical benefit, defined as how a patient, feels, functions, or survives, in at least one adequate and well-controlled pivotal study conducted according to Good Clinical Practice. In some cases, full regulatory approval can occur using a validated surrogate biomarker, while accelerated, or provisional, approval can occur using a biomarker that is likely to predict clinical benefit. Rare disease studies are small by necessity and require the use of endpoints with large effect sizes to demonstrate statistical significance. Understanding the quantitative factors that determine effect size and its impact on powering the study with an adequate sample size is key to the successful choice of endpoints. Interpreting the clinical meaningfulness of an observed change in an efficacy endpoint can be justified by statistical methods, regulatory precedence, and clinical context. Heterogeneous diseases that affect multiple organ systems may be better accommodated by endpoints that assess mean change across multiple endpoints within the same patient rather than mean change in an individual endpoint across all patients. © 2018 Wiley Periodicals, Inc.

Incidence and severity of maxillofacial injuries during the Second Lebanon War among Israeli soldiers and civilians.

PubMed

Levin, Liran; Zadik, Yehuda; Peleg, Kobi; Bigman, Galya; Givon, Adi; Lin, Shaul

2008-08-01

To analyze the incidence and severity of maxillofacial injuries in the Second Lebanon War, that occurred during the summer of 2006, among Israeli soldiers and civilians. This is a retrospective cohort study of patients recorded in the Israel National Trauma Registry during the Second Lebanon War. Data refer to all general hospitals throughout the country. Data were analyzed according to the etiology of the injury, severity of trauma using the Injury Severity Score, trauma location, and duration of hospital stay. Cases with multiple injuries that included maxillofacial injuries were separated and further analyzed according to the above parameters. Patients with only dental injuries and superficial facial soft tissue lacerations were excluded because they were referred to the military dental clinics and not to general hospitals. Maxillofacial injuries were found in 36 (6.4%) of the 565 wounded. Patients with maxillofacial injuries ranged in age from 20 to 44 years (mean age, 25.5 +/- 5.7 years). Greater than 50% of the injuries required more than 3 hospitalization days. Mortality rate of the maxillofacial injured was 2.8%. Most of the maxillofacial injuries (33; 91.7%) were combined with other organ injuries; 9 (25%) patients also had dental injuries. In the Second Lebanon War, the incidence and severity of true maxillofacial injuries, without dental injuries alone, were relatively low compared with previous reports of other conflicts. However, because most injuries involved multiple organs, special attention is required when planning and providing emergency, as well as secondary and tertiary medical care to war wounded.

Parry-Romberg reconstruction: optimal timing for hard and soft tissue procedures.

PubMed

Slack, Ginger C; Tabit, Christina J; Allam, Karam A; Kawamoto, Henry K; Bradley, James P

2012-11-01

For the treatment of Parry-Romberg syndrome or progressive hemifacial atrophy, we studied 3 controversial issues: (1) optimal timing, (2) need for skeletal reconstruction, and (3) need for soft tissue (medial canthus/lacrimal duct) reconstruction. Patients with Parry-Romberg syndrome (>5 y follow-up) were divided into 2 groups: (1) younger than 14 years and (2) 14 years or older (n = 43). Sex, age, severity of deformity, number of procedures, operative times, and augmentation fat volumes were recorded. Physician and patient satisfaction surveys (5-point scale) were obtained, preoperative and postoperative three-dimensional computed tomographic scans were reviewed, and a digital three-dimensional photogrammetry system was used to determine volume retention. Our results indicate that the younger patient group required more procedures compared with the older patient group (4.3 versus 2.8); however, the younger group had higher patient/family satisfaction scores (3.8 versus 3.0). Skeletal and soft tissue reconstruction resulted in improved symmetry score (60% preoperatively to 93% final) and satisfaction scores (3.4 preoperatively to 3.8 final). Patients with Parry-Romberg syndrome required multiple corrective surgeries but showed improvements even when beginning before puberty. Soft and hard tissue reconstruction was beneficial.

The Holistic, Interactive and Persuasive Model to Facilitate Self-care of Patients with Diabetes

NASA Astrophysics Data System (ADS)

Vargas-Lombard, Miguel; Jipsion, Armando; Vejarano, Rafael; Camargo, Ismael; Álvarez, Humberto; Mora, Elena Villalba; Menasalva Ruíz, Ernestina

The patient, in his multiple facets of citizen and user of services of health, needs to acquire during, and later in his majority of age, favorable conditions of health to accentuate his quality of life and it is the responsibility of the health organizations to initiate the process of support for that patient during the process of mature life. The provision of services of health and the relation doctor-patient are undergoing important changes in the entire world, forced to a large extent by the indefensibility of the system itself. Nevertheless decision making requires previous information and, what more the necessity itself of being informed requires having a “culture” of health that generates pro activity and the capacity of searching for instruments that facilitate the awareness of the suffering and the self-care of the same. Therefore it is necessary to put into effect a ICT model (hiPAPD) that has the objective of causing Interaction, Motivation and Persuasion towards the surroundings of the diabetic Patient facilitating his self-care. As a result the patient himself individually manages his services through devices and AmI Systems (Ambient Intelligent).

Decision-making analysis for allergen immunotherapy versus nasal steroids in the treatment of nasal steroid-responsive allergic rhinitis.

PubMed

Kennedy, Joshua L; Robinson, Derek; Christophel, Jared; Borish, Larry; Payne, Spencer

2014-01-01

The purpose of the study was to determine the age at which initiation of specific subcutaneous immunotherapy (SCIT) becomes more cost-effective than continued lifetime intranasal steroid (NS) therapy in the treatment of allergic rhinitis, with the use of a decision analysis model. A Markov decision analysis model was created for this study. Economic analyses were performed to identify "break-even" points in the treatment of allergic rhinitis with the use of SCIT and NS. Efficacy rates for therapy and cost data were collected from the published literature. Models in which there was only incomplete improvement while receiving SCIT were also evaluated for economic break-even points. The primary perspective of the study was societal. Multiple break-even point curves were obtained corresponding to various clinical scenarios. For patients with seasonal allergic rhinitis requiring NS (i.e., fluticasone) 6 months per year, the age at which initiation of SCIT provides long-term direct cost advantage is less than 41 years. For patients with perennial rhinitis symptoms requiring year-round NS, the cut-off age for SCIT cost-effectiveness increases to 60 years. Hypothetical subjects who require continued NS treatment (50% reduction of previous dosage) while receiving SCIT also display break-even points, whereby it is economically advantageous to consider allergy referral and SCIT, dependent on the cost of the NS prescribed. The age at which SCIT provides economic advantages over NS in the treatment of allergic rhinitis depends on multiple clinical factors. Decision analysis models can assist the physician in accounting for these factors and customize patient counseling with regard to treatment options.

Comparison thoracic epidural and intercostal block to improve ventilation parameters and reduce pain in patients with multiple rib fractures.

PubMed

Hashemzadeh, Shahryar; Hashemzadeh, Khosrov; Hosseinzadeh, Hamzeh; Aligholipour Maleki, Raheleh; Golzari, Samad E J; Golzari, Samad

2011-01-01

Chest wall blunt trauma causes multiple rib fractures and will often be associated with significant pain and may compromise ventilator mechanics. Analgesia has great roll in rib fracture therapies, opioid are useful, but when used as sole agent may require such high dose that they produce respiratory depression, especially in elderly .the best analgesia for a severe chest wall injury is a continuous epidural infusion of local anesthetic. This provides complete analgesia allowing inspiration and coughing without of the risk of respiratory depression. sixty adult patients who with multiple rib fractures were enrolled in this study. They were divided into Group A or thoracic epidural with bupivacaine 0.125 % +1mg/5ml morphine and group B or intercostal block with 0.25% bupivacaine. The patients were assessed through ICU and hospital stay length, ventilation function tests. Pain score among the patients was measured with verbal rating scale, before and after administration of the analgesia. We found a significant improvement in ventilatory function tests during the 1st, 2nd, and 3rd days after epidural analgesia compared with the intercostal block (P < 0.004). Changes in the visual Analogue Scale were associated with marked improvement regarding pain at rest and pain caused by coughing and deep breathing in group A compared group B... ICU and hospital stay markedly reduced in Group A. thoracic epidural analgesia is superior to intercostals block regarding pain relief of rib fractures. Patients who received epidural analgesia had significantly lower pain scores at all studied times.

The increased level of COX-dependent arachidonic acid metabolism in blood platelets from secondary progressive multiple sclerosis patients.

PubMed

Morel, Agnieszka; Miller, Elzbieta; Bijak, Michal; Saluk, Joanna

2016-09-01

Platelet activation is increasingly postulated as a possible component of the pathogenesis of multiple sclerosis (MS), especially due to the increased risk of cardiovascular events in MS. Arachidonic acid cascade metabolized by cyclooxygenase (COX) is a key pathway of platelet activation. The aim of our study was to investigate the COX-dependent arachidonic acid metabolic pathway in blood platelets from secondary progressive multiple sclerosis (SP MS) patients. The blood samples were obtained from 50 patients (man n = 22; female n = 28), suffering from SP MS, diagnosed according to the revised McDonald criteria. Platelet aggregation was measured in platelet-rich plasma after arachidonic acid stimulation. The level of COX activity and thromboxane B2 concentration were determined by ELISA method. Lipid peroxidation was assessed by measuring the level of malondialdehyde. The results were compared with a control group of healthy volunteers. We found that blood platelets obtained from SP MS patients were more sensitive to arachidonic acid and their response measured as platelet aggregation was stronger (about 14 %) relative to control. We also observed a significantly increased activity of COX (about 40 %) and synthesis of thromboxane B2 (about 113 %). The generation of malondialdehyde as a marker of lipid peroxidation was about 10 % higher in SP MS than in control. Cyclooxygenase-dependent arachidonic acid metabolism is significantly increased in blood platelets of patients with SP MS. Future clinical studies are required to recommend the use of low-dose aspirin, and possibly other COX inhibitors in the prevention of cardiovascular risk in MS.

Impact of dose reductions on efficacy outcome in heart transplant patients receiving enteric-coated mycophenolate sodium or mycophenolate mofetil at 12 months post-transplantation.

PubMed

Segovia, Javier; Gerosa, Gino; Almenar, Luis; Livi, Ugolino; Viganò, Mario; Arizón, Jose Maria; Yonan, Nizar; Di Salvo, Thomas G; Renlund, Dale G; Kobashigawa, Jon A

2008-01-01

Mycophenolic acid (MPA) dose reduction is associated with increased risk of rejection and graft loss in renal transplantation. This analysis investigated the impact of MPA dose changes with enteric-coated mycophenolate sodium (EC-MPS) or mycophenolate mofetil (MMF) in de novo heart transplant recipients. In a 12-month, single-blind trial, 154 patients (EC-MPS, 78; MMF, 76) were randomized to either EC-MPS (1080 mg bid) or MMF (1500 mg bid) in combination with cyclosporine and steroids. The primary efficacy variable was the incidence of treatment failure, comprising a composite of biopsy-proven (BPAR) and treated acute rejection, graft loss or death. Significantly fewer patients receiving EC-MPS required > or =2 dose reductions than patients on MMF (26.9% vs. 42.1% of patients, p = 0.048). Accordingly, the average daily dose of EC-MPS as a percentage of the recommended dose was significantly higher than for MMF (88.4% vs. 79.0%, p = 0.016). Among patients requiring > or =1 dose reduction, the incidence of treated BPAR grade > or =3A was significantly lower with EC-MPS compared with MMF (23.4% vs. 44.0%, p = 0.032). These data suggest that EC-MPS-treated heart transplant patients are less likely to require multiple dose reductions than those on MMF which may be associated with a significantly lower risk of treated BPAR > or =3A.

Multiple Myeloma in the Very Old: An IASIA Conference Report

PubMed Central

Shapiro, Gary R.; Ershler, William B.; Badros, Ashraf; Cohen, Harvey J.; Dispenzieri, Angela; Flores, Irene Q.; Kanapuru, Bindu; Jurivich, Donald; Longo, Dan L.; Nourbakhsh, Ali; Palumbo, Antonio; Walston, Jeremy; Yates, Jerome W.

2014-01-01

Multiple myeloma (MM) in patients aged greater than 80 years poses an increasingly common challenge for oncology providers. A multidisciplinary workshop was held in which MM-focused hematologists/oncologists, geriatricians, and associated health-care team members discussed the state of research for MM therapy, as well as themes from geriatric medicine that pertain directly to this patient population. A summary statement of our discussions is presented here, in which we highlight several topics. MM disproportionately affects senior adults, and demographic trends indicate that this trend will accelerate. Complex issues impact cancer in seniors, and although factors such as social environment, comorbidities, and frailty have been well characterized in nononcological geriatric medicine, these themes have been inadequately explored in cancers such as MM, despite their clear relevance to this field. Therapeutically, novel agents have improved survival for MM patients of all ages, but less so for seniors than younger patients for a variety of reasons. Lastly, both MM- and treatment-related symptoms and toxicities require special attention in senior adults. Existing research provides limited insight into how best to manage these often complex patients, who are often not reflected in typical clinical trial populations. We hence offer suggestions for clinical trials that address knowledge gaps in how to manage very old and/or frail patients with MM, given the complicated issues that often surround this patient population. PMID:24700806

Adverse events in patients in home healthcare: a retrospective record review using trigger tool methodology

PubMed Central

Schildmeijer, Kristina Görel Ingegerd; Unbeck, Maria; Ekstedt, Mirjam; Lindblad, Marléne; Nilsson, Lena

2018-01-01

Objective Home healthcare is an increasingly common part of healthcare. The patients are often aged, frail and have multiple diseases, and multiple caregivers are involved in their treatment. This study explores the origin, incidence, types and preventability of adverse events (AEs) that occur in patients receiving home healthcare. Design A study using retrospective record review and trigger tool methodology. Setting and methods Ten teams with experience of home healthcare from nine regions across Sweden reviewed home healthcare records in a two-stage procedure using 38 predefined triggers in four modules. A random sample of records from 600 patients (aged 18 years or older) receiving home healthcare during 2015 were reviewed. Primary and secondary outcome measures The cumulative incidence of AEs found in patients receiving home healthcare; secondary measures were origin, types, severity of harm and preventability of the AEs. Results The patients were aged 20–79 years, 280 men and 320 women. The review teams identified 356 AEs in 226 (37.7%; 95% CI 33.0 to 42.8) of the home healthcare records. Of these, 255 (71.6%; 95% CI 63.2 to 80.8) were assessed as being preventable, and most (246, 69.1%; 95% CI 60.9 to 78.2) required extra healthcare visits or led to a prolonged period of healthcare. Most of the AEs (271, 76.1%; 95% CI 67.5 to 85.6) originated in home healthcare; the rest were detected during home healthcare but were related to care outside home healthcare. The most common AEs were healthcare-associated infections, falls and pressure ulcers. Conclusions AEs in patients receiving home healthcare are common, mostly preventable and often cause temporary harm requiring extra healthcare resources. The most frequent types of AEs must be addressed and reduced through improvements in interprofessional collaboration. This is an important area for future studies. PMID:29301764

Diagnosis and Surgical Management of Nonsyndromic Nine Supernumerary Teeth and Leong's Tubercle

PubMed Central

Cruz, Christiane V.; Soares, Andrea L.; Braga, David N.; Costa, Marcelo C.

2016-01-01

Nonsyndromic multiple supernumerary teeth (ST) and Leong's tubercle are a condition with a very low prevalence and a multidisciplinary approach is required to restore function and aesthetics. So, this case report aimed at presenting a rare case of nonsyndromic nine supernumerary teeth and Leong's tubercle in a pediatric patient, without any evident familial history, showing its diagnosis and surgical management. PMID:27066278

Multiple enhancers located in a 1-Mb region upstream of POU3F4 promote expression during inner ear development and may be required for hearing

PubMed Central

Naranjo, Silvia; Voesenek, Krysta; de la Calle-Mustienes, Elisa; Robert-Moreno, Alex; Kokotas, Haris; Grigoriadou, Maria; Economides, John; Van Camp, Guy; Hilgert, Nele; Moreno, Felipe; Alsina, Berta; Petersen, Michael B.; Kremer, Hannie

2010-01-01

POU3F4 encodes a POU-domain transcription factor required for inner ear development. Defects in POU3F4 function are associated with X-linked deafness type 3 (DFN3). Multiple deletions affecting up to ~900-kb upstream of POU3F4 are found in DFN3 patients, suggesting the presence of essential POU3F4 enhancers in this region. Recently, an inner ear enhancer was reported that is absent in most DFN3 patients with upstream deletions. However, two indications suggest that additional enhancers in the POU3F4 upstream region are required for POU3F4 function during inner ear development. First, there is at least one DFN3 deletion that does not eliminate the reported enhancer. Second, the expression pattern driven by this enhancer does not fully recapitulate Pou3f4 expression in the inner ear. Here, we screened a 1-Mb region upstream of the POU3F4 gene for additional cis-regulatory elements and searched for novel DFN3 mutations in the identified POU3F4 enhancers. We found several novel enhancers for otic vesicle expression. Some of these also drive expression in kidney, pancreas and brain, tissues that are known to express Pou3f4. In addition, we report a new and smallest deletion identified so far in a DFN3 family which eliminates 3.9 kb, comprising almost exclusively the previous reported inner ear enhancer. We suggest that multiple enhancers control the expression of Pou3f4 in the inner ear and these may contribute to the phenotype observed in DFN3 patients. In addition, the novel deletion demonstrates that the previous reported enhancer, although not sufficient, is essential for POU3F4 function during inner ear development. Electronic supplementary material The online version of this article (doi:10.1007/s00439-010-0864-x) contains supplementary material, which is available to authorized users. PMID:20668882

Dissolution of cholesterol gall stones using methyltertbutyl ether: a safe effective treatment.

PubMed Central

McNulty, J; Chua, A; Keating, J; Ah-Kion, S; Weir, D G; Keeling, P W

1991-01-01

Methyltertbutyl ether (MTBE) administered by percutaneous transhepatic catheter rapidly dissolves radiolucent cholesterol gall bladder stones. However, complete dissolution and clearance of non-cholesterol debris is essential to prevent recurrence. In this study we analysed 25 consecutive patients with reference to efficacy and recurrence based on the presence or absence of non-cholesterol stone fragments after dissolution. Placement of the catheter was successful in 24 patients, one patient requiring cholecystectomy for bile peritonitis. MTBE was infused and aspirated continuously, four to six cycles per minute, resulting in rapid stone dissolution (median six hours; range 4-23 hours for solitary stones and median seven hours, range 4-30 hours for multiple stones). In 18 patients who had complete dissolution, four (22%) had recurrent stones within six to 18 months. Five patients had residual debris which failed to clear completely despite bile acid treatment. One patient with an incomplete rim of calcium in a large stone did not respond to MTBE treatment. A further patient required cholecystectomy for symptomatic recurrence. There were no serious side effects observed. MTBE treatment is a rapid, safe, and effective treatment for patients who refuse surgery or who for medical reasons cannot undergo cholecystectomy. The results of this study confirm that complete dissolution of all fragments is essential and may prevent recurrence. Images Figure 2 PMID:1773965

Training doctors to manage patients with multimorbidity: a systematic review.

