Cabrera López, F
Aflibercept is a new anti-vegf drug that, unlike ranibizumab and bevacizumab blocks both vegf-A and placental growth factor. Moreover, it binds with much greater strength and affinity to human VEGF-A165 than other endogenous vegf receptors, conferring it with a more extended effect and allowing a lower frequency of intravitreal injections. This facilitates the adoption of fixed treatment regimens other than monthly or individual regimens such as "treat and extend". Aflibercept is indicated for the treatment of neovascular (exudative) age-related macular degeneration (ARMD), visual alteration due to macular edema secondary to central retinal vein occlusion (CRVO) and visual alteration due to diabetic macular edema (DME). The present article reviews the management of aflibercept in routine clinical practice, based on the specifications of its new core data sheet, which includes all the therapeutic indications in which its use has been approved and evaluating the distinct alternatives and treatment regimens after the initial loading doses.
Edgar, J. D.; McMillan, S. A.; Bruce, I. N.; Conlan, S. K.
We have reviewed the medical records of 301/327 consecutive patients in whom anti-neutrophil cytoplasmic antibodies (ANCA) were detected by the Regional Immunology Laboratory in Northern Ireland between January 1988 and October 1991 (45 months). We have collected data for each patient regarding age, sex, smoking habit, area of residence, and details of any other autoantibody activity. Clinical diagnosis was established, with the number of organ systems involved and the evidence for that involvement (symptomatic, biochemical, radiological, and histological). Diagnoses were divided into four groups according to their recognised vasculitic features and these were related to the pattern of immunofluorescence and maximum ANCA titre detected. The most frequent diagnosis was rheumatoid arthritis (18.2% of patients) and the connective tissue disorders as a whole accounted for 27.9% of patients. ANCA were also detected in a wide range of clinical conditions which are not associated with vasculitis and these patients were an important source of 'false-positives'. The positive predictive value (PPV) of ANCA of all patterns and titres for vasculitic conditions was 27%, however, the detection of a classical ANCA pattern at high titre (> or = 1:640) was associated with an increased PPV of 75%. The coexistence of an antinuclear antibody (ANA) reduces the PPV of both classical and perinuclear ANCA, although perinuclear ANCA with antimyeloperoxidase specificity had an improved PPV. We conclude that ANCA testing should not be used as the only screening investigation for vasculitis but should be included in a rational investigative scheme. The interpretation of a positive ANCA result must take into account the presence of other autoantibodies and the full range of non-vasculitic conditions when the clinical situation is not typical of vasculitis. PMID:8545289
Kacířová, Ivana; Grundmann, Milan
Therapeutic drug monitoring (TDM) is specific method of clinical pharmacology for monitoring of the therapy using measurement of drug serum concentrations followed interpretation and good cooperation with clinician. TDM help clinicians to quickly optimize vancomycin dosing regimens to maximize the clinical effect and minimize the toxicity of the drugs. Minimum serum vancomycin trough concentrations should always be maintained above 10 mg/L to avoid development of resistance, neverthelles trough concentrations > 20 mg/L are not recommended because of the risk of nephrotoxicity. For serious infections vancomycin trough concentrations of 15-20 mg/L are recommended and for a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L to generate the target AUC24/MIC 400 (area under the curve/minimal inhibitory concentration). In non-complicated infections trough concentrations of 10-15 mg/L should be sufficient. For continuous infusions of vancomycin target steady-state concentration values of 15-25 mg/L have been advocated for critically ill patients.Key words: therapeutic monitoring - trough concentration - vancomycin.
Mosca, M.; Tani, C.; Aringer, M.; Bombardieri, S.; Boumpas, D.; Cervera, R.; Doria, A.; Jayne, D.; Khamashta, M. A.; Kuhn, A.; Gordon, C.; Petri, M.; Schneider, M.; Shoenfeld, Y.; Smolen, J. S.; Talarico, R.; Tincani, A.; Ward, M. M.; Werth, V. P.; Carmona, L.
The assessment of systemic lupus erythematosus (SLE) patients in routine clinical practice is mainly based on the experience of the treating physician. This carries the risk of unwanted variability. Variability may have an impact on the quality of care offered to SLE patients, thereby affecting outcomes. Recommendations represent systematically developed statements to help practitioners in reducing variability. However, major difficulties arise in the application of recommendations into clinical practice. In this respect, the use of quality indicators may raise the awareness among rheumatologists regarding potential deficiencies in services and improve the quality of health care. The aim of this study was to develop a set of quality indicators (QI) for SLE by translating into QIs the recently developed EULAR Recommendations for monitoring SLE patients in routine clinical practice and observational studies. Eleven QIs have been developed referring to the use of validated activity and damage indices in routine clinical practice, general evaluation of drug toxicity, evaluation of comorbidities, eye evaluation, laboratory assessment, evaluation of the presence of chronic viral infections, documentation of vaccination and of antibody testing at baseline. A disease specific set of quality assessment tools should help physicians deliver high quality of care across populations. Routine updates will be needed. PMID:21224016
Myers, Martin G
1. Conventional manual measurement of blood pressure (BP) in clinical practice is no longer considered to be the best method for evaluating a patient's BP status. Home BP and 24 h ambulatory BP monitoring are now recommended for the diagnosis and management of hypertension. 2. Recent studies provide an alternative to conventional office BP, namely automated office (AO) BP, which involves multiple BP readings taken with a fully automated device with the patient resting quietly alone. Automated office BP is preferable to routine manual office BP in that it exhibits improved accuracy and a stronger relationship to both ambulatory BP and target organ damage. 3. Having the patient alone eliminates conversation between the patient and the observer, a cause of 'white coat hypertension'. The use of an automated device improves accuracy, reduces digit preference, minimizes observer bias and facilitates the recording of multiple BP readings. 4. Comparative BP data obtained in clinical studies in both research settings and routine community practice support the use of a cut-off point of 135/85 mmHg for defining hypertension using AOBP, which is the same cut-off point currently recommended for awake ambulatory BP and home BP. 5. Reduction of the white coat response using AOBP should reduce the need to monitor patients with ambulatory BP and home BP after initiation of antihypertensive therapy. There is now sufficient evidence to consider replacing manual office BP with AOBP in routine clinical practice.