PubMed

Lewis, Cliona; Wallace, Emma; Kyne, Lorraine; Cullen, Walter; Smith, Susan M

2016-01-01

Patients with multimorbidity (two or more chronic conditions) are now the norm in clinical practice, and place an increasing burden on the healthcare system. Management of these patients is challenging, and requires doctors who are skilled in the complexity of multiple chronic diseases. To perform a systematic review of the literature to ascertain whether there are education and training formats which have been used to train postgraduate medical doctors in the management of patients with multimorbidity in primary and/or secondary care, and which have been shown to improve knowledge, skills, attitudes, and/or patient outcomes. Overall, 75,110 citations were screened, of which 65 full-text articles were then independently assessed for eligibility by two reviewers, and two studies met the inclusion criteria for the review. The two included studies implemented and evaluated multimorbidity workshops, and highlight the need for further research addressing the learning needs of doctors tasked with managing patients with multimorbidity in their daily practice. While much has been published about the challenges presented to medical staff by patients with multimorbidity, published research regarding education of doctors to manage these problems is lacking. Further research is required to determine whether there is a need for, or benefit from, specific training for doctors to manage patients with multimorbidity. PROSPERO registration number: CRD42013004010.

New Breast Cancer Recursive Partitioning Analysis Prognostic Index in Patients With Newly Diagnosed Brain Metastases

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

Niwinska, Anna, E-mail: alphaonetau@poczta.onet.pl; Murawska, Magdalena

2012-04-01

Purpose: The aim of the study was to present a new breast cancer recursive partitioning analysis (RPA) prognostic index for patients with newly diagnosed brain metastases as a guide in clinical decision making. Methods and Materials: A prospectively collected group of 441 consecutive patients with breast cancer and brain metastases treated between the years 2003 and 2009 was assessed. Prognostic factors significant for univariate analysis were included into RPA. Results: Three prognostic classes of a new breast cancer RPA prognostic index were selected. The median survival of patients within prognostic Classes I, II, and III was 29, 9, and 2.4more » months, respectively (p < 0.0001). Class I included patients with one or two brain metastases, without extracranial disease or with controlled extracranial disease, and with Karnofsky performance status (KPS) of 100. Class III included patients with multiple brain metastases with KPS of {<=}60. Class II included all other cases. Conclusions: The breast cancer RPA prognostic index is an easy and valuable tool for use in clinical practice. It can select patients who require aggressive treatment and those in whom whole-brain radiotherapy or symptomatic therapy is the most reasonable option. An individual approach is required for patients from prognostic Class II.« less

Bronchoscopy with endobronchial ultrasound guided transbronchial needle aspiration vs. transthoracic needle aspiration in lung cancer diagnosis and staging.

PubMed

Munoz, Mark L; Lechtzin, Noah; Li, Qing Kay; Wang, KoPen; Yarmus, Lonny B; Lee, Hans J; Feller-Kopman, David J

2017-07-01

In evaluating patients with suspected lung cancer, it is important to not only obtain a tissue diagnosis, but also to obtain enough tissue for both histologic and molecular analysis in order to appropriately stage the patient with a safe and efficient strategy. The diagnostic approach may often be dependent on local resources and practice patterns rather than current guidelines. We Describe lung cancer staging at two large academic medical centers to identify the impact different procedural approaches have on patient outcomes. We conducted a retrospective cohort study of all patients undergoing a lung cancer diagnostic evaluation at two multidisciplinary centers during a 1-year period. Identifying complication rates and the need for multiple biopsies as our primary outcomes, we developed a multivariate regression model to determine features associated with complications and need for multiple biopsies. Of 830 patients, 285 patients were diagnosed with lung cancers during the study period. Those staged at the institution without an endobronchial ultrasound (EBUS) program were more likely to require multiple biopsies (OR 3.62, 95% CI: 1.71-7.67, P=0.001) and suffer complications associated with the diagnostic procedure (OR 10.2, 95% CI: 3.08-33.58, P<0.001). Initial staging with transthoracic needle aspiration (TTNA) and conventional bronchoscopy were associated with greater need for subsequent biopsies (OR 8.05 and 14.00, 95% CI: 3.43-18.87 and 5.17-37.86, respectively) and higher complication rates (OR 37.75 and 7.20, 95% CI: 10.33-137.96 and 1.36-37.98, respectively). Lung cancer evaluation at centers with a dedicated EBUS program results in fewer biopsies and complications than at multidisciplinary counterparts without an EBUS program.

Urgent Chemotherapy in Sepsis-Like Shock Related to Hematologic Malignancies.

PubMed

Cherruault, Marlène; Le Goff, Marielle; Tamburini, Jérôme; Pène, Frédéric

2018-05-01

Hematologic malignancies may result in multiple organ involvement including pulmonary and renal dysfunctions, and the less common acute circulatory failure. We herein addressed the outcome of patients with sepsis-like shock related to aggressive hematologic malignancies. A 10-year (2007-2016) monocenter retrospective study. A medical ICU in a tertiary care center. Patients with circulatory shock requiring vasopressors and who subsequently received chemotherapy. Shock was presumably related to the underlying malignancy after ruling out an ongoing or new-onset infectious process. The extent and time course of organ failures was assessed by a modified Sequential Organ Failure Assessment score devoid of the platelet component. None. Seventeen patients were included, including 13 with non-Hodgkin lymphoma, two with hyperleukocytic acute myeloid leukemia, and two with "Human Herpes virus 8"-associated multicentric Castleman's disease. The following associated conditions prompted urgent administration of chemotherapy: tumor lysis syndrome (n = 10), hemophagocytic lymphohistiocytosis (n = 3), compressive bulky tumor (n = 3), pulmonary involvement (n = 3), and disseminated intravascular coagulation (n = 1). Following the initiation of chemotherapy, a number of patients died rapidly from untractable multiple organ failure. In contrast, chemotherapy led to a fast and dramatic improvement in organ failures in early survivors, as shown by the decrease in the modified Sequential Organ Failure Assessment score. However, the overall outcome was poor since only four and three patients could be discharged alive from the ICU and the hospital, and three and two patients remained alive at 6 months and 1 year. Multiple organ dysfunction syndrome related to hematologic malignancies is associated with a dismal outcome. A chemotherapy trial may provide a fast prognostic assessment of the reversibility of organ failure.

Is the NIHSS Certification Process Too Lenient?

PubMed Central

Hills, Nancy K.; Josephson, S. Andrew; Lyden, Patrick D.; Johnston, S. Claiborne

2009-01-01

Background and Purpose The National Institutes of Health Stroke Scale (NIHSS) is a widely used measure of neurological function in clinical trials and patient assessment; inter-rater scoring variability could impact communications and trial power. The manner in which the rater certification test is scored yields multiple correct answers that have changed over time. We examined the range of possible total NIHSS scores from answers given in certification tests by over 7,000 individual raters who were certified. Methods We analyzed the results of all raters who completed one of two standard multiple-patient videotaped certification examinations between 1998 and 2004. The range for the correct score, calculated using NIHSS ‘correct answers’, was determined for each patient. The distribution of scores derived from those who passed the certification test then was examined. Results A total of 6,268 raters scored 5 patients on Test 1; 1,240 scored 6 patients on Test 2. Using a National Stroke Association (NSA) answer key, we found that correct total scores ranged from 2 correct scores to as many as 12 different correct total scores. Among raters who achieved a passing score and were therefore qualified to administer the NIHSS, score distributions were even wider, with 1 certification patient receiving 18 different correct total scores. Conclusions Allowing multiple acceptable answers for questions on the NIHSS certification test introduces scoring variability. It seems reasonable to assume that the wider the range of acceptable answers in the certification test, the greater the variability in the performance of the test in trials and clinical practice by certified examiners. Greater consistency may be achieved by deriving a set of ‘best’ answers through expert consensus on all questions where this is possible, then teaching raters how to derive these answers using a required interactive training module. PMID:19295205

Implementation of evidence-based patient navigation programs.

PubMed

Freund, Karen M

2017-02-01

Patient navigation refers to a direct patient care role that links patients with clinical providers and their support system and provides individualized support during cancer care, ensuring that patients have access to the knowledge and resources necessary to complete recommended treatment. While most reports have studied the role of patient navigators during the cancer screening or diagnostic process, emerging evidence indicates the benefits of patient navigation during active cancer treatment. Reports in the literature are conflicting on the impact of patient navigation during cancer care and on the benefits to timely or quality care in all populations. Recent sub-analyses of the Patient Navigation Research Program data demonstrated specifically the benefits of targeting patient navigation to the most vulnerable populations, including those with low educational attainment, low income and unstable housing, less social support, multiple comorbidities, and minority race/ethnicity. The implications of the Patient Navigation Research Program are that this resource is best utilized when directed to support the care of patients at locations with known challenges to timely care and for specific patients with risk factors for delays in care, including comorbidities, low educational attainment and low income. Implementation of patient navigation programs requires the following processes: needs assessment, selection of a navigator to meet the community and care needs, supervision and integration of the navigator into clinical processes, and systems support to facilitate the identification and tracking of those patients requiring patient navigation. There is a need for ongoing research on methods to fund and sustain patient navigation programs.

The most important psychological and psychosocial needs of Polish multiple sclerosis patients and their significant others

PubMed Central

Potemkowski, Andrzej; Brola, Waldemar; Ratajczak, Anna; Ratajczak, Marcin; Kowalewski, Mariusz; Lewita, Małgorzata; Kapica-Topczewska, Katarzyna; Tarasiuk, Joanna; Stępień, Adam; Gocyła-Dudar, Katarzyna; Zaborski, Jacek; Bartosik-Psujek, Halina

2017-01-01

Background People with multiple sclerosis (MS) and their relatives often have multiple, complex needs which require support from a wide range of services. The aim of the study, the first of its kind in Poland, was to identify the most important needs of patients with MS and their significant others (SO). Methods A questionnaire developed from focus groups consisting of 20 needs-related statements was administered in seven MS centers to 573 MS patients and 220 SO. The mean age of the patients was 42.61 years old; the mean MS duration was 9.43 years. The respondents were asked to rate the needs statements according to their importance on an 11-point scale. The questionnaire was similar for the MS patients and their SO. Results The most important needs in the patient group were: to feel needed and efficient in life; to have easy access to professional rehabilitation; and to be sure that doctors are interested in my condition. The three most important needs in the SO group were: to know that relatives/friends feel needed and efficient in life; to have good living conditions; and to be sure that doctors are interested in my relative’s/friend’s condition. Correlation analysis revealed that in the patients group, there was a positive correlation between patient’s age and the importance of factors such as the need for support and interest in their disease from the family doctor (P<0.004), receiving educational materials from an MS clinic (P<0.011), interest from the clinic in life issues of the patient (P<0.001), and the need for access to self-rehabilitation (P<0.003); while the need to continue working part-time was inversely correlated with age (P<0.009). Conclusion The needs of the MS patients and SO were similar. The data validate the importance of interdisciplinary care for the MS population. PMID:28744132

Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity.

PubMed

Knowles, Martyn; Nation, David A; Timaran, David E; Gomez, Luis F; Baig, M Shadman; Valentine, R James; Timaran, Carlos H

2015-01-01

Fenestrated endovascular aortic aneurysm repair (FEVAR) is an alternative to open repair in patients with complex abdominal aortic aneurysms who are neither fit nor suitable for standard open or endovascular repair. Chimney and snorkel grafts are other endovascular alternatives but frequently require bilateral upper extremity access that has been associated with a 3% to 10% risk of stroke. However, upper extremity access is also frequently required for FEVAR because of the caudal orientation of the visceral vessels. The purpose of this study was to assess the use of upper extremity access for FEVAR and the associated morbidity. During a 5-year period, 148 patients underwent FEVAR, and upper extremity access for FEVAR was used in 98 (66%). Outcomes were compared between those who underwent upper extremity access and those who underwent femoral access alone. The primary end point was a cerebrovascular accident or transient ischemic attack, and the secondary end point was local access site complications. The mean number of fenestrated vessels was 3.07 ± 0.81 (median, 3) for a total of 457 vessels stented. Percutaneous upper extremity access was used in 12 patients (12%) and open access in 86 (88%). All patients who required a sheath size >7F underwent high brachial open access, with the exception of one patient who underwent percutaneous axillary access with a 12F sheath. The mean sheath size was 10.59F ± 2.51F (median, 12F), which was advanced into the descending thoracic aorta, allowing multiple wire and catheter exchanges. One hemorrhagic stroke (one of 98 [1%]) occurred in the upper extremity access group, and one ischemic stroke (one of 54 [2%]) occurred in the femoral-only access group (P = .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0%) compared with the left being accessed 92 times with one stroke (1%; P = .8). Four patients (4%) had local complications related to upper extremity access. One (1%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath, and two patients (2%) with small hematomas did not require intervention. Two (two of 12 [17%]) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (two of 86 [2%]; P = .02). Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting. Copyright © 2015 Society for Vascular Surgery. All rights reserved.

Synchronous and metachronous neoplasms in gastric cancer patients: A 23-year study

PubMed Central

Ławniczak, Małgorzata; Gawin, Alicja; Jaroszewicz-Heigelmann, Halina; Rogoza-Mateja, Wiesława; Raszeja-Wyszomirska, Joanna; Białek, Andrzej; Karpińska-Kaczmarczyk, Katarzyna; Starzyńska, Teresa

2014-01-01

AIM: To determine the prevalence and characteristics of additional primary malignancies in gastric cancer (GC) patients. METHODS: GC patients (862 total; 570 men, 292 women; mean age 59.8 ± 12.8 years) diagnosed at the Department of Gastroenterology at Pomeranian Medical University over a period of 23 years were included in this retrospective analysis of a prospectively maintained database. Mean follow-up time was 31.3 ± 38.6 mo (range 1-241 mo). The following clinicopathological features of patients with synchronous tumors were compared to those with metachronous tumors: age, sex, symptom duration, family history of cancer, tumor site, stage (early vs advanced), histology, and blood group. GC patients with and without a second tumor were compared in terms of the same clinicopathological features. RESULTS: Of 862 GC patients, 58 (6.7%) developed a total of 62 multiple primary tumors, of which 39 (63%) were metachronous and 23 (37%) synchronous. Four (6.9%) of the 58 multiple GC patients developed two or more neoplasms. The predominant tumor type of the secondary neoplasms was colorectal (n = 17), followed by lung (n = 9), breast (n = 8), and prostate (n = 7). Age was the only clinicopathological feature that differed between GC patients with synchronous vs metachronous malignancies; GC patients with synchronous neoplasms were older than those with metachronous neoplasms (68.0 ± 10.3 years vs 59.9 ± 11.1 years, respectively, P = 0.008). Comparisons between patients with and without a second primary cancer revealed that the only statistically significant differences were in age and blood group. The mean age of the patients with multiple GC was higher than that of those without a second primary tumor (63.4 ± 11.4 years vs 59.5 ± 13.0 years, respectively, P = 0.026). GC patients with a second primary tumor were more commonly blood group O than those without (56.2% vs 31.6%, respectively, P = 0.002). CONCLUSION: GC patients may develop other primary cancers; appropriate preoperative and postoperative diagnostic modalities are thus required, particularly if patients are older and blood group O. PMID:24966619

A decreased soluble Klotho level with normal eGFR, FGF23, serum phosphate, and FEP in an ADPKD patient with enlarged kidneys due to multiple cysts.

PubMed

Kanai, Takahiro; Shiizaki, Kazuhiro; Betsui, Hiroyuki; Aoyagi, Jun; Yamagata, Takanori

2018-05-16

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disorder. ADPKD is characterized clinically by the presence of multiple bilateral renal cysts that lead to chronic renal failure. The cysts evolve from renal tubular epithelial cells that express the Klotho gene. Notably, Klotho acts as a co-receptor for fibroblast growth factor 23 (FGF23); in this context, it induces phosphaturia and maintains serum phosphate at a normal level. Many reports have shown that decreases in the soluble Klotho level and increases in the FGF23 level are associated with glomerular filtration rate (GFR) decline, but a recent study observed these changes in patient with normal eGFR. It remains unclear whether the decrease in the Klotho level precedes the increase in FGF23. Here, we present an ADPKD patient with enlarged kidneys due to multiple cysts who had a decreased soluble Klotho level but a normal eGFR and a normal FGF23 level. The patient's serum phosphate level was normal, as was the fractional excretion of phosphate (FEP). This appears to be the first reported case to show a decreased soluble Klotho level plus normal eGFR, FGF23, and FEP. These results suggest that Klotho decreases before FGF23 increases and further suggest that Klotho is not required to maintain normal serum phosphate levels in ADPKD if the FEP and serum phosphate levels are normal.

Veterans Affairs general surgery service: the last bastion of integrated specialty care.

PubMed

Poteet, Stephen; Tarpley, Margaret; Tarpley, John L; Pearson, A Scott

2011-11-01

In a time of increasing specialization, academic training institutions provide a compartmentalized learning environment that often does not reflect the broad clinical experience of general surgery practice. This study aimed to evaluate the contribution of the Veterans Affairs (VA) general surgery surgical experience to both index Accreditation Council for Graduate Medical Education (ACGME) requirements and as a unique integrated model in which residents provide concurrent care of multiple specialty patients. Institutional review board approval was obtained for retrospective analysis of electronic medical records involving all surgical cases performed by the general surgery service from 2005 to 2009 at the Nashville VA. Over a 5-year span general surgery residents spent an average of 5 months on the VA general surgery service, which includes a postgraduate year (PGY)-5, PGY-3, and 2 PGY-1 residents. Surgeries involved the following specialties: surgical oncology, endocrine, colorectal, hepatobiliary, transplant, gastrointestinal laparoscopy, and elective and emergency general surgery. The surgeries were categorized according to ACGME index requirements. A total of 2,956 surgeries were performed during the 5-year period from 2005 through 2009. Residents participated in an average of 246 surgeries during their experience at the VA; approximately 50 cases are completed during the chief year. On the VA surgery service alone, 100% of the ACGME requirement was met for the following categories: endocrine (8 cases); skin, soft tissue, and breast (33 cases); alimentary tract (78 cases); and abdominal (88 cases). Approximately 50% of the ACGME requirement was met for liver, pancreas, and basic laparoscopic categories. The VA hospital provides an authentic, broad-based, general surgery training experience that integrates complex surgical patients simultaneously. Opportunities for this level of comprehensive care are decreasing or absent in many general surgery training programs. The increasing level of responsibility and simultaneous care of multiple specialty patients through the VA hospital systems offers a crucial experience for those pursuing a career in general surgery. Published by Elsevier Inc.

The challenges of healthcare delivery to people with multiple sclerosis in Iran.

PubMed

Yazdannik, Ahmadreza; Abolhassani, Shahla; Taleghani, Fariba; Zamani, Ahmadreza

2015-01-01

Multiple sclerosis (MS) is a chronic disease prevalent in young and middle-aged people. Patients with MS often have numerous complicated needs and, consequently, require a broad range of health services. Results of a number of studies indicate that patients' needs are only partially met. This study was conducted to explore the challenges of healthcare delivery to patients with MS in Iran. In this qualitative case study, 43 participants selected through purposeful sampling were interviewed using semi-structured method in the cities of Isfahan and Tehran in 2012-2013. Besides the interview, documentations relevant to healthcare delivery were collected from different sources, including websites of all Iranian universities of medical sciences, insurance organizations, patients' weblogs, news agencies, the MS Center forum for MS patients, and MS Payam bimonthly. The data were analyzed through the constant comparative analysis. The data were categorized into four main categories, including functional challenges (diagnosis problems, failure to pay attention to patient needs, failure to follow-up, and miscommunication), administrative challenges (resource allocation and supervision), policy-making challenges (lack of comprehensive services, bureaucracy, and problems in provision of medications), and structural challenges (difficult access to services, lack of comprehensive centers, space limit, and long wait). Despite all attempts of governmental and nongovernmental organizations for healthcare delivery to MS patients, these services cannot satisfy all needs of the patients. In this regard, service providers and administrators should pay more attention to the needs and expectations of patients and their families.

[Adjuvant cryosurgery in the treatment of unicameral bone cysts].

PubMed

Tena-Sanabria, Mario Edgar; Hernández-Hernández, Melissa Jesús; Tena-González, Mario Edgar; Mejía-Aranguré, Juan Manuel

2014-01-01

Multiple treatments have been used for the unicameral bone cyst lesion, such as steroid application, multiple perforations, bone curettages, partial resection and bone grafting. The purpose of this study was to describe the evolution of children with unicameral bone cyst who were treated with cryosurgery as coadjuvant therapy. Cross-sectional descriptive study over the period between January 2001 and December 2006. Twelve patients were studied and treated at the Pediatric Orthopedics Department of the Pediatrics Hospital at the Centro Médico Nacional Siglo XXI. Twelve patients were analyzed; all of them were treated with curettage, cryotherapy and bone grafting. In 7 patients, the lesions were located in the humerus (58.3 %), in 3 in the tibia (25 %), in 1 in the ilio-ischiopubic branch (8.3 %), and in 1 in the clavicle (8.3 %). Follow-up ranged from 12 to 36 months. Bone healing required 2 to 3 months after the surgery; the response was complete in 9 (75 %) patients and partial in 3 (25 %). Function was restored in all cases, without recurrences. Cryosurgery as an adjuvant treatment and autologous or homologous bone grafting prevented local recurrence of unicameral bone cyst lesions, favored bone healing and allowed for a full range of motion functionality without complications.

Mass screening of multiple abdominal solid organs using mobile helical computed tomography scanner--a preliminary report.

PubMed

Ishikawa, Susumu; Aoki, Jun; Ohwada, Susumu; Takahashi, Toru; Morishita, Yasuo; Ueda, Keisuke

2007-04-01

The possibility of a new screening procedure for multiple abdominal solid organs using a mobile helical computed tomography (CT) scanner was evaluated. A total of 4,543 residents, who were 40 years of age or older, received CT scanning without contrast medium. The mean age of participants was 64 years including 2,022 males and 2,521 females. A total of 2,105 abnormal findings were uniquely detected in 1,594 participants. Liver and kidney diseases including ureter occupied around 30% of total abnormal findings, respectively. Besides frequent cystic or calcified lesions, solid tumours were suspected in 56 lesions, which received further examination by specialized physicians. Five (9%) of them were confirmed as being malignant tumours including pancreatic cancer in two patients, and liver, lung and ovary cancers in one patient each, respectively. All five patients with each malignant lesion received curative operations. Small-sized abdominal aortic aneurysms and heart valve diseases were uniquely found in 22 and two patients, respectively. Qualitative diagnoses of solid tumours were difficult using CT findings without contrast medium. CT screening procedures require further investigation in aspect of the selection of examinees, CT scanning procedure, sensitivity and specificity, and cost-effectiveness.

Follow-up of IgD-κ multiple myeloma by monitoring free light chains and total heavy chain IgD: A case report

PubMed Central

De Santis, Elena; Masi, Serena; Cordone, Iole; Pisani, Francesco; Zuppi, Cecilia; Mattei, Fabrizio; Conti, Laura; Cigliana, Giovanni

2016-01-01

Immunoglobulin (Ig)D-κ multiple myeloma (MM) is a rare neoplastic disease characterized by an aggressive and rapidly progressing course, which constitutes only a very small proportion of all MM cases. In the present report, the clinical case of a 51-year-old Caucasian woman diagnosed with IgD-κ MM is described. The patient underwent different chemotherapeutic treatments subsequently to a single autologous stem cell transplantation. Despite the inherent difficulty of monitoring IgD levels and performing serum immunofixation electrophoresis, the clinical outcome of the patient was almost uniquely monitored by measuring the levels of κ and λ free light chains (FLCs) and total heavy chain IgD. The data suggest the non-invasive potential and usefulness of FLCs evaluation for early detection of stringent complete remission, follow-up and early detection of disease relapse. In addition, this diagnostic procedure has successfully been employed for the therapeutic monitoring of the present patient, and may represent a very helpful, non-invasive tool for the follow-up of IgD myeloma patients without the requirement of serial bone marrow aspirate. PMID:27588135

Nonalcoholic fatty liver disease and liver transplantation - Where do we stand?

PubMed Central

Mikolasevic, Ivana; Filipec-Kanizaj, Tajana; Mijic, Maja; Jakopcic, Ivan; Milic, Sandra; Hrstic, Irena; Sobocan, Nikola; Stimac, Davor; Burra, Patrizia

2018-01-01

Nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) is a challenging and multisystem disease that has a high socioeconomic impact. NAFLD/NASH is a main cause of macrovesicular steatosis and has multiple impacts on liver transplantation (LT), on patients on the waiting list for transplant, on post-transplant setting as well as on organ donors. Current data indicate new trends in the area of chronic liver disease. Due to the increased incidence of metabolic syndrome (MetS) and its components, NASH cirrhosis and hepatocellular carcinoma caused by NASH will soon become a major indication for LT. Furthermore, due to an increasing incidence of MetS and, consequently, NAFLD, there will be more steatotic donor livers and less high quality organs available for LT, in addition to a lack of available liver allografts. Patients who have NASH and are candidates for LT have multiple comorbidities and are unique LT candidates. Finally, we discuss long-term grafts and patient survival after LT, the recurrence of NASH and NASH appearing de novo after transplantation. In addition, we suggest topics and areas that require more research for improving the health care of this increasing patient population. PMID:29662288

Electrolyte and Acid-Base Disturbances in End-Stage Liver Disease: A Physiopathological Approach.

PubMed

Jiménez, José Víctor; Carrillo-Pérez, Diego Luis; Rosado-Canto, Rodrigo; García-Juárez, Ignacio; Torre, Aldo; Kershenobich, David; Carrillo-Maravilla, Eduardo

2017-08-01

Electrolyte and acid-base disturbances are frequent in patients with end-stage liver disease; the underlying physiopathological mechanisms are often complex and represent a diagnostic and therapeutic challenge to the physician. Usually, these disorders do not develop in compensated cirrhotic patients, but with the onset of the classic complications of cirrhosis such as ascites, renal failure, spontaneous bacterial peritonitis and variceal bleeding, multiple electrolyte, and acid-base disturbances emerge. Hyponatremia parallels ascites formation and is a well-known trigger of hepatic encephalopathy; its management in this particular population poses a risky challenge due to the high susceptibility of cirrhotic patients to osmotic demyelination. Hypokalemia is common in the setting of cirrhosis: multiple potassium wasting mechanisms both inherent to the disease and resulting from its management make these patients particularly susceptible to potassium depletion even in the setting of normokalemia. Acid-base disturbances range from classical respiratory alkalosis to high anion gap metabolic acidosis, almost comprising the full acid-base spectrum. Because most electrolyte and acid-base disturbances are managed in terms of their underlying trigger factors, a systematic physiopathological approach to their diagnosis and treatment is required.

Pregnancy with aortic dissection in Ehler-Danlos syndrome. Staged replacement of the total aorta (10-year follow-up).

PubMed

Babatasi, G; Massetti, M; Bhoyroo, S; Khayat, A

1997-10-01

Pregnancy complicated by aortic dissection in patients with hereditary disorder of connective tissue presents interesting considerations including management of caesarean section with the unexpected need for cardiac surgery in emergency. Generalizations can be made on management principles with long-term follow-up requiring an aggressive individualized approach by a multidisciplinary team. A 33-year-old parturient presenting an aortic dissection at 37 weeks gestation required prompt diagnosis of Ehlers-Danlos syndrome in combination with correct surgical therapy resulted in the survival of both the mother and infant. During the 10-year follow-up, multiple complex dissection required transverse aortic arch and thoracoabdominal aortic replacement.

Outcome of mechanical cardiac support in children using more than one modality as a bridge to heart transplantation.

PubMed

De Rita, Fabrizio; Hasan, Asif; Haynes, Simon; Peng, Edward; Gandolfo, Fabrizio; Ferguson, Lee; Kirk, Richard; Smith, Jon; Griselli, Massimo

2015-12-01

Mechanical cardiac support (MCS) can successfully be applied as a bridging strategy for heart transplantation (OHTx) in children with life-threatening heart failure. Emergent use of MCS is often required before establishing the likelihood of OHTx. This can require bridge-to-bridge strategies to increase survival on the waiting list. We compared the outcome of children with heart failure who underwent single MCS with those who required multiple MCS as a bridge to OHTx. A retrospective study of patients aged less than 16 years was conducted. From March 1998 to October 2005, we used either a veno-arterial extracorporeal membrane oxygenator (VA-ECMO), or the Medos® para-corporeal ventricular assist device (VAD). From November 2005 onwards, the Berlin Heart EXCOR® (BHE) device was implanted in the majority of cases. Several combinations of bridge-to-bridge strategies have been used: VA-ECMO and then conversion to BHE; BHE and then conversion to VA-ECMO; left VAD and then upgraded to biventricular support (BIVAD); conversion from pulsatile to continuous-flow pumps. A total of 92 patients received MCS with the intent to bridge to OHTx, including 21 (23%) supported with more than one modality. The mean age and weight at support was similar in both groups, but multimodality MCS was used more often in infancy (P = 0.008) and in children less than 10 kg in weight (P = 0.02). The mean duration of support was longer in the multiple MCS group: 40 ± 48 vs 84 ± 43 days (P = 0.0003). Usage of multimodality MCS in dilated cardiomyopathy (19%) and in other diagnoses (29%) was comparable. Incidence of major morbidity (haematological sequelae, cerebrovascular events and sepsis) was similar in both groups. Survival to OHTx/explantation of the device (recovery) and survival to discharge did not differ between single MCS and multiple MCS groups (78 vs 81% and 72 vs 76%, respectively). Bridge to OHTx with multiple MCS does not seem to influence the outcome in our population. Infancy and body weight less than 10 kg do not tend to produce higher mortality in the multiple MCS group. However, children receiving more than one modality are supported for longer durations. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Airway reconstruction: review of an approach to the advanced-stage laryngotracheal stenosis.

PubMed

Bitar, Mohamad Ahmad; Al Barazi, Randa; Barakeh, Rana

The management of laryngotracheal stenosis is complex and is influenced by multiple factors that can affect the ultimate outcome. Advanced lesions represent a special challenge to the treating surgeon to find the best remedying technique. To review the efficacy of our surgical reconstructive approach in managing advanced-stage laryngotracheal stenosis treated at a tertiary medical center. A retrospective review of all patients that underwent open laryngotracheal repair/reconstruction by the senior author between 2002 and 2014. Patients with mild/moderate stenosis (e.g. stage 1 or 2), or those who had an open reconstructive procedure prior to referral, were excluded. Patients who had only endoscopic treatment (e.g. laser, balloon dilatation) and were not subjected to an open reconstructive procedure at our institution, were not included in this study. Variables studied included patient demographics, clinical presentation, etiology of the laryngotracheal pathology, the location of stenosis, the stage of stenosis, the type of corrective or reconstructive procedure performed with the type of graft used (where applicable), the type and duration of stent used, the post-reconstruction complications, and the duration of follow-up. Outcome measures included decannulation rate, total number of reconstructive surgeries needed to achieve decannulation, and the number of post-operative endoscopies needed to reach a safe patent airway. Twenty five patients were included, aged 0.5 months to 45 years (mean 13.5 years, median 15 years) with 16 males and 9 females. Seventeen patients (68%) were younger than 18 years. Most patients presented with stridor, failure of decannulation, or respiratory distress. Majority had acquired etiology for their stenosis with only 24% having a congenital pathology. Thirty-two reconstructive procedures were performed resulting in decannulating 24 patients (96%), with 15/17 (88%) pediatric patients and 5/8 (62.5%) adult patients requiring only a single reconstructive procedure. Cartilage grafts were mostly used in children (84% vs. 38%) and stents were mostly silicone made, followed by endotracheal tubes. The number of endoscopies required ranged from 1 to 7 (mean 3). More co-morbidities existed in young children, resulting in failure to decannulate one patient. Adult patients had more complex pathologies requiring multiple procedures to achieve decannulation, with grafting less efficacious than in younger patients. The pediatric patients had double the incidence of granulation tissue compared to adults. The decannulated patients remained asymptomatic at a mean follow-up of 50.5 months. The review of our approach to open airway repair/reconstruction showed its efficacy in advanced-stage laryngotracheal stenosis. Good knowledge of a variety of reconstructive techniques is important to achieve good results in a variety of age groups. Copyright © 2016 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Assessment of nutritional status in cancer patients in Osijek health area center.

PubMed

Ebling, Barbara; Brumnić, Vesna; Rendić-Miocević, Zrinka; Gmajnić, Rudika; Pribić, Sanda; Juretić, Antonio; Ebling, Zdravko; Muha, Ivana

2014-03-01

The aim of this research was to perform the nutritional screening and clinical assessment of malnutrition and of cachexia as well as the need for enteral nutritional support. We used an international questionnaire for nutrition screening and clinical assessment of malnutrition. 103 cancer patients participated in the research. The results indicate that 80patients (78%) have recently unintentionally lost weight in the last six months. Of those 80 patients 12 (15%) have lost more than 15 kilograms. Three patients (3%) suffer from hunger because of their inability to eat. Presence of multiple (3 or more) symptoms (nausea, vomiting, diarrhea or anorexia) was reported by 11 patients (11%). Severe work dysfunction was found in 28 patients (27%). 14 patients (14%) experience significant loss of musculature (musculus quadriceps femoris, musculus deltoideus). The obtained results indicate that 15patients (14%) are severely, and 39 patients (38%) are moderately undernourished. This survey confirmed the significance of nutritional screening in cancer patients, as it detected 30 patients (29%) who required introduction of enteral nutrition.

Iron Chelation Therapy with Deferasirox Results in Improvement of Liver Enzyme Level in Patients with Iron Overload-Associated Liver Dysfunction

PubMed Central

Miura, Yasuo; Matsui, Yusuke; Kaneko, Hitomi; Watanabe, Mitsumasa; Tsudo, Mitsuru

2010-01-01

Iron chelation therapy (ICT) has been applied for the patients with iron overload-associated liver dysfunction since it is one of the causes of death in patients with intractable hematological diseases requiring multiple red blood cell transfusions. Recently, deferasirox (DSX), a novel, once-daily oral iron chelator, was demonstrated to have similar efficacy to the conventional continuous infusion of deferoxamine on a decrease in serum ferritin (SF) level in heavily transfused patients. We show three cases of transfusion-mediated iron-overloaded patients with an elevated serum alanine aminotransaminase (ALT). All three patients who received the ICT with DSX showed a decrease in ALT level in association with a decrease in SF level. It is suggested that DSX therapy could be considered to expect the improvement of liver damage for iron-overloaded patients with an abnormal ALT level. PMID:20592762

The Use of TKM-100802 and Convalescent Plasma in 2 Patients With Ebola Virus Disease in the United States

PubMed Central

Kraft, Colleen S.; Hewlett, Angela L.; Koepsell, Scott; Winkler, Anne M.; Kratochvil, Christopher J.; Larson, LuAnn; Varkey, Jay B.; Mehta, Aneesh K.; Lyon, G. Marshall; Friedman-Moraco, Rachel J.; Marconi, Vincent C.; Hill, Charles E.; Sullivan, James N.; Johnson, Daniel W.; Lisco, Steven J.; Mulligan, Mark J.; Uyeki, Timothy M.; McElroy, Anita K.; Sealy, Tara; Campbell, Shelley; Spiropoulou, Christina; Ströher, Ute; Crozier, Ian; Sacra, Richard; Connor, Michael J.; Sueblinvong, Viranuj; Franch, Harold A.; Smith, Philip W.; Ribner, Bruce S.; Smith, Philip; Hewlett, Angela; Schwedhelm, Shelly; Boulter, Kate; Beam, Elizabeth; Gibbs, Shawn; Lowe, John; Kratochvil, Chris; Sullivan, James; Johnson, Dan; Lisco, Steve; Piquette, Craig; Bailey, Kristina; Auxier, Joseph; Boer, Brian; Hanson, Travis; Kaseman, Julia; Khan, M. Salman; Rhee, Ji Hyun; Wells, Adam; Florescu, Diana; Kalil, Andre; Rupp, Mark; Becker, Valerie; Boeckman, Bridget; Elder, Erica; Fitch, Abby; Flood, Elizabeth; Freml, Meagan; Frigge, Roman; Hanzlik, Kelly Ann; Jensen, Lois; Kraus, Nicole; Molacek, Drew; Nevins, Jerry; Parker, Alicia; Peters, Jeff; Rand, Cheryl; Roesler, Karen; Ryalls, Kendall; Shradar, Morgan; Strain, Amanda; Sunderman, Timothy; Sundermeier, Jennifer; Swanhorst, John; Vasa, Angela; Bellinghausen, Jean; Freihaut, Frank; Denny, Susan; Mainelli, Lauren; Pinkney, Dee; Ray, Deborah; Jevne, Jay; Knight, Kalen; McCroy, Derrick; Nadeau, Ralph; Nightser, Anna; Iwen, Pete; Sambol, Tony; Herrera, Vicki; Morgan, David; Trotter, Sarah; Kerby, Amy; Peters, Sue; Southern, Timothy; Murphy, Caitlin; Morris, Rosanna; Nuss, Sue; Franco, Theresa; Ogden, Connie; Lazure, Julie; Straub, Dawn; Koepsell, Scott; Hinrichs, Steve; Plumb, Troy; Florescu, Marius; Becker, John; Souchek, Jenna; Beck, Jon; Larson, Luann; Heires, Peggy; Gordon, Bruce; Paulsen, Gail; Wolford, Barb; Petersen, Jill; Marion, Nedra; Hayes, Kim; Tyner, Kate; Wilson, Taylor; Baltes, Paul; Nowatzke, Jenny; Nguyen, Jonathan; Turner, Paul; Boonstra, Barb; Jelden, Katelyn; Portrey, Randy; Stringfield, Doug; Scofield, Bryan; Svanda, Gary; Horihan, Jolene; Dahl, Chris; Bruno, Megan; Malm, Kelsey; Litz, Ron; Fehringer, Jessica; Paladino, Katie; Opp, Tammy; Bell, Sonia; Adams, Anne; Allen, Mary Beth; Bachman, Robert; Bornstein, William; Cantrell, Dee; Cosper, Pam; Feistritzer, Nancye; Fox, John; Gartland, Bryce; Goodman, Jen; Grant, Susan; Howard-Crow, Dallis; Horowitz, Ira; Pugh, David; Ritenour, Chad; Ash, Toni; Barnes, Christopher; Calhoun, Jason; Chapman, Lauren; Daye, Tracey; Durr, Haley; Evans, Shunasee; Gentry, Janice; Ginnane, Jan; Grant, Susan; Haynes, Chris; Hill, Carolyn; Hillis, Dustin; Johnson, Crystal; Loomis, Jessica; Mamora, Josia; Mitchell, Laura; Morgan, Jill; Osakwe, Nancy; Owen, Jacqueline; Piazza, Sarah; Shirley, Kristina; Siddens, Jodi; Silas, Carrie; Slabach, Jason; Tirador, Elaina; Todd, Donnette; Vanairsdale, Sharon; Brammer, Nicole; Buchanan, Juli; Burd, Eileen; Cardella, John; Eaves, Brenda; Evans, Crystal; Hostetler, Krista; Jenkins, Karen; Lindsey, Maureen; Magee, Jordan; Powers, Randall; Ritchie, James; Ryan, Emily; Bonds, Shannon; Emamifar, Amir; Kuban, Tish; Pack, Jan; Rogers, Susan; Golston, George; Kaufman, Sean; Olinger, Patricia; Olinger, Sean; Rengarajan, Kalpana; Thomaston, Scott; Beck, Emily; Desroches, Paula; Hall, Cynthia; Walker, Celeste; Bryant, Connie; Hackman, Betsy; Howard, Regina; Jones, Marolyn; Broughton, Jeff; Frisle, Brian; Jackson, Robert; Lewis, Jerry; Brown-Haithco, Robin; Gartin, Miranda Lynn; Geralds-Washington, Erica; James-Jones, Rhonda; Miller, Donald; Stark, Dan; McGee, Gentrice; Jones, Porcia; Scott-Harris, Linda; Cain, James; Davis, Roderick; Johnson, Tyrone; Pickett, Tyrone; Shaw, Anthony; Truesdale, Tenina; Blum, Jim; Hill, Laureen; Sevransky, Jon; Zivot, Joel; Walker, Seth; Klopman, Matthew; Matkins, Ricky; Meechan, Cathy; Meechan, Paul; Schwock, Kathy; Schuck, Jen; Stack, Kathy; Wolf, Francis; Bray, Bruce; Isakov, Alex; Shartar, Sam; Miles, Wade; Jamison, Aaro; Arevalo, John; Stallings, Gail; Christenbury, Janet; Dollard, Vince; De Gennaro, Melanie; Korschun, Holly; Seideman, Nancy; Ziegler, Tom; Griffith, Daniel P.; Dave, Nisha; Wall, Susan; Hall, Melida; McGhee, Dwania; Clarke, Tim; Vaught, Rachel; Peterson-Pileri, Katrina

2015-01-01

Background. The current West Africa Ebola virus disease (EVD) outbreak has resulted in multiple individuals being medically evacuated to other countries for clinical management. Methods. We report two patients who were transported from West Africa to the United States for treatment of EVD. Both patients received aggressive supportive care measures, as well as an investigational therapeutic (TKM-100802) and convalescent plasma. Results. While one patient experienced critical illness with multi-organ failure requiring mechanical ventilation and renal replacement therapy, both patients recovered without serious long-term sequelae to date. Conclusions. It is unclear what role the experimental drug and convalescent plasma had in the recovery of these patients. Prospective clinical trials are needed to delineate the role of investigational therapies in the care of patients with EVD. PMID:25904375

Clinical Application and Pharmacodynamic Monitoring of Apixaban in a Patient with End-Stage Renal Disease Requiring Chronic Hemodialysis.

PubMed

Kufel, Wesley D; Zayac, Adam S; Lehmann, David F; Miller, Christopher D

2016-11-01

Despite prescribing guidance, limited data exist to describe the use of apixaban in patients with end-stage renal disease (ESRD) requiring hemodialysis (HD). Current apixaban dosing recommendations for this patient population are based largely on a single-dose pharmacokinetic study of eight patients. We describe the clinical application and pharmacodynamic monitoring of apixaban in a 62-year-old 156-kg African-American woman with nonvalvular atrial fibrillation and ESRD requiring hemodialysis who developed calciphylaxis while receiving warfarin therapy. Based on a multidisciplinary clinical judgment decision due to concern for drug accumulation after multiple doses in patients with ESRD receiving HD, she was anticoagulated with apixaban 2.5 mg twice/day, as opposed to 5 mg twice/day as recommended by the package insert. Antifactor Xa monitoring was used, and resultant peak and trough apixaban concentrations were above the upper limit of detection for our clinical laboratory (more than 2.00 IU/ml). On day 7 of her hospitalization, the patient developed gastrointestinal bleeding, and apixaban was discontinued; no further clinical signs of bleeding occurred during her subsequent hospitalization course. Use of the Naranjo Adverse Drug Reaction Probability Scale indicated a probable relationship (score of 6) between apixaban exposure and the manifestation of gastrointestinal bleeding. The patient ultimately died 44 days after the acute bleeding event; however, coagulation concerns were not implicated in the patient's death. To our knowledge, this is the first case report that describes apixaban use and associated antifactor Xa monitoring in a patient with ESRD receiving HD, and it provides concern for current apixaban dosing recommendations in this patient population. Further pharmacokinetic and clinical data are likely necessary to better characterize apixaban use in these patients to optimize safety and efficacy. © 2016 Pharmacotherapy Publications, Inc.

The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PubMed

Hayn, Matthew H; Hussain, Abid; Mansour, Ahmed M; Andrews, Paul E; Carpentier, Paul; Castle, Erik; Dasgupta, Prokar; Rimington, Peter; Thomas, Raju; Khan, Shamim; Kibel, Adam; Kim, Hyung; Manoharan, Murugesan; Menon, Mani; Mottrie, Alex; Ornstein, David; Peabody, James; Pruthi, Raj; Palou Redorta, Joan; Richstone, Lee; Schanne, Francis; Stricker, Hans; Wiklund, Peter; Chandrasekhar, Rameela; Wilding, Greg E; Guru, Khurshid A

2010-08-01

Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer. We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure. Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009. Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points. Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients. RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality. Copyright (c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Chronic Colovesical Fistula Leading to Chronic Urinary Tract Infection Resulting in End-Stage Renal Disease in a Chronic Granulomatous Disease Patient.

PubMed

Siddiqui, M R; Sanford, T; Nair, A; Zerbe, C S; Hughes, M S; Folio, L; Agarwal, Piyush K; Brancato, S J

2017-02-01

A 46-year old man with X-linked chronic granulomatous disease (CGD) being followed at the National Institute of Health with uncontrolled CGD colitis who developed chronic colovesical fistula, and end-stage renal disease (ESRD). Despite aggressive medical management of symptoms with immunomodulators and antibiotic prophylaxis, the chronic colovesical fistula led to chronic pyelonephritis, recurrent urinary tract infections, persistent air in the collecting system and bladder, and post-renal obstruction resulting in renal failure. Patient is now hemodialysis dependent and required diverting loop ileostomy placement. This report highlights multiple potential etiologies of rising serum creatinine in patients with CGD.

Hospital at night: an organizational design that provides safer care at night

PubMed Central

2014-01-01

The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day. Increasing the number of doctors to support multiple specialty rosters is not the solution for economic or organizational reasons. This paper outlines an alternative, economically viable multidisciplinary solution that has been shown to improve patient outcomes and provides organizational consistency. The change requires strong clinical leadership, with organizational commitment to both cultural and structural change. Careful attention to ensuring the teams possess the appropriate competencies, implementing a reliable process to identify the sickest patients and escalate their care, and structuring rotas efficiently are essential features of success. PMID:25561063

Tachycardia detection in ICDs by Boston Scientific : Algorithms, pearls, and pitfalls.

PubMed

Zanker, Norbert; Schuster, Diane; Gilkerson, James; Stein, Kenneth

2016-09-01

The aim of this study was to summarize how implantable cardioverter defibrillators (ICDs) by Boston Scientific sense, detect, discriminate rhythms, and classify episodes. Modern devices include multiple programming selections, diagnostic features, therapy options, memory functions, and device-related history features. Device operation includes logical steps from sensing, detection, discrimination, therapy delivery to history recording. The program is designed to facilitate the application of the device algorithms to the individual patient's clinical needs. Features and functions described in this article represent a selective excerpt by the authors from Boston Scientific publicly available product resources. Programming of ICDs may affect patient outcomes. Patient-adapted and optimized programming requires understanding of device operation and concepts.

Exciting Directions in Glaucoma

PubMed Central

Rasmussen, Carol A; Kaufman, Paul L

2014-01-01

Glaucoma is a complex, life-long disease that requires an individualized, multifaceted approach to treatment. Most patients will be started on topical ocular hypotensive eyedrop therapy and over time, multiple classes of drugs will be needed to control their intraocular pressure (IOP). The search for drugs with novel mechanisms of action, to treat those who do not achieve adequate IOP control with, or become refractory to, current therapeutics, is ongoing, as is the search for more efficient, targeted drug delivery methods. Gene transfer and stem cell applications for glaucoma therapeutics are moving forward. Advances in imaging technologies improve our understanding of glaucoma pathophysiology and enable more refined patient evaluation and monitoring, improving patient outcomes. PMID:25433744

[Orange Platform].

PubMed

Toba, Kenji

2017-07-01

The Organized Registration for the Assessment of dementia on Nationwide General consortium toward Effective treatment in Japan (ORANGE platform) is a recently established nationwide clinical registry for dementia. This platform consists of multiple registries of patients with dementia stratified by the following clinical stages: preclinical, mild cognitive impairment, early-stage, and advanced-stage dementia. Patients will be examined in a super-longitudinal fashion, and their lifestyle, social background, genetic risk factors, and required care process will be assessed. This project is also notable because the care registry includes information on the successful, comprehensive management of patients with dementia. Therefore, this multicenter prospective cohort study will contribute participants to all clinical trials for Alzheimer's disease as well as improve the understanding of individuals with dementia.

Risk evaluation and monitoring in multiple sclerosis therapeutics.

PubMed

Clanet, Michel C; Wolinsky, Jerry S; Ashton, Raymond J; Hartung, Hans-Peter; Reingold, Stephen C

2014-09-01

Risk for multiple sclerosis (MS) disease-modifying therapies (DMT) must be assessed on an ongoing basis. Early concerns regarding the first-approved DMTs for MS have been mitigated, but recently licensed therapies have been linked to possibly greater risks. The objective of this review is to discuss risk assessment in MS therapeutics based on an international workshop and comprehensive literature search and recommend strategies for risk assessment/monitoring. Assessment and perception of therapeutic risks vary between patients, doctors and regulators. Acceptability of risk depends on the magnitude of risk and the demonstrated clinical benefits of any agent. Safety signals must be distinguishable from chance occurrences in a clinical trial and in long-term use of medications. Post-marketing research is crucial for assessing longer-term safety in large patient cohorts. Reporting of adverse events is becoming more proactive, allowing more rapid identification of risks. Communication about therapeutic risks and their relationship to clinical benefit must involve patients in shared decision making. It is difficult to produce a general risk-assessment algorithm for all MS therapies. Specific algorithms are required for each DMT in every treated-patient population. New and evolving risks must be evaluated and communicated rapidly to allow patients and physicians to be well informed and able to share treatment decisions. © The Author(s) 2013.

Treatment of hypophosphatemia in the intensive care unit: a review

PubMed Central

2010-01-01

Introduction Currently no evidence-based guideline exists for the approach to hypophosphatemia in critically ill patients. Methods We performed a narrative review of the medical literature to identify the incidence, symptoms, and treatment of hypophosphatemia in critically ill patients. Specifically, we searched for answers to the questions whether correction of hypophosphatemia is associated with improved outcome, and whether a certain treatment strategy is superior. Results Incidence: hypophosphatemia is frequently encountered in the intensive care unit; and critically ill patients are at increased risk for developing hypophosphatemia due to the presence of multiple causal factors. Symptoms: hypophosphatemia may lead to a multitude of symptoms, including cardiac and respiratory failure. Treatment: hypophosphatemia is generally corrected when it is symptomatic or severe. However, although multiple studies confirm the efficacy and safety of intravenous phosphate administration, it remains uncertain when and how to correct hypophosphatemia. Outcome: in some studies, hypophosphatemia was associated with higher mortality; a paucity of randomized controlled evidence exists for whether correction of hypophosphatemia improves the outcome in critically ill patients. Conclusions Additional studies addressing the current approach to hypophosphatemia in critically ill patients are required. Studies should focus on the association between hypophosphatemia and morbidity and/or mortality, as well as the effect of correction of this electrolyte disorder. PMID:20682049

Improving the efficacy of RAAS blockade in patients with chronic kidney disease.

PubMed

Lambers Heerspink, Hiddo J; de Borst, Martin H; Bakker, Stephan J L; Navis, Gerjan J

2013-02-01

Reduction of blood pressure and proteinuria by blockade of the renin-angiotensin-aldosterone system (RAAS) has been the cornerstone of renoprotective intervention for patients with chronic kidney disease (CKD) for many years. Despite the proven efficacy of RAAS blockade, however, the reduction in proteinuria is insufficient in many patients, and does not prevent further deterioration of renal function. Short-term studies have shown that a variety of treatment intensification strategies have a beneficial effect on blood pressure and proteinuria, including RAAS blockade using either dose escalation or multiple drugs, and restriction of dietary sodium. Large clinical trials have shown that RAAS blockade with multiple drugs does not improve patients' long-term renal or cardiovascular outcome. By contrast, two post-hoc analyses of landmark trials in nephrology show beneficial renal and cardiovascular effects from avoiding excessive dietary sodium intake during single-agent RAAS blockade therapy. The effects of dietary sodium restriction on renal or cardiovascular outcome still require prospective confirmation. However, current data support the implementation of lifestyle changes to reduce dietary sodium intake in combination with single-agent RAAS blockade, rather than dual-agent RAAS blockade, as a potent and feasible strategy to mitigate the burden of renal and cardiovascular disease in patients with CKD.

Switching to multiple daily injection therapy with glulisine improves glycaemic control, vascular damage and treatment satisfaction in basal insulin glargine-injected diabetic patients.

PubMed

Yanagisawa, Katsuyuki; Ashihara, Junya; Obara, Shinji; Wada, Norio; Takeuchi, Masayoshi; Nishino, Yuri; Maeda, Sayaka; Ishibashi, Yuji; Yamagishi, Sho-ichi

2014-11-01

Basal and bolus insulin therapy is required for strict blood control in diabetic patients, which could lead to prevention of vascular complications in diabetes. However, the optimal combination regimen is not well established. Fifty-nine diabetic patients (49 type 1 and 10 type 2; 52.9 ± 13.3 years old) whose blood glucose levels were uncontrolled (HbA1c  > 6.2%) by combination treatment of basal insulin glargine with multiple daily pre-meal injections of bolus short-acting insulin [aspart (n = 19), lispro (n = 37) and regular human insulin (n = 3)] for at least 8 weeks were enrolled in this study. We examined whether glycaemic control and vascular injury were improved by replacement of short-acting insulin with glulisine. Patient satisfaction was assessed with Diabetes Treatment Satisfaction Questionnaire. Although bolus and basal insulin doses were almost unchanged before and after replacement therapy, switching to glulisine insulin for 24 weeks significantly decreased level of HbA1c , advanced glycation end products (AGEs), soluble receptor for AGEs (sRAGE), monocyte chemoattractant protein-1 (MCP-1) and urinary albumin excretion. In multiple stepwise regression analysis, change in MCP-1 values from baseline (ΔMCP-1) was a sole determinant of log urinary albumin excretion. ΔAGEs and ΔsRAGE were independently correlated with each other. The relationship between ΔMCP-1 and ΔsRAGE was marginally significant (p = 0.05). Replacement of short-acting insulin by glulisine significantly increased Diabetes Treatment Satisfaction Questionnaire scores. Our present study suggests that combination therapy of glargine with multiple daily pre-meal injections of glulisine might show superior efficacy in controlling blood glucose, preventing vascular damage and improving treatment satisfaction in diabetic patients. Copyright © 2014 John Wiley & Sons, Ltd.

Developing dimensions for a multicomponent multidisciplinary approach to obesity management: a qualitative study.

PubMed

Cochrane, Anita J; Dick, Bob; King, Neil A; Hills, Andrew P; Kavanagh, David J

2017-10-16

There have been consistent recommendations for multicomponent and multidisciplinary approaches for obesity management. However, there is no clear agreement on the components, disciplines or processes to be considered within such an approach. In this study, we explored multicomponent and multidisciplinary approaches through an examination of knowledge, skills, beliefs, and recommendations of stakeholders involved in obesity management. These stakeholders included researchers, practitioners, educators, and patients. We used qualitative action research methods, including convergent interviewing and observation, to assist the process of inquiry. The consensus was that a multicomponent and multidisciplinary approach should be based on four central meta-components (patient, practitioner, process, and environmental factors), and specific components of these factors were identified. Psychologists, dieticians, exercise physiologists and general practitioners were nominated as key practitioners to be included. A complex condition like obesity requires that multiple components be addressed, and that both patients and multiple disciplines are involved in developing solutions. Implementing cycles of continuous improvement to deal with complexity, instead of trying to control for it, offers an effective way to deal with complex, changing multisystem problems like obesity.

Brain activation patterns elicited by the 'Faces Symbol Test' -- a pilot fMRI study.

PubMed

Grabner, Rh; Popotnig, F; Ropele, S; Neuper, C; Gorani, F; Petrovic, K; Ebner, F; Strasser-Fuchs, S; Fazekas, F; Enzinger, C

2008-04-01

The Faces Symbol Test (FST) has recently been proposed as a brief and patient-friendly screening instrument for the assessment of cognitive dysfunction in patients with multiple sclerosis (MS). However, in contrast to well-established MS screening tests such as the Paced Auditory Serial Addition Test, the neural correlates of the FST have not been investigated so far. In the present study, we developed a functional MRI (fMRI) version of the FST to provide first data on brain regions and networks involved in this test. A sample of 19 healthy participants completed a version of the FST adapted for fMRI, requiring matching of faces and symbols in a multiple choice test and two further experimental conditions drawing on cognitive subcomponents (face matching and symbol matching). Imaging data showed a differential involvement of a fronto-parieto-occipital network in the three conditions. The most demanding FST condition elicited brain activation patterns related with sustained attention and executive control. These results suggest that the FST recruits brain networks critical for higher-order cognitive functions often impaired in MS patients.

Unrecognized magic mushroom abuse in a 28-year-old man.

PubMed

McClintock, Ryan L; Watts, David J; Melanson, Scott

2008-10-01

A 28-year-old man with a history of drug and alcohol abuse presented multiple times to the hospital over 2 months with an elusive constellation of symptoms, resolving spontaneously in each instance. This patient required a high level of care for management and stabilization, including 3 emergency department visits, 2 medical floor admissions, and 1 intensive care unit admission. In both the emergency department and inpatient setting, all laboratory and imaging study results, including gas chromatography/mass spectrophotometry of the urine, were negative/normal. A definitive diagnosis eluded multiple emergency medicine, critical care, and consulting physicians. His symptoms included altered mental status, vomiting, diaphoresis, and mydriasis. The patient later admitted using mushrooms to a nurse. In the absence of confirmatory testing, but supported by exclusionary and anecdotal data, we believe that our patient's symptoms are consistent with Psilocybe mushroom toxicity. We feel that had this been considered initially, the correct diagnosis would have led to a better utilization of resources, and we want to remind emergency physicians of the possibility of mushroom abuse in any similar clinical setting.

Auditory decision aiding in supervisory control of multiple unmanned aerial vehicles.

PubMed

Donmez, Birsen; Cummings, M L; Graham, Hudson D

2009-10-01

This article is an investigation of the effectiveness of sonifications, which are continuous auditory alerts mapped to the state of a monitored task, in supporting unmanned aerial vehicle (UAV) supervisory control. UAV supervisory control requires monitoring a UAV across multiple tasks (e.g., course maintenance) via a predominantly visual display, which currently is supported with discrete auditory alerts. Sonification has been shown to enhance monitoring performance in domains such as anesthesiology by allowing an operator to immediately determine an entity's (e.g., patient) current and projected states, and is a promising alternative to discrete alerts in UAV control. However, minimal research compares sonification to discrete alerts, and no research assesses the effectiveness of sonification for monitoring multiple entities (e.g., multiple UAVs). The authors conducted an experiment with 39 military personnel, using a simulated setup. Participants controlled single and multiple UAVs and received sonifications or discrete alerts based on UAV course deviations and late target arrivals. Regardless of the number of UAVs supervised, the course deviation sonification resulted in reactions to course deviations that were 1.9 s faster, a 19% enhancement, compared with discrete alerts. However, course deviation sonifications interfered with the effectiveness of discrete late arrival alerts in general and with operator responses to late arrivals when supervising multiple vehicles. Sonifications can outperform discrete alerts when designed to aid operators to predict future states of monitored tasks. However, sonifications may mask other auditory alerts and interfere with other monitoring tasks that require divided attention. This research has implications for supervisory control display design.

Clinical and Radiologic Predictive Factors of Rib Fractures in Outpatients With Chest Pain.

PubMed

Zhang, Liang; McMahon, Colm J; Shah, Samir; Wu, Jim S; Eisenberg, Ronald L; Kung, Justin W

To identify the clinical and radiologic predictive factors of rib fractures in stable adult outpatients presenting with chest pain and to determine the utility of dedicated rib radiographs in this population of patients. Following Institutional Review Board approval, we performed a retrospective review of 339 consecutive cases in which a frontal chest radiograph and dedicated rib series had been obtained for chest pain in the outpatient setting. The frontal chest radiograph and dedicated rib series were sequentially reviewed in consensus by two fellowship-trained musculoskeletal radiologists blinded to the initial report. The consensus interpretation of the dedicated rib series was used as the gold standard. Multiple variable logistic regression analysis assessed clinical and radiological factors associated with rib fractures. Fisher exact test was used to assess differences in medical treatment between the 2 groups. Of the 339 patients, 53 (15.6%) had at least 1 rib fracture. Only 20 of the 53 (37.7%) patients' fractures could be identified on the frontal chest radiograph. The frontal chest radiograph had a sensitivity of 38% and specificity of 100% when using the rib series as the reference standard. No pneumothorax, new mediastinal widening or pulmonary contusion was identified. Multiple variable logistic regression analysis of clinical factors associated with the presence of rib fractures revealed a significant association of trauma history (odds ratio 5.7 [p < 0.05]) and age ≥40 (odds radio 3.1 [p < 0.05]). Multiple variable logistic regression analysis of radiographic factors associated with rib fractures in this population demonstrated a significant association of pleural effusion with rib fractures (odds ratio 18.9 [p < 0.05]). Patients with rib fractures received narcotic analgesia in 47.2% of the cases, significantly more than those without rib fractures (21.3%, p < 0.05). None of the patients required hospitalization. In the stable outpatient setting, rib fractures have a higher association with a history of minor trauma and age ≥40 in the adult population. Radiographic findings associated with rib fractures include pleural effusion. The frontal chest radiograph alone has low sensitivity in detecting rib fractures. The dedicated rib series detected a greater number of rib fractures. Although no patients required hospitalization, those with rib fractures were more likely to receive narcotic analgesia. Copyright © 2018 Elsevier Inc. All rights reserved.

service line analytics in the new era.

PubMed

Spence, Jay; Seargeant, Dan

2015-08-01

To succeed under the value-based business model, hospitals and health systems require effective service line analytics that combine inpatient and outpatient data and that incorporate quality metrics for evaluating clinical operations. When developing a framework for collection, analysis, and dissemination of service line data, healthcare organizations should focus on five key aspects of effective service line analytics: Updated service line definitions. Ability to analyze and trend service line net patient revenues by payment source. Access to accurate service line cost information across multiple dimensions with drill-through capabilities. Ability to redesign key reports based on changing requirements. Clear assignment of accountability.

AQBE — QBE Style Queries for Archetyped Data

NASA Astrophysics Data System (ADS)

Sachdeva, Shelly; Yaginuma, Daigo; Chu, Wanming; Bhalla, Subhash

Large-scale adoption of electronic healthcare applications requires semantic interoperability. The new proposals propose an advanced (multi-level) DBMS architecture for repository services for health records of patients. These also require query interfaces at multiple levels and at the level of semi-skilled users. In this regard, a high-level user interface for querying the new form of standardized Electronic Health Records system has been examined in this study. It proposes a step-by-step graphical query interface to allow semi-skilled users to write queries. Its aim is to decrease user effort and communication ambiguities, and increase user friendliness.

APD in the developing world: is there a future?

PubMed

Correa-Rotter, Ricardo

2002-01-01

Automated peritoneal dialysis (APD) has experienced significant growth in highly developed nations in the last few years, while in developing countries with important social, educational, and financial constraints this treatment modality is, at best, trying to emerge. APD offers advantages that make it popular. Some of these advantages include increased adequacy for some patient groups, enhanced patient well-being and positive changes in lifestyle, as well as a reduction in peritonitis rates attributed to fewer connect-disconnect procedures. The development of APD in developing nations has been very poor mainly due to educational and financial constraints. APD growth as a treatment modality in the developing world requires multiple approaches, some of them general and others related to the specific needs of each nation. There is a need to develop APD research projects and pilot programs to demonstrate the benefits for specific subpopulations. In addition, the development of research and industry-market strategies directed at reducing costs related to this form of treatment are required. The relatively low use of APD in developing nations is primarily influenced by nonmedical factors. Given the financial and educational constraints, APD programs may need to be directed toward specific subpopulations such as young working adults, individuals who require assistance to perform procedures, or patients who require an increased dialysis dose in order to reach adequate clearances.

Defining quality for distal pancreatectomy: does the laparoscopic approach protect patients from poor quality outcomes?

PubMed

Baker, Marshall S; Sherman, Karen L; Stocker, Susan; Hayman, Amanda V; Bentrem, David J; Prinz, Richard A; Talamonti, Mark S

2013-02-01

Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage a complication. Studies using these systems may misrepresent outcomes for the surgical procedures being evaluated. We define a quality outcome for distal pancreatectomy (DP) and use this metric to compare laparoscopic distal pancreatectomy (LDP) to open distal pancreatectomy (ODP). Records for patients undergoing DP between January 2006 and December 2009 were reviewed. Clavien-Dindo grade IIIb, IV, and V complications were classified as severe adverse--poor quality--postoperative outcomes (SAPOs). II and IIIa complications requiring either significantly prolonged overall lengths of stay including readmissions within 90 days or more than one invasive intervention were also classified as SAPOs. By Clavien-Dindo system alone, 91 % of DP patients had either no complication or a low/moderate grade (I, II, IIIa) complication. Using our reclassification, however, 25 % had a SAPO. Patients undergoing LDP demonstrated a Clavien-Dindo complication profile identical to that for SDP but demonstrated significantly shorter overall lengths of stay, were less likely to require perioperative transfusion, and less likely to have a SAPO. Established systems undergrade the severity of some complications following DP. Using a procedure-specific metric for quality, we demonstrate that LDP affords a higher quality postoperative outcome than ODP.

Uptake, Results, and Outcomes of Germline Multiple-Gene Sequencing After Diagnosis of Breast Cancer.

PubMed

Kurian, Allison W; Ward, Kevin C; Hamilton, Ann S; Deapen, Dennis M; Abrahamse, Paul; Bondarenko, Irina; Li, Yun; Hawley, Sarah T; Morrow, Monica; Jagsi, Reshma; Katz, Steven J

2018-05-10

Low-cost sequencing of multiple genes is increasingly available for cancer risk assessment. Little is known about uptake or outcomes of multiple-gene sequencing after breast cancer diagnosis in community practice. To examine the effect of multiple-gene sequencing on the experience and treatment outcomes for patients with breast cancer. For this population-based retrospective cohort study, patients with breast cancer diagnosed from January 2013 to December 2015 and accrued from SEER registries across Georgia and in Los Angeles, California, were surveyed (n = 5080, response rate = 70%). Responses were merged with SEER data and results of clinical genetic tests, either BRCA1 and BRCA2 (BRCA1/2) sequencing only or including additional other genes (multiple-gene sequencing), provided by 4 laboratories. Type of testing (multiple-gene sequencing vs BRCA1/2-only sequencing), test results (negative, variant of unknown significance, or pathogenic variant), patient experiences with testing (timing of testing, who discussed results), and treatment (strength of patient consideration of, and surgeon recommendation for, prophylactic mastectomy), and prophylactic mastectomy receipt. We defined a patient subgroup with higher pretest risk of carrying a pathogenic variant according to practice guidelines. Among 5026 patients (mean [SD] age, 59.9 [10.7]), 1316 (26.2%) were linked to genetic results from any laboratory. Multiple-gene sequencing increasingly replaced BRCA1/2-only testing over time: in 2013, the rate of multiple-gene sequencing was 25.6% and BRCA1/2-only testing, 74.4%;in 2015 the rate of multiple-gene sequencing was 66.5% and BRCA1/2-only testing, 33.5%. Multiple-gene sequencing was more often ordered by genetic counselors (multiple-gene sequencing, 25.5% and BRCA1/2-only testing, 15.3%) and delayed until after surgery (multiple-gene sequencing, 32.5% and BRCA1/2-only testing, 19.9%). Multiple-gene sequencing substantially increased rate of detection of any pathogenic variant (multiple-gene sequencing: higher-risk patients, 12%; average-risk patients, 4.2% and BRCA1/2-only testing: higher-risk patients, 7.8%; average-risk patients, 2.2%) and variants of uncertain significance, especially in minorities (multiple-gene sequencing: white patients, 23.7%; black patients, 44.5%; and Asian patients, 50.9% and BRCA1/2-only testing: white patients, 2.2%; black patients, 5.6%; and Asian patients, 0%). Multiple-gene sequencing was not associated with an increase in the rate of prophylactic mastectomy use, which was highest with pathogenic variants in BRCA1/2 (BRCA1/2, 79.0%; other pathogenic variant, 37.6%; variant of uncertain significance, 30.2%; negative, 35.3%). Multiple-gene sequencing rapidly replaced BRCA1/2-only testing for patients with breast cancer in the community and enabled 2-fold higher detection of clinically relevant pathogenic variants without an associated increase in prophylactic mastectomy. However, important targets for improvement in the clinical utility of multiple-gene sequencing include postsurgical delay and racial/ethnic disparity in variants of uncertain significance.

29 CFR 1926.1432 - Multiple-crane/derrick lifts-supplemental requirements.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 29 Labor 8 2011-07-01 2011-07-01 false Multiple-crane/derrick lifts-supplemental requirements... Cranes and Derricks in Construction § 1926.1432 Multiple-crane/derrick lifts—supplemental requirements... implementation. (1) The multiple-crane/derrick lift must be directed by a person who meets the criteria for both...

Impact of concomitant trauma in the management of blunt splenic injuries.

PubMed

Lo, Albert; Matheson, Anne-Marie; Adams, Dave

2004-09-10

Conservative management of isolated blunt splenic injuries has become widely accepted for haemodynamically stable patients, but may be untenable in those with multiple injuries. A retrospective review was performed to evaluate of our cumulative experience with non-operative management of splenic injuries, and to identify the risk factors for operative management. Eighty patients were identified. Demographics, mechanism of injury, injury severity score (ISS), clinical signs at presentation, utility of computed tomography scans and methods of treatment (operative management vs conservative management) were documented and statistically analysed to identify predictors for operative management. Initially, 45 patients (56%) were managed without operation, while 35 patients underwent urgent laparotomy - with 26 (74% in operative group) of these having splenectomy performed. Two patients (out of 45) failed conservative management and required delayed splenectomy, a 96% success rate for intended conservative management. Thus, overall rates of 54% non-operative management and 65% splenic conservation were achieved. The mean ISS of the operative management group (ISS=30) was higher than that of the non-operative treatment group (ISS=13, p<0.05), reflecting not only the grade of the splenic injury but also the severity of concomitant trauma. Risk factors for patients with blunt splenic injuries requiring operative management include ISS > or =16, hypotension, GCS < or =13, and requirement for blood transfusion (p<0.05). Appropriate patient selection is the most important element of non-operative management. Patients with splenic injuries who are haemodynamically stable can be managed non-operatively with acceptable outcome. However, in the presence of concomitant trauma, there is an increasing trend towards operative management.

Carotid and coronary disease management prior to open and endovascular aortic surgery. What are the current guidelines?

PubMed

Thompson, J P

2014-04-01

Several bodies produce broadly concurring and updated guidelines for the evaluation and treatment of cardiovascular disease in both surgical and non-surgical patients. Recent developments include revised recommendations on preoperative stress testing, referral for possible coronary revascularization and medical management. It is recognized that non-invasive cardiac tests are relatively poor at predicting perioperative risk, and "prophylactic" coronary revascularization has a limited role. The planned aortic intervention (open or endovascular repair) also influences preoperative management. Patients presenting for elective abdominal aortic aneurysm (AAA) repair should only be referred for cardiological testing if they have active symptoms of coronary artery disease (CAD), known CAD and poor functional exercise capacity, or multiple risk factors for CAD. Coronary revascularization before AAA surgery should be limited to patients with established indications, so cardiac stress testing should only be performed if it would change management i.e. the patient is a candidate for and would benefit from coronary revascularization. When endovascular aortic repair is planned, it is reasonable to proceed to surgery without further cardiac stress testing or evaluation unless otherwise indicated. All non-emergency patients require medical optimization, but perioperative beta blockade benefits only certain patients. Some of the data informing recent guidelines have been questioned and some guidelines are being revised. Current guidelines do not specifically address the management of patients with known or suspected carotid artery disease who may require aortic surgery. For these patients, an individualized approach is required. This review considers recent guidelines. Algorithms for investigation and management based on their recommendations are included.

Avianca flight No. 052 accident: a plastic surgical perspective.

PubMed

Greenberg, B M; Brewer, B W

1991-09-01

The crash of Avianca Airlines flight no. 052 en route to JFK Airport on January 25, 1990, in Cove Neck, New York, resulted in the death of 72 passengers. Eighty-nine victims were admitted to 13 regional hospitals. Despite difficult access to the wooded crash site, early warning and prompt response by 37 volunteer fire and rescue units resulted in organized EMS triage and rapid hospital transport. This report reviews the specific injuries incurred, highlights the team management approach to a major aviation accident in a suburban area, and studies the likelihood of accidents of this magnitude. Thirty-eight patients triaged to two level I trauma centers, North Shore University Hospital-Cornell University Medical Center and Nassau County Medical Center, form the basis of this report. Seventeen patients were male; 21 were female. The average patient age was 33 years. Eight patients were children. The average length of stay was 30.9 days (range 2 to greater than 90 days). Twenty-six patients (including nonsurvivors) (68 percent) sustained significant multiple orthopedic injuries. The majority of fractures were open grade II to III tibia-fibula fractures. Bilaterality was commonly seen. Soft-tissue coverage of open long bone fractures was required in 10 patients (11 extremities) and included 3 microvascular muscle transfers, 7 muscle transposition flaps, and 3 skin grafts. Seven patients required open reduction and fixation of complex facial fractures (two of Le Fort II to III type, four of complex naso-orbital-ethmoid type). Plastic surgical repair of complex lacerations was common. Peripheral nerve exploration was required in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute and critical care management of a pediatric patient with medullo-cerebellar impaling.

PubMed

Sherr, Gregory T; Beal, Alan; Irwin, Eric; Roach, Robert; Dyste, Gregg

2009-09-01

The authors present a child with an accidental cervical medullo-cerebellar impaling by an aluminum rod. Careful planning for safe removal of the rod as well as vigilant attention to early cardiac instability and flash neurogenic pulmonary edema were paramount to her successful recovery. This patient illustrates that it is possible to survive impaling of the brainstem but it requires both innovation and collaboration by multiple specialists across different departments. The value of well coordinated and collaborative neuro surgical intensive care is demonstrated in this young girl's nearly complete recovery from the accident.

Ileocolic perforation secondary to sodium polystyrene sulfonate in sorbitol use: A case report

PubMed Central

Trottier, Vincent; Drolet, Sébastien; Morcos, Mohib W

2009-01-01

Hyperkalemia is a common condition encountered in medical and surgical patients. It can lead to various complications including cardiac arrhythmias. Sodium polystyrene sulfonate (SPS) in sorbitol is an ion-exchange resin that can be used to treat hyperkalemia. It can be used in enema or in oral form. The present article describes the case of an intensive care unit patient who experienced severe, diffuse, intestinal perforation induced by the use of SPS-sorbitol, requiring multiple laparotomies, followed by a brief review of the relevant literature and recommendations regarding the use of SPS-sorbitol. PMID:19826644

[Echinocandins: searching for differences. The example of their use in patients requiring continuous renal replacement therapy].

PubMed

de la Llama-Celis, Natalia; Huarte-Lacunza, Rafael; Gómez-Baraza, Cristina; Cañamares-Orbis, Iciar; Sebastián-Aldeanueva, Manuel; Arrieta-Navarro, Raquel

2012-12-01

The echinocandins have a growing role in the treatment of fungal infections because of their novel mechanism of action. This is reflected in recently published management guidelines, but available in vitro data, animal studies, and clinical studies do not clearly differentiate the three agents in class. Comparative clinical efficacy among agents within the class, pharmacokinetic profiles in special populations, pharmacoeconomics justifications, and place in therapy have been largely unanswered. They share many common properties but marketing strategies of drug manufacturers are engaged in product differentiation. Although exist similarities in the pharmacokinetic (PK) profiles of the echinocandins, limited data have been published regarding their pharmacokinetics in continuous renal replacement therapy (CRRT) patients. The pharmacokinetics of drug removal in critically ill patients receiving CRRT is very complex, with multiple variables affecting clearance. This review outlines the basic principles that determine whether a dose adjustment is required. Two studies with data on PK parameters of micafungin and anidulafungin in CRRT patients have been published and are compared following that basic principles in the review.

Design of admission medication reconciliation technology: a human factors approach to requirements and prototyping.

PubMed

Lesselroth, Blake J; Adams, Kathleen; Tallett, Stephanie; Wood, Scott D; Keeling, Amy; Cheng, Karen; Church, Victoria L; Felder, Robert; Tran, Hanna

2013-01-01

Our objectives were to (1) develop an in-depth understanding of the workflow and information flow in medication reconciliation, and (2) design medication reconciliation support technology using a combination of rapid-cycle prototyping and human-centered design. Although medication reconciliation is a national patient safety goal, limitations both of physical environment and in workflow can make it challenging to implement durable systems. We used several human factors techniques to gather requirements and develop a new process to collect a medication history at hospital admission. We completed an ethnography and time and motion analysis of pharmacists in order to illustrate the processes used to reconcile medications. We then used the requirements to design prototype multimedia software for collecting a bedside medication history. We observed how pharmacists incorporated the technology into their physical environment and documented usability issues. Admissions occurred in three phases: (1) list compilation, (2) order processing, and (3) team coordination. Current medication reconciliation processes at the hospital average 19 minutes to complete and do not include a bedside interview. Use of our technology during a bedside interview required an average of 29 minutes. The software represents a viable proof-of-concept to automate parts of history collection and enhance patient communication. However, we discovered several usability issues that require attention. We designed a patient-centered technology to enhance how clinicians collect a patient's medication history. By using multiple human factors methods, our research team identified system themes and design constraints that influence the quality of the medication reconciliation process and implementation effectiveness of new technology. Evidence-based design, human factors, patient-centered care, safety, technology.

Narrative writing: Effective ways and best practices

PubMed Central

Ledade, Samir D.; Jain, Shishir N.; Darji, Ankit A.; Gupta, Vinodkumar H.

2017-01-01

A narrative is a brief summary of specific events experienced by patients, during the course of a clinical trial. Narrative writing involves multiple activities such as generation of patient profiles, review of data sources, and identification of events for which narratives are required. A sponsor outsources narrative writing activities to leverage the expertise of service providers which in turn requires effective management of resources, cost, time, quality, and overall project management. Narratives are included as an appendix to the clinical study report and are submitted to the regulatory authorities as a part of dossier. Narratives aid in the evaluation of the safety profile of the investigational drug under study. To deliver high-quality narratives within the specified timeframe to the sponsor can be achieved by standardizing processes, increasing efficiency, optimizing working capacity, implementing automation, and reducing cost. This paper focuses on effective ways to design narrative writing process and suggested best practices, which enable timely delivery of high-quality narratives to fulfill the regulatory requirement. PMID:28447014

Narrative writing: Effective ways and best practices.

PubMed

Ledade, Samir D; Jain, Shishir N; Darji, Ankit A; Gupta, Vinodkumar H

2017-01-01

A narrative is a brief summary of specific events experienced by patients, during the course of a clinical trial. Narrative writing involves multiple activities such as generation of patient profiles, review of data sources, and identification of events for which narratives are required. A sponsor outsources narrative writing activities to leverage the expertise of service providers which in turn requires effective management of resources, cost, time, quality, and overall project management. Narratives are included as an appendix to the clinical study report and are submitted to the regulatory authorities as a part of dossier. Narratives aid in the evaluation of the safety profile of the investigational drug under study. To deliver high-quality narratives within the specified timeframe to the sponsor can be achieved by standardizing processes, increasing efficiency, optimizing working capacity, implementing automation, and reducing cost. This paper focuses on effective ways to design narrative writing process and suggested best practices, which enable timely delivery of high-quality narratives to fulfill the regulatory requirement.

Incorporating medication indications into the prescribing process.

PubMed

Kron, Kevin; Myers, Sara; Volk, Lynn; Nathan, Aaron; Neri, Pamela; Salazar, Alejandra; Amato, Mary G; Wright, Adam; Karmiy, Sam; McCord, Sarah; Seoane-Vazquez, Enrique; Eguale, Tewodros; Rodriguez-Monguio, Rosa; Bates, David W; Schiff, Gordon

2018-04-19

The incorporation of medication indications into the prescribing process to improve patient safety is discussed. Currently, most prescriptions lack a key piece of information needed for safe medication use: the patient-specific drug indication. Integrating indications could pave the way for safer prescribing in multiple ways, including avoiding look-alike/sound-alike errors, facilitating selection of drugs of choice, aiding in communication among the healthcare team, bolstering patient understanding and adherence, and organizing medication lists to facilitate medication reconciliation. Although strongly supported by pharmacists, multiple prior attempts to encourage prescribers to include the indication on prescriptions have not been successful. We convened 6 expert panels to consult high-level stakeholders on system design considerations and requirements necessary for building and implementing an indications-based computerized prescriber order-entry (CPOE) system. We summarize our findings from the 6 expert stakeholder panels, including rationale, literature findings, potential benefits, and challenges of incorporating indications into the prescribing process. Based on this stakeholder input, design requirements for a new CPOE interface and workflow have been identified. The emergence of universal electronic prescribing and content knowledge vendors has laid the groundwork for incorporating indications into the CPOE prescribing process. As medication prescribing moves in the direction of inclusion of the indication, it is imperative to design CPOE systems to efficiently and effectively incorporate indications into prescriber workflows and optimize ways this can best be accomplished. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Anticholinergics and Central Nervous System Effects: Are We Confused?

PubMed Central

Staskin, David R; Zoltan, Edward

2007-01-01

The central nervous system (CNS) effects of anticholinergic agents have been documented in various patient populations and to varying degrees in case reports, brain-activity surrogates, and computerized cognitive testing. The older patient population with overactive bladder represents a group at increased risk of cognitive impairment and other CNS side effects associated with antimuscarinic agents. The complexity of the effect of anticholinergic agents on CNS function requires an increased level of careful investigation. Studies need to be performed in the at-risk population with multiple, validated tests at clinically prescribed doses in acute and chronic situations. These studies need to take into account the effect of commonly prescribed dosing regimens, with doses selected to represent with equivalent bladder potency. The alterations in the serum levels and parent/metabolite effects contributed by metabolic issues or drug delivery systems require special attention. PMID:18231615

Somnambulism: Emergency Department Admissions Due to Sleepwalking-Related Trauma.

PubMed

Sauter, Thomas C; Veerakatty, Sajitha; Haider, Dominik G; Geiser, Thomas; Ricklin, Meret E; Exadaktylos, Aristomenis K

2016-11-01

Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and no published investigations on the epidemiology or trauma patterns associated with somnambulism. We included all emergency department (ED) admissions to University Hospital Inselspital, Berne, Switzerland, from January 1, 2000, until August 11, 2015, when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included. Of 620,000 screened ED admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known non-rapid eye movement parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died. Although sleepwalking seems benign in the majority of cases and most of the few injured patients did not require hospitalization, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism.

Somnambulism: Emergency Department Admissions Due to Sleepwalking-Related Trauma

PubMed Central

Sauter, Thomas C.; Veerakatty, Sajitha; Haider, Dominik G.; Geiser, Thomas; Ricklin, Meret E.; Exadaktylos, Aristomenis K.

2016-01-01

Introduction Somnambulism is a state of dissociated consciousness, in which the affected person is partially asleep and partially awake. There is pervasive public opinion that sleepwalkers are protected from hurting themselves. There have been few scientific reports of trauma associated with somnambulism and no published investigations on the epidemiology or trauma patterns associated with somnambulism. Methods We included all emergency department (ED) admissions to University Hospital Inselspital, Berne, Switzerland, from January 1, 2000, until August 11, 2015, when the patient had suffered a trauma associated with somnambulism. Demographic data (age, gender, nationality) and medical data (mechanism of injury, final diagnosis, hospital admission, mortality and medication on admission) were included. Results Of 620,000 screened ED admissions, 11 were associated with trauma and sleepwalking. Two patients (18.2%) had a history of known non-rapid eye movement parasomnias. The leading cause of admission was falls. Four patients required hospital admission for orthopedic injuries needing further diagnostic testing and treatment (36.4%). These included two patients with multiple injuries (18.2%). None of the admitted patients died. Conclusion Although sleepwalking seems benign in the majority of cases and most of the few injured patients did not require hospitalization, major injuries are possible. When patients present with falls of unknown origin, the possibility should be evaluated that they were caused by somnambulism. PMID:27833677

Licensing Surrogate Decision-Makers.

PubMed

Rosoff, Philip M

2017-06-01

As medical technology continues to improve, more people will live longer lives with multiple chronic illnesses with increasing cumulative debilitation, including cognitive dysfunction. Combined with the aging of society in most developed countries, an ever-growing number of patients will require surrogate decision-makers. While advance care planning by patients still capable of expressing their preferences about medical interventions and end-of-life care can improve the quality and accuracy of surrogate decisions, this is often not the case, not infrequently leading to demands for ineffective, inappropriate and prolonged interventions. In 1980 LaFollette called for the licensing of prospective parents, basing his argument on the harm they can do to vulnerable people (children). In this paper, I apply his arguments to surrogate decision-makers for cognitively incapacitated patients, rhetorically suggesting that we require potential surrogates to qualify for this position by demonstrating their ability to make reasonable and rational decisions for others. I employ this theoretical approach to argue that the loose criteria by which we authorize surrogates' generally unchallenged power should be reconsidered.

Hemangiopericytoma of the maxilla in a pediatric patient: a case report.

PubMed

Anand, Rohit; Gupta, Sonal

2010-01-01

The hemangiopericytoma is a malignant vascular tumor arising from mesenchymal cells with pericytic differentiation. Hemangiopericytoma is most commonly seen in adults, and only 5% to 10% of cases occur in children. The tumor is extremely rare in the head and neck region (16%). Cytogenic abnormalities have been present in some hemangiopericytoma cases. Surgical resection remains the mainstay treatment. Adjuvant chemotherapy and radiotherapy is appropriate for cases of incomplete resections and life-threatening tumors particularly in children. Late relapses may occur and require long-term follow-up. A 4-year-old child patient with hemangiopericytoma of the maxilla presented with firm, recurrent, but painless jaw mass. Radiographic investigations revealed a poorly circumscribed radiolucency. The lesion biopsy showed wellcircumscribed multiple lobules of tumor mass consisting of tightly packed, spindleshaped cells. Chemotherapy and radiotherapy of the lesion was conducted. The role of the pediatric dental team is extensive in children with hemangiopericytoma, who require a regular dental review. The patient's oncologist should be immediately contacted if there is any suspicion of recurrence.

Hemangiopericytoma of maxilla in a pediatric patient: a case report.

PubMed

Anand, Rohit; Gupta, Sonal

2010-01-01

The Hemangiopericytoma is a malignant vascular tumor arising from mesenchymal cells with pericytic differentiation. Hemangiopericytoma is most commonly seen in adults, and only 5% to 10% of cases occur in children. The tumor is extremely rare in the head and neck region (16%)1. Cytogenic abnormalities have been present in some hemangiopericytoma cases. Surgical resection remains the mainstay treatment. Adjuvant chemotherapy and radiotherapy is appropriate for cases of incomplete resections and life-threatening tumors particularly in children. Late relapses may occur and require long-term follow-up. A 4-year-old child patient with hemangiopericytoma of the maxilla presented with firm, recurrent, but painless jaw mass. Radiographic investigations revealed a poorly circumscribed radiolucency. The lesion biopsy showed well-circumscribed multiple lobules of tumor mass consisting of tightly packed, spindle-shaped cells. Chemotherapy and radiotherapy of the lesion was conducted. The role of the pediatric dental team is extensive in children with hemangiopericytoma, who require a regular dental review. The patient's oncologist should be immediately contacted if there is any suspicion of recurrence.

Glaucoma filtration surgery following sustained elevation of intraocular pressure secondary to intravitreal anti-VEGF injections.

PubMed

Skalicky, Simon E; Ho, Ivan; Agar, Ashish; Bank, Allan

2012-07-01

To document cases of sustained elevation of intraocular pressure (IOP) while receiving intravitreal anti-vascular endothelial growth factor (VEGF) agents and subsequent management. A retrospective series of all cases managed by the authors and colleagues was performed. Six patients developed sustained elevated IOP; five received ranibizumab and one bevacizumab. Four received unilateral and two received bilateral injections. Two had preexisting primary open-angle glaucoma and one had pseudoexfoliative glaucoma, all with stable IOP prior to anti-VEGF treatment. Angles were open in all cases. Peak IOP averaged 43 mm Hg (range: 34 to 60 mm Hg). The mean number of injections preceding the IOP increase was 10 (range: 1 to 20). Four patients required trabeculectomy, one selective laser trabeculoplasty, and one multiple topical medications. A sustained increase in IOP requiring glaucoma filtering surgery is a rare but important treatment complication for patients receiving intravitreal anti-VEGF therapy, especially those with preexisting glaucoma or glaucoma risk factors. Copyright 2012, SLACK Incorporated.

A review of recent literature - nurse case managers in diabetes care: equivalent or better outcomes compared to primary care providers.

PubMed

Watts, Sharon A; Lucatorto, Michelle

2014-07-01

Primary care has changed remarkably with chronic disease burden growth. Nurse case managers assist with this chronic disease by providing if not significantly better care, than equivalent care to that provided by usual primary care providers. Chronic disease management requires patient-centered skills and tools, such as registries, panel management, review of home data, communicating with patients outside of face-to-face care, and coordinating multiple services. Evidence reviewed in this article demonstrates that registered nurse care managers (RNCM) perform many actions required for diabetes chronic disease management including initiation and titration of medications with similar or improved physiologic and patient satisfaction outcomes over usual care providers. Selection and training of the nurse case managers is of utmost importance for implementation of a successful chronic disease management program. Evidence based guidelines, algorithms, protocols, and adequate ongoing education and mentoring are generally cited as necessary support tools for the nurse case managers.

Contemporary update on the treatment of dog bite: injuries to the oral and maxillofacial region.

PubMed

Foster, Michael D; Hudson, John W

2015-05-01

The purpose of the present retrospective record review was to evaluate the patient demographics, treatment rendered, and long-term outcomes of patients injured in dog bite attacks to the oral and maxillofacial region. In the present study, a retrospective medical record review was conducted of patients treated by the oral and maxillofacial surgery department at the University of Tennessee Medical Center who had presented with injuries to the head, neck, and face region from dog bite attacks from February 1, 2006 to October 31, 2013. Each patient included had to have had at least 1 follow-up visit. The data obtained from the patients' medical records included patient demographics, event details, injuries sustained, and treatment rendered and analyzed. The medical records from 20 patients were included and reviewed. More than one half (60%) of the patients were younger than 12 years old. The dog was owned by the patient or a relative in 58% of the cases. The children sustained injuries requiring hospital admission and repair in an operating room setting more often than did the adults. Pit bulls were more frequently associated with injuries than other breeds (9 of 20). Our patients required a total of 28 hospital inpatient days, 29 total procedures, and follow-up treatment for up to 2 years. Our review has shown the complexity of soft tissue injury treatment and the significant financial impact associated with dog bite injuries owing to the multiple hospital admissions, surgical revisions, and lengthy follow-up period required. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

High-grade vulval intraepithelial neoplasia (VIN 3): a retrospective analysis of patient characteristics, management, outcome and relationship to squamous cell carcinoma of the vulva 1989-1999.

PubMed

Sykes, Peter; Smith, Natasha; McCormick, Peter; Frizelle, Frank A

2002-02-01

To determine patient and disease characteristics, treatment patterns and long-term outcomes, in order to help direct management of patients with VIN 3, to examine the risk of development of cancer following a diagnosis of VIN 3 and the risk of recurrent disease requiring multiple treatment episodes, and to review patients with vulval cancer, in order to establish the relative prevalence of VIN 3 related vulval cancers. Retrospective chart review of 65 consecutive patients diagnosed with VIN 3 between 1989 and 1999. All patients diagnosed with VIN 3 at Christchurch Womens' Hospital (1 January 1989 to 31 December 1999) and Dunedin Public Hospital (1 January 1990 to 31 December 1999). Age at diagnosis, symptoms, medical history disease characteristics, treatment, outcome and follow-up. The median age at diagnosis was 38 years. Smokers were younger than non-smokers. Two-thirds had associated dysplasia of the lower genital tract, 43% had high-grade lesions. Seventy-nine per cent were symptomatic for a median of 9.5 months. All had macroscopically visible disease. Colposcopy and histology diagnoses correlated in 72% of cases. Treatment by local excision was undertaken in 84% of cases of which 65% had involved margins. Fifty-one per cent required further treatment, risk factors were positive margins and multifocal disease. Three developed micro-invasive cancer. Treatment by local excision is both diagnostic and therapeutic. Excision may reveal micro-invasive cancer, patients are usually symptomatic and VIN 3 has some potential to become invasive. Treated patients may develop microinvasive disease but frank invasion was not seen. The true rate of malignant progression in untreated patients remains unclear and radical surgery is rarely indicated. All patients require long-term follow up.

Can disease management target patients most likely to generate high costs? The impact of comorbidity.

PubMed

Charlson, Mary; Charlson, Robert E; Briggs, William; Hollenberg, James

2007-04-01

Disease management programs are increasingly used to manage costs of patients with chronic disease. We sought to examine the clinical characteristics and measure the health care expenditures of patients most likely to be targeted by disease management programs. Retrospective analysis of prospectively obtained data. A general medicine practice with both faculty and residents at an urban academic medical center. Five thousand eight hundred sixty-one patients enrolled in the practice for at least 1 year. Annual cost of diseases targeted by disease management. Patients' clinical and demographic information were collected from a computer system used to manage patients. Data included diagnostic information, medications, and resource usage over 1 year. We looked at 10 common diseases targeted by disease management programs. Unadjusted annual median costs for chronic diseases ranged between $1,100 and $1,500. Congestive heart failure ($1,500), stroke ($1,500), diabetes ($1,500), and cancer ($1,400) were the most expensive. As comorbidity increased, annual adjusted costs increased exponentially. Those with comorbidity scores of 2 or more accounted for 26% of the population but 50% of the overall costs. Costs for individual chronic conditions vary within a relatively narrow range. However, the costs for patients with multiple coexisting medical conditions increase rapidly. Reducing health care costs will require focusing on patients with multiple comorbid diseases, not just single diseases. The overwhelming impact of comorbidity on costs raises significant concerns about the potential ability of disease management programs to limit the costs of care.

Allergic proctocolitis refractory to maternal hypoallergenic diet in exclusively breast-fed infants: a clinical observation.

PubMed

Lucarelli, Sandra; Di Nardo, Giovanni; Lastrucci, Ginevra; D'Alfonso, Ylenia; Marcheggiano, Adriana; Federici, Tatiana; Frediani, Simone; Frediani, Tullio; Cucchiara, Salvatore

2011-07-16

Allergic proctocolitis (APC) in exclusively breast-fed infants is caused by food proteins, deriving from maternal diet, transferred through lactation. In most cases a maternal cow milk-free diet leads to a prompt resolution of rectal bleeding, while in some patients a multiple food allergy can occur. The aim of this study was to assess whether the atopy patch test (APT) could be helpful to identify this subgroup of patients requiring to discontinue breast-feeding due to polisensitization. Additionally, we assessed the efficacy of an amino acid-based formula (AAF) when multiple food allergy is suspected. amino acid-based formula We have prospectively enrolled 14 exclusively breast-fed infants with APC refractory to maternal allergen avoidance. The diagnosis was confirmed by endoscopy with biopsies. Skin prick tests and serum specific IgE for common foods, together with APTs for common foods plus breast milk, were performed. After a 1 month therapy of an AAF all patients underwent a follow-up rectosigmoidoscopy. Prick tests and serum specific IgE were negative. APTs were positive in 100% infants, with a multiple positivity in 50%. Sensitization was found for breast milk in 100%, cow's milk (50%), soy (28%), egg (21%), rice (14%), wheat (7%). Follow-up rectosigmoidoscopy confirmed the remission of APC in all infants. These data suggest that APT might become a useful tool to identify subgroups of infants with multiple gastrointestinal food allergy involving a delayed immunogenic mechanism, with the aim to avoid unnecessary maternal dietary restrictions before discontinuing breast-feeding.

Physician and nurse relationships, a key to patient safety.

PubMed

Benner, Annalisa B

2007-04-01

A negative or intimidating relationship between a physician and a nurse can create a situation that puts the patient at risk. There are four areas in which communication between these groups affect patient safety and physician liability. Multiple studies have revealed that nurses who are intimidated by physicians do not contact the care provider as quickly for a patient condition change or consult with the physician as readily to clarify a medication order. Patients will be put at risk if there are not enough nurses to staff hospitals. The nursing shortage will become a greater issue as the current nursing workforce ages. The average age of a nurse in Kentucky is 44 years old. To avoid a serious nursing shortage there is a need to fill the open positions left by retiring nursing staff. Attracting the new graduates will require a positive, healthy working environment. If a course of treatment is challenged by the courts, a solid partner relationship between a physician and a nurse puts the physician in a stronger position. There are multiple organizations that have developed suggested actions that will encourage a healthy working relationship with better communication between physicians and nurses. Collaboration between physicians, nurses, and hospital administrators is the only way a healthy work environment will be attained. It is the responsibility of each group to begin the conversations that will improve this patient safety barrier.

Spinal cord injury following operative shoulder intervention: A case report.

PubMed

Cleveland, Christine; Walker, Heather

2015-07-01

Cervical myelopathy is a spinal cord dysfunction that results from extrinsic compression of the spinal cord, its blood supply, or both. It is the most common cause of spinal cord dysfunction in patients greater than 55 years of age. A 57-year-old male with right shoulder septic arthritis underwent surgical debridement of his right shoulder and sustained a spinal cord injury intraoperatively. The most likely etiology is damage to the cervical spinal cord during difficult intubation requiring multiple attempts in this patient with underlying asymptomatic severe cervical stenosis. Although it is not feasible to perform imaging studies on all patients undergoing intubation for surgery, this patient's outcome would suggest consideration of inclusion of additional pre-surgical screening examination techniques, such as testing for a positive Hoffman's reflex, is appropriate to detect asymptomatic patients who may have underlying cervical stenosis.

The role of ICP monitoring in patients with persistent cerebrospinal fluid leak following spinal surgery: a case series.

PubMed

Craven, Claudia; Toma, Ahmed K; Khan, Akbar A; Watkins, Laurence D

2016-09-01

Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A disturbance in the underlying CSF dynamics could be the causative factor in a small group of patients with refractory CSF leaks that require multiple surgical repairs and prolonged hospital admission. A retrospective case series of patients with persistent post spinal surgery CSF leak referred to the hydrocephalus service for continuous intracranial pressure (ICP) monitoring. Patients' notes were reviewed for medical history, ICP data, radiological data, and subsequent management and outcome. Five patients (two males/three females, mean age, 35.4 years) were referred for ICP monitoring over a 12-month period. These patients had prolonged CSF leak despite multiple repair attempts 252 ± 454 days (mean ± SD). On ICP monitoring, all five patients had abnormal results, with the mean ICP 8.95 ± 4.41 mmHg. Four had abnormal pulse amplitudes, mean 6.15 mmHg ± 1.22 mmHg. All five patients underwent an intervention. Three patients underwent insertion of ventriculoperitoneal (VP) shunts. One patient had venous sinus stent insertion and one patient underwent medical management with acetazolamide. All five of the patients' CSF leak resolved post intervention. The mean time to resolution of CSF leak post intervention was 10.8  ± 12.9 days. Abnormal cerebrospinal fluid dynamics could be the underlying factor in patients with a persistent and treatment-refractory CSF leak post spinal surgery. Treatments aimed at lowering ICP may be beneficial in this group of patients. Whether abnormal pressure and dynamics represent a pre-existing abnormality or is induced by spinal surgery should be a subject of further study.

"My love-hate relationship": Ethical issues associated with nurses' interactions with industry.

PubMed

Grundy, Quinn

2014-08-01

Ethical issues associated with nurses' interactions with industry have implications for the safety, quality, and cost of healthcare. To date, little work has explored nurse-industry interactions and their associated ethical issues empirically. A phenomenological study was conducted to explore registered nurses' interactions with industry in clinical practice. Five registered nurses working in direct patient care were recruited and individual, in-depth interviews were conducted. The University's Committee on Human Research approved the study. Nurses frequently interacted with industry in their practice and felt ambivalent about these interactions. Nurses described systemic cuts to multiple "goods" central to nursing practice, including patient support, but paradoxically relied on industry resources to deliver these "goods." They relied on a particular conception of trust to navigate these interactions but were left to do so individually on the basis of their experience. Conflicts of interest arose as a result of multiple competing interests, and were frequently mediated through nurses' superiors. Nursing as a profession requires a guiding narrative to aid nurses in interpreting and navigating interactions with industry. A conception of trust that incorporates both the work of caring and attention to social justice could form the basis of these interactions, but would require that nursing take a much more critical stance toward marketing interactions. © The Author(s) 2013.

Combined use of flexible ureteroscopic lithotripsy with micro-percutaneous nephrolithotomy in pediatric multiple kidney stones.

PubMed

Li, Jun; Wang, Wenying; Du, Yuan; Tian, Ye

2018-03-28

We investigated the clinical value of treating pediatric multiple kidney stones with extensive distribution using flexible ureteroscopic lithotripsy (FUL) combined with micro-percutaneous nephrolithotomy (micro-PNL). In total, 21 pediatric patients with multiple renal calculi between May 2016 and June 2017 received FUL combined with micro-PNL. The group included 13 boys and eight girls; the patients' mean age was 3.8 years (range 1-8 years). The maximum stone diameter ranged from 1.0 to 1.5 cm. FUL was first performed in the lithotomy position to fragment stones that were located in the renal pelvis, and upper and mid-renal calyx. Patients were then moved to a prone position, and micro-PNL was performed to treat lower pole stones that could not be reached by the flexible ureteroscope during FUL. Percutaneous renal access to the lower calyx was achieved using a 4.8F "all-seeing needle" with ultrasound guidance, and stone fragmentation was performed with a 200-μm holmium laser at different settings to disintegrate 1- to 2-mm fragments. All 21 pediatric patients with multiple kidney stones underwent combined FUL and micro-PNL. The stone free rate (SFR) was 85.7% (18/21). The mean surgical time was 45 min (range 30-70 min). The mean volume of irrigation fluid used was 480 mL (range 300-1200 mL). The mean surgical time for FUL and micro-PNL was 31 min and 14 min, respectively, and the mean volume of fluid used for FUL and micro-PNL was 360 mL and 120 mL, respectively. According to the modified Clavien classification, grade 1 and 2 postoperative complications occurred in five and one patients, respectively. The mean decrease in the level of hemoglobin was 0.4 g/dL (0-0.7 g/dL), and no patients required a transfusion. The average hospital stay was 3 days (range 2-5 days). Combined FUL and micro-PNL is a safe, effective, and minimally invasive operation to remove multiple renal calculi with extensive distribution in children in selected cases. Copyright © 2018 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

A preliminary study of painless and effective transdermal botulinum toxin A delivery by jet nebulization for treatment of primary hyperhidrosis.

PubMed

Iannitti, Tommaso; Palmieri, Beniamino; Aspiro, Anna; Di Cerbo, Alessandro

2014-01-01

Hyperhidrosis is a chronic disease characterized by increased sweat production. Local injections of botulinum toxin A (BTX-A) have been extensively used for treatment of primary hyperhidrosis (idiopathic). The current treatment for this condition involves several intradermal injections, resulting in poor patient compliance due to injection-related pain. Therefore, new protocols, including an improved anesthetic regimen, are required. We designed the present study to determine whether JetPeel™-3, a medical device used for transdermal delivery of drugs by jet nebulization, could be used to deliver lidocaine prior to the standard multiple BTX-A injections or deliver lidocaine together with BTX-A in order to determine the protocol giving better results in terms of procedure-related pain, sweating, and patient satisfaction in subjects affected by primary axillary, palmar or plantar hyperhidrosis. Twenty patients with a visual analog scale (VAS) sweating score ≥ 8 cm were randomized to receive lidocaine 2% (5 mL) delivered by JetPeel™-3 followed by multiple injections of BTX-A (100 units) or lidocaine 2% (5 mL) and BTX-A (50 units) delivered together by JetPeel™-3. Effect of treatment on sweating was measured by VAS (0= minimum sweating; 10= maximum sweating) at 3-month follow-up. Pain induced by the procedure was assessed by VAS (0= minimum pain; 10= maximum pain) immediately after the procedure. Patient satisfaction was assessed at 3-month follow-up using a 5-point scale (1= not at all satisfied; 2= not satisfied; 3= partially satisfied; 4= satisfied; 5= highly satisfied). Both treatment modalities reduced sweating at 3-month follow-up, if compared with baseline (all P<0.001). Delivery of lidocaine and BTX-A by JetPeel™-3 resulted in lower procedure-related pain and reduced sweating, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (all P<0.001). Patient satisfaction with the procedure was higher in the group receiving lidocaine and BTX-A treatment by JetPeel™-3, if compared with lidocaine delivered by JetPeel™-3 followed by multiple BTX-A injections (P<0.001). No side effects were observed in both groups. Lidocaine and BTX-A can be safely delivered together by JetPeel™-3 to treat primary palmar, plantar and axillary hyperhidrosis, resulting in lower procedure-related pain, improved sweating and higher patient satisfaction, if compared with lidocaine delivered by JetPeel™-3 followed by standard BTX-A injection therapy. Our protocol delivering lidocaine and BTX-A together by JetPeel™-3 requires a reduced quantity of BTX-A, further supporting the use of the transdermal drug delivery by jet nebulization over standard injection therapy for treatment of primary hyperhidrosis.

How I treat transfusional iron overload.

PubMed

Hoffbrand, A Victor; Taher, Ali; Cappellini, Maria Domenica

2012-11-01

Patients with β-thalassemia major (TM) and other refractory anemias requiring regular blood transfusions accumulate iron that damages the liver, endocrine system, and most importantly the heart. The prognosis in TM has improved remarkably over the past 10 years. This improvement has resulted from the development of magnetic resonance imaging (MRI) techniques, especially T2*, to accurately measure cardiac and liver iron, and from the availability of 3 iron-chelating drugs. In this article we describe the use of MRI to determine which adult and pediatric patients need to begin iron chelation therapy and to monitor their progress. We summarize the properties of each of the 3 drugs, deferoxamine (DFO), deferiprone (DFP), and deferasirox (DFX), including their efficacy, patient acceptability, and side effects. We describe when to initiate or intensify therapy, switch to another drug, or use combined therapy. We also discuss the management of refractory anemias other than TM that may require multiple blood transfusions, including sickle cell anemia and myelodysplasia. The development of a potential fourth chelator FBS 0701 and the combined use of oral chelators may further improve the quality of life and survival in patients with TM and other transfusion-dependent patients.

Care of Adults With Intellectual and Developmental Disabilities: Traumatic Brain Injury.

PubMed

Jones, Kyle Bradford; Wilson, Benjamin; Weedon, Dean; Bilder, Deborah

2015-12-01

Traumatic brain injuries (TBIs) manifest in various forms and severities, and patients with TBIs can have multiple physical and psychological comorbidities. The physician should be prepared to assess effects of the injury and associated comorbidities, and provide needed social support. Common comorbidities include cognitive changes; epilepsy; chronic pain; headache; sleep disorders; neuroendocrine disorders; dizziness and balance issues; substance abuse; depression and anxiety; dementia; and behavioral disturbances, such as aggression. Early severity and cognitive assessment after TBI is key. For patients with mild TBIs, short-term management focuses on cognitive rest, symptom management, and gradual return to regular activities. Short-term management of patients with moderate to severe TBI often requires intensive care unit admission, early psychological consultation, and use of mannitol and probiotics. Long-term care includes monitoring and managing of the physical, behavioral, emotional, and psychological comorbidities that commonly occur in patients with TBIs. Assisting patients in accessing community and government resources can be crucial for improving their independence and quality of life. Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.

Directed Retrograde Cerebral Protection during Moderate Hypothermic Circulatory Arrest

PubMed Central

Yacoubian, Vahe; Jyrala, Aarne; Kay, Gregory L.

2006-01-01

There are many choices for neurologic protection for aortic arch surgery. Although numerous investigators have challenged the efficacy of retrograde cerebral perfusion, we have had good results with our application of this technique. We performed a retrospective review of 8 consecutive patients who underwent surgery from 1 June 2001 through 31 March 2003; the age range was 33 to 97 years. All patients required circulatory arrest and underwent retrograde cerebral perfusion with use of a tourniquet on the patients' left and right arms above the elbow to direct retrograde flow to the brain. Moderate hypothermia (around 24 °C nasopharyngeal) was used; circulatory arrest time ranged from 27 to 63 minutes. There was 1 late hospital death due to multiple-organ system failure. There were no neurologic complications (stroke or temporary neurologic dysfunction). There was no substantive neurologic or renal dysfunction in this cohort, in which moderate hypothermia was used. These results are comparable to those reported in the literature for similar patients. We conclude that, for patients who require circulatory arrest, directed retrograde cerebral perfusion at moderate nasopharyngeal hypothermia gives results comparable to those reported with other techniques. PMID:17215968

The pharmacotherapy implications of ventricular assist device in the patient with end-stage heart failure.

PubMed

Von Ruden, Serena A S; Murray, Margaret A; Grice, Jennifer L; Proebstle, Amy K; Kopacek, Karen J

2012-04-01

Advances in mechanical circulatory support, such as the use of ventricular assist devices (VADs), have become a means for prolonging survival in end-stage heart failure (HF). VADs decrease the symptoms of HF and improve quality of life by replacing some of the work of a failing heart. They unload the ventricle to provide improved cardiac output and end-organ perfusion, resulting in improvement in cardiorenal syndromes and New York Heart Association functional class rating. VADs are currently used asa bridge to heart transplantation, a bridge to recovery of cardiac function, or as destination therapy. Complications of VAD include bleeding, infections, arrhythmias, multiple organ failure, right ventricular failure, and neurological dysfunction. Patients with VAD have unique pharmacotherapeutic requirements in terms of anticoagulation, appropriate antibiotic selection, and continuation of HF medications. Pharmacists in acute care and community settings are well prepared to care for the patient with VAD. These patients require thorough counseling and follow-up with regard to prevention and treatment of infections, appropriate levels of anticoagulation, and maintenance of fluid balance. A basic understanding of this unique therapy can assist pharmacists in attending to the needs of patients with VAD.

Hereditary hemochromatosis as a risk factor for joint replacement surgery.

PubMed

Sahinbegovic, Enijad; Dallos, Tomás; Aigner, Elmar; Axmann, Roland; Engelbrecht, Matthias; Schöniger-Hekele, Maximilian; Karonitsch, Thomas; Farkas, Martin; Karger, Thomas; Willeit, Johann; Stölzel, Ulrich; Keysser, Gernot; Datz, Christian; Kiechl, Stefan; Schett, Georg; Zwerina, Jochen

2010-07-01

Hemochromatosis is an inherited disease with iron overload and joint involvement resembling osteoarthritis. To determine the rate of joint replacement surgery in patients with hemochromatosis, we performed a cross-sectional cohort study. A total of 199 individuals with hereditary hemochromatosis were included. The prevalence of joint replacement surgery in hip, knee, and ankle joints because of secondary osteoarthritis was assessed. Data were compared with 917 healthy subjects from the population-based Bruneck study. A total of 32 of 199 individuals with hemochromatosis received joint replacement surgery with a total number of 52 joints replaced. Compared with expected rates in healthy individuals, patients with hemochromatosis had a significantly higher risk for joint replacement surgery (odds ratio 9.0; confidence interval, 4.6-17.4). Joint replacement occurred significantly earlier in life in patients with hemochromatosis; 21.9% of the patients with hemochromatosis and 1.7% of healthy individuals required joint replacement before the age of 50 years (P=.0027). Moreover, patients with hemochromatosis were more likely to require multiple joint replacements (8.5%) than the control group (expected rate 0.3%; P=.0001). Hemochromatosis is a risk factor for joint replacement surgery because of severe secondary osteoarthritis. Copyright 2010 Elsevier Inc. All rights reserved.

Diabetic nephropathy. Is end-stage renal disease inevitable?

PubMed

Bogusky, R T

1983-10-01

The appearance of proteinuria in an insulin-dependent diabetic patient is an ominous sign. Proteinuria heralds the presence of diabetic nephropathy and early death, or chronic renal failure requiring dialysis or transplantation, in 50% of patients. The pathogenesis of diabetic nephropathy is unknown. Adequate insulin administration is the most important preventive measure. Hypertension, if present, should be aggressively treated to delay progression of renal disease. Good nutrition, prompt treatment of urinary tract infections, and caution in the use of radiocontrast agents are other important preventive measures. Hemodialysis, peritoneal dialysis, and transplantation are options for patients with end-stage renal disease. No matter which is selected, the patient may still have multiple amputations, blindness, congestive heart failure, infections, and uncontrolled glycemia. Advancements are being made, however, that promise a better future for insulin-dependent diabetics.

[Quality of health care for diabetic and hypertensive patients in primary care settings servicing Mexican Seguro Popular].

PubMed

Ortiz-Domínguez, Maki E; Garrido-Latorre, Francisco; Orozco, Ricardo; Pineda-Pérez, Dayana; Rodríguez-Salgado, Marlenne

2011-01-01

To assess health care quality provided to type-2 diabetic and hypertensive patients in primary care settings from the Mexican Ministry of Health and to evaluate whether accredited clinics providing services to the Mexican Seguro Popular performed better in terms of metabolic control of those patients compared to the non-accredited. Cross-sectional study performed on 2008. Previous year clinical measures were obtained from 5 444 diabetic and 5 827 hypertensive patient's clinical records. Adequate metabolic control (glucose <110 mg/dl for diabetes and blood pressure <140/90 mmHg for hypertension) associated factors were assessed by multiple-multilevel logistic regression methods. Patients attending accredited clinics were more likely to be controlled, however, metabolic control was not constant over time of accreditation. Additional efforts are required to monitor accredited clinics' performance in order to maintain both metabolic control and clinical assessment of patients.

Laparoscopic Choledochoduodenostomy.

PubMed

Cuendis-Velázquez, Adolfo; E Trejo-Ávila, Mario; Rosales-Castañeda, Enrique; Cárdenas-Lailson, Eduardo; E Rojano-Rodríguez, Martin; Romero-Loera, Sujey; A Sanjuan-Martínez, Carlos; Moreno-Portillo, Mucio

Today's options for biliary bypass procedures, for difficult choledocholithiasis, range from open surgery to laparo-endoscopic hybrid procedures. The aim of this study was to analyze the outcomes of patients with difficult choledocholithiasis treated with laparoscopic choledochoduodenostomy. We performed a prospective observational study from March 2011 to June 2016. We included patients with difficult common bile duct stones (recurrent or unresolved by ERCP) in which a biliary bypass procedure was required. We performed a laparoscopic bile duct exploration with choledochoduodenostomy and intraoperative cholangioscopy. A total of 19 patients were included. We found female predominance (78.9%), advanced mean age (72.4±12 years) and multiple comorbidities. Most patients with previous episodes of choledocholitiasis or cholangitis, mode 1 (min-max: 1-7). Mean common bile duct diameter 24.9±7mm. Mean operative time 218.5±74min, estimated blood loss 150 (30-600)mL, resume of oral intake 3.2±1 days, postoperative length of stay 4.9±2 days. We found a median of 18 (12-32) months of follow-up. All patients with normalization of liver enzymes during follow-up. One patient presented with sump syndrome and one patient died due to nosocomial pneumonia. Laparoscopic choledochoduodenostomy with intraoperative cholangioscopy seems to be safe and effective treatment for patients with difficult common bile duct stones no resolved by endoscopic procedures. This procedure is a good option for patients with advanced age and multiple comorbidities. We offer all the advantages of minimally invasive surgery to these patients. Copyright © 2017 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Hair transplantation in burn scar alopecia

PubMed Central

Farjo, Bessam; Farjo, Nilofer; Williams, Greg

2015-01-01

Treating patients with burn alopecia or hair loss can often be a challenge to both the surgeon and the patient. As with other reconstructive procedures that are required in the post-burn phase, this is usually a multiple stage process often requiring surgery over several years. This is because graft take is not as reliable as in healthy non-scarred skin and may need repeating to achieve adequate density. Also, different areas of hair loss may need to be addressed in separate procedures. There are several limiting factors that will determine whether or not a patient is a candidate for hair restoration which includes but is not limited to the amount of hair loss and the availability of suitable donor hair. Here we discuss how the current surgical technique of hair transplant surgery by follicular unit extraction (FUE) or strip follicular unit transplant (FUT) has become the treatment of choice for alopecic areas that require a more refined aesthetic result. Eyebrow, eyelash, beard and scalp hair loss can all have a negative impact on a burn survivor’s self-esteem and even if surgery is not a possibility, there are non-surgical options available for hair restoration and these are also discussed. PMID:29799573

Epilepsy surgery in developing countries.

PubMed

Williamson, P D; Jobst, B C

2000-01-01

Epilepsy surgery (ES) is a well-accepted treatment for medically intractable epilepsy patients in developed countries, but it is highly technology dependent. Such technology is not usually available in developing countries. For presurgical evaluation, magnetic resonance imaging (MRI) and electroencephalogram recording while videotaping the patient have been important. High technology equipment will, in conjunction with MRI, identify approximately 70% of ES candidates. Introducing ES into developing countries will require determining the candidates that are appropriate for the existing medical infrastructure. This article reviews ES and its possible introduction into conditions existing in developing countries. The authors address (a) the types of patients to be considered for resective ES (some patients require a fairly standard series of noninvasive studies: others will require extensive invasive studies), (b) ways to determine which patients might be appropriate for the existing situation (unilateral mesial temporal lobe epilepsy detected with MRI, epilepsy with a circumscribed MRI lesion, hemispheric lesions, circumscribed MRI detected neuronal migration, and development disorders), (c) surgical procedures (local resection, functional hemispherectomy, multiple subpial transections, corpus callosotomy, and implantation of a vagal nerve stimulator), (d) special considerations for introducing ES into developing countries (medical infrastructure, technology, seizure monitoring systems, selective intracarotid/carotid Amytal testing, and surgical equipment), and (e) the limitations, realistic expectations, personnel requirements, and educational function for selected professionals. Delivery of the technology and expertise to perform ES in developing regions of the world is a realizable project, but it would be limited by available technology and existing medical infrastructure. It should be possible in most areas to train local personnel and thereby leave a lasting legacy.

Laparoscopic Myomectomy for a Plethora of Submucous Myomas.

PubMed

Paul, P G; Paul, George; Radhika, K T; Bulusu, Saumya; Shintre, Hemant

To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae. Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.

Multiple versus single virus respiratory infections: viral load and clinical disease severity in hospitalized children

PubMed Central

Martin, Emily T.; Kuypers, Jane; Wald, Anna; Englund, Janet A.

2011-01-01

Please cite this paper as: Martin et al. (2012) Multiple versus single virus respiratory infections: viral load and clinical disease severity in hospitalized children. Influenza and Other Respiratory Viruses 6(1), 71–77. Background  Molecular testing for viral pathogens has resulted in increasing detection of multiple viruses in respiratory secretions of ill children. The clinical impact of multiple virus infections on clinical presentation and outcome is unclear. Objectives  To compare clinical characteristics and viral load between children with multiple virus versus single virus illnesses. Patients/methods  Eight hundred and ninety‐three residual nasal wash samples from children treated for respiratory illness at Children’s Hospital, Seattle, from September 2003 to September 2004 were evaluated by quantitative PCR for respiratory syncytial virus (RSV), human metapneumovirus (hMPV), influenza (Flu), parainfluenza, adenoviruses, and coronaviruses (CoV). Illness severity and patient characteristics were abstracted from medical charts. Results  Coinfections were identified in 103 (18%) of 566 virus‐positive samples. Adenovirus was most commonly detected in coinfections (52%), followed by CoV (50%). Illnesses with a single virus had increased risk of oxygen requirement (P = 0·02), extended hospital stays (P = 0·002), and admissions to the inpatient (P = 0·02) or intensive care units (P = 0·04). For Adv and PIV‐1, multiple virus illnesses had a significantly lower viral load (log10 copies/ml) than single virus illnesses (4·2 versus 5·6, P = 0·007 and 4·2 versus 6·9, P < 0·001, respectively). RSV, Flu‐A, PIV‐3, and hMPV viral loads were consistently high whether or not another virus was detected. Conclusions  Illnesses with multiple virus detections were correlated with less severe disease. The relationship between viral load and multiple virus infections was virus specific, and this may serve as a way to differentiate viruses in multiple virus infections. PMID:21668660

Magnetic resonance imaging in patients with cardiac pacemakers: era of "MR Conditional" designs.

PubMed

Shinbane, Jerold S; Colletti, Patrick M; Shellock, Frank G

2011-10-27

Advances in cardiac device technology have led to the first generation of magnetic resonance imaging (MRI) conditional devices, providing more diagnostic imaging options for patients with these devices, but also new controversies. Prior studies of pacemakers in patients undergoing MRI procedures have provided groundwork for design improvements. Factors related to magnetic field interactions and transfer of electromagnetic energy led to specific design changes. Ferromagnetic content was minimized. Reed switches were modified. Leads were redesigned to reduce induced currents/heating. Circuitry filters and shielding were implemented to impede or limit the transfer of certain unwanted electromagnetic effects. Prospective multicenter clinical trials to assess the safety and efficacy of the first generation of MR conditional cardiac pacemakers demonstrated no significant alterations in pacing parameters compared to controls. There were no reported complications through the one month visit including no arrhythmias, electrical reset, inhibition of generator output, or adverse sensations. The safe implementation of these new technologies requires an understanding of the well-defined patient and MR system conditions. Although scanning a patient with an MR conditional device following the strictly defined patient and MR system conditions appears straightforward, issues related to patients with pre-existing devices remain complex. Until MR conditional devices are the routine platform for all of these devices, there will still be challenging decisions regarding imaging patients with pre-existing devices where MRI is required to diagnose and manage a potentially life threatening or serious scenario. A range of other devices including ICDs, biventricular devices, and implantable physiologic monitors as well as guidance of medical procedures using MRI technology will require further biomedical device design changes and testing. The development and implementation of cardiac MR conditional devices will continue to require the expertise and collaboration of multiple disciplines and will need to prove safety, effectiveness, and cost effectiveness in patient care.

Magnetic resonance imaging in patients with cardiac pacemakers: era of "MR Conditional" designs

PubMed Central

2011-01-01

Advances in cardiac device technology have led to the first generation of magnetic resonance imaging (MRI) conditional devices, providing more diagnostic imaging options for patients with these devices, but also new controversies. Prior studies of pacemakers in patients undergoing MRI procedures have provided groundwork for design improvements. Factors related to magnetic field interactions and transfer of electromagnetic energy led to specific design changes. Ferromagnetic content was minimized. Reed switches were modified. Leads were redesigned to reduce induced currents/heating. Circuitry filters and shielding were implemented to impede or limit the transfer of certain unwanted electromagnetic effects. Prospective multicenter clinical trials to assess the safety and efficacy of the first generation of MR conditional cardiac pacemakers demonstrated no significant alterations in pacing parameters compared to controls. There were no reported complications through the one month visit including no arrhythmias, electrical reset, inhibition of generator output, or adverse sensations. The safe implementation of these new technologies requires an understanding of the well-defined patient and MR system conditions. Although scanning a patient with an MR conditional device following the strictly defined patient and MR system conditions appears straightforward, issues related to patients with pre-existing devices remain complex. Until MR conditional devices are the routine platform for all of these devices, there will still be challenging decisions regarding imaging patients with pre-existing devices where MRI is required to diagnose and manage a potentially life threatening or serious scenario. A range of other devices including ICDs, biventricular devices, and implantable physiologic monitors as well as guidance of medical procedures using MRI technology will require further biomedical device design changes and testing. The development and implementation of cardiac MR conditional devices will continue to require the expertise and collaboration of multiple disciplines and will need to prove safety, effectiveness, and cost effectiveness in patient care. PMID:22032338

A budget impact analysis of parenteral iron treatments for iron deficiency anemia in the UK: reduced resource utilization with iron isomaltoside 1000.

PubMed

Pollock, Richard F; Muduma, Gorden

2017-01-01

The reported prevalence of iron deficiency anemia (IDA) varies widely but estimates suggest that 3% of men and 8% of women have IDA in the UK. Parenteral iron is indicated for patients intolerant or unresponsive to oral iron or requiring rapid iron replenishment. This study evaluated differences in the cost of treating these patients with iron isomaltoside (Monofer ® , IIM) relative to other intravenous iron formulations. A budget impact model was developed to evaluate the cost of using IIM relative to ferric carboxymaltose (Ferinject ® , FCM), low molecular weight iron dextran (Cosmofer ® , LMWID), and iron sucrose (Venofer ® , IS) in patients with IDA. To establish iron need, iron deficits were modeled using a simplified dosing table. The base case analysis was conducted over 1 year in patients with IDA with mean bodyweight of 82.4 kg (SD 22.5 kg) and hemoglobin levels of 9.99 g/dL (SD 1.03 g/dL) based on an analysis of patient characteristics in IDA trials. Costs were modeled using UK health care resource groups. Using IIM required 1.3 infusions to correct the mean iron deficit, compared with 1.3, 1.8, and 7.7 with LMWID, FCM, and IS, respectively. Patients using IIM required multiple infusions in 35% of cases, compared with 35%, 77%, and 100% of patients with LMWID, FCM, and IS, respectively. Total costs were estimated to be GBP 451 per patient with IIM or LMWID, relative to GBP 594 with FCM (a GBP 143 or 24% saving with IIM) or GBP 2,600 with IS (a GBP 2,149 or 83% saving with IIM). Using IIM or LMWID in place of FCM or IS resulted in a marked reduction in the number of infusions required to correct iron deficits in patients with IDA. The reduction in infusions was accompanied by substantial reductions in cost relative to FCM and IS over 1 year.

Management of multiple myeloma in older adults: Gaining ground with geriatric assessment.

PubMed

Wildes, Tanya M; Campagnaro, Erica

2017-01-01

Multiple myeloma increases in incidence with age. With the aging of the population, the number of cases of multiple myeloma diagnosed in older adults each year will nearly double in the next 20years. The novel therapeutic agents have significantly improved survival in older adults, but their outcomes remain poorer than in younger patients. Older adults may be more vulnerable to toxicity of therapy, resulting in decreased dose intensity and contributing to poorer outcomes. Data are beginning to emerge to aid in identifying which individuals are at greater risk for toxicity of therapy; comorbidities, functional limitations, and age over 80years are among the factors associated with greater risk. Geriatric assessment holds promise in the care of older adults with multiple myeloma, both to allow modification of treatment to prevent toxicity, and to identify vulnerabilities that may require intervention. Emerging treatments with low toxicity and attention to individualizing therapy based on geriatric assessment may aid in further improving outcomes in older adults with multiple myeloma. Copyright © 2016 Elsevier Inc. All rights reserved.

Patients with Alzheimer disease with multiple microbleeds: relation with cerebrospinal fluid biomarkers and cognition.

PubMed

Goos, Jeroen D C; Kester, M I; Barkhof, Frederik; Klein, Martin; Blankenstein, Marinus A; Scheltens, Philip; van der Flier, Wiesje M

2009-11-01

Microbleeds (MBs) are commonly observed in Alzheimer disease. A minority of patients has multiple MBs. We aimed to investigate associations of multiple MBs in Alzheimer disease with clinical and MRI characteristics and cerebrospinal fluid biomarkers. Patients with Alzheimer disease with multiple (>or=8) MBs on T2*-weighted MRI were matched for age, sex, and field strength with patients with Alzheimer disease without MBs on a 1:2 basis. We included 21 patients with multiple MBs (73+/-7 years, 33% female) and 42 patients without MBs (72+/-7 years, 38% female). Mini-Mental State Examination was used to assess dementia severity. Cognitive functions were assessed using neuropsychological tests. Medial temporal lobe atrophy (0 to 4), global cortical atrophy (0 to 3), and white matter hyperintensities (0 to 30) were assessed using visual rating scales. In a subset, apolipoprotein E genotype and cerebrospinal fluid amyloid beta 1-42, total tau and tau phosphorylated at threonine 181 were determined. Patients with multiple MBs performed worse on Mini-Mental State Examination (multiple MB: 17+/-7; no MB: 22+/-4, P<0.05) despite similar disease duration. Atrophy was not related to presence of MBs, but patients with multiple MBs had more white matter hyperintensities (multiple MB: 8.8+/-4.8; no MB: 3.2+/-3.6, P<0.05). Adjusted for age, sex, white matter hyperintensities, and medial temporal lobe atrophy, the multiple MB group additionally performed worse on Visual Association Test object naming and animal fluency. Patients with multiple MBs had lower cerebrospinal fluid amyloid beta 1-42 levels (307+/-61) than patients without MBs (505+/-201, P<0.05). Adjusted for the same covariates, total tau, and tau phosphorylated at threonine 181 were higher in the multiple MB group. Microbleeds are associated with the clinical manifestation and biochemical hallmarks of Alzheimer disease, suggesting possible involvement of MBs in the pathogenesis of Alzheimer disease.