Luyt, David; Bravin, Kristian; Luyt, Jessica
Background Although the natural history of cow’s milk allergy is to resolve during childhood or adolescence, a small but significant proportion of children will remain allergic. Specific oral tolerance induction to cow’s milk (CM-SOTI) provides a treatment option in these children with continuing allergy with high success rates. However current sentiment limits widespread availability as existing reports advise that it is too soon to translate CM-SOTI into routine clinical practice. Methods In January 2007 we implemented a slow up-dosing CM-SOTI program. Eligible subjects were identified at routine visits to our children’s allergy clinic. Persisting cow’s milk allergy was confirmed from recent contact symptoms or a positive baked milk challenge. As allergic symptoms are common during CM-SOTI, families were provided with ready dietetic access for advice on dosing and symptom treatment. Subjects were continuously monitored at subsequent clinic visits or telephonically, where no longer followed, for a median of 49 months. Results The first 50 subjects (35 males) treated ranged in age from 5.1 to 15.8 years (median 10.3 years). Full tolerance (250 mL) was achieved in 23 subjects, 9 without any symptoms, and a further 9 achieved partial tolerance with continued ingestion. Eighteen children failed to achieve any regular milk ingestion; 11 because of persistent or significant symptoms whilst 8 withdrew against medical advice. Allergic symptoms were predominantly mild to moderate in severity, although 2 cases needed treatment with inhaled salbutamol and a further 2 required intramuscular adrenaline. Clinical tolerance, both full and partial, persists beyond 5 years. Conclusion We have demonstrated that a CM-SOTI program can be successfully and safely implemented as routine clinical practice with acceptable compliance during prolonged home up-dosing, despite frequent allergic symptoms, and for up to 4 years after starting treatment. CM-SOTI can thus be put into
Caudle, Kelly E; Klein, Teri E; Hoffman, James M; Muller, Daniel J; Whirl-Carrillo, Michelle; Gong, Li; McDonagh, Ellen M; Sangkuhl, Katrin; Thorn, Caroline F; Schwab, Matthias; Agundez, Jose A G; Freimuth, Robert R; Huser, Vojtech; Lee, Ming Ta Michael; Iwuchukwu, Otito F; Crews, Kristine R; Scott, Stuart A; Wadelius, Mia; Swen, Jesse J; Tyndale, Rachel F; Stein, C Michael; Roden, Dan; Relling, Mary V; Williams, Marc S; Johnson, Samuel G
The Clinical Pharmacogenetics Implementation Consortium (CPIC) publishes genotype-based drug guidelines to help clinicians understand how available genetic test results could be used to optimize drug therapy. CPIC has focused initially on well-known examples of pharmacogenomic associations that have been implemented in selected clinical settings, publishing nine to date. Each CPIC guideline adheres to a standardized format and includes a standard system for grading levels of evidence linking genotypes to phenotypes and assigning a level of strength to each prescribing recommendation. CPIC guidelines contain the necessary information to help clinicians translate patient-specific diplotypes for each gene into clinical phenotypes or drug dosing groups. This paper reviews the development process of the CPIC guidelines and compares this process to the Institute of Medicine's Standards for Developing Trustworthy Clinical Practice Guidelines.
Symons, J; Vandekerckhove, L; Paredes, R; Verhofstede, C; Bellido, R; Demecheleer, E; van Ham, P M; van Lelyveld, S F L; Stam, A J; van Versendaal, D; Nijhuis, M; Wensing, A M J
Guidelines state that the CCR5-inhibitor Maraviroc should be prescribed to patients infected with R5-tropic HIV-1 only. Therefore, viral tropism needs to be assessed phenotypically or genotypically. Preliminary clinical trial data suggest that genotypic analysis in triplicate is associated with improved prediction of virological response by increasing the detection of X4-tropic variants. Our objective was to evaluate the impact of triplicate genotypic analysis on prediction of co-receptor usage in routine clinical practice. Samples from therapy-naive and therapy-experienced patients were collected for routine tropism testing at three European clinical centres. Viral RNA was isolated from plasma and proviral DNA from peripheral blood mononuclear cells. Gp120-V3 was amplified in a triplicate nested RT-PCR procedure and sequenced. Co-receptor usage was predicted using the Geno2Pheno([coreceptor]) algorithm and analysed with a false-positive rate (FPR) of 5.75%, 10%, or an FPR of 20% and according to the current European guidelines on the clinical management of HIV-1 tropism testing. A total of 266 sequences were obtained from 101 patient samples. Discordance in tropism prediction for the triplicates was observed in ten samples using an FPR of 10%. Triplicate testing resulted in a 16.7% increase in X4-predicted samples and to reclassification from R5 to X4 tropism for four cases rendering these patients ineligible for Maraviroc treatment. In conclusion, triplicate genotypic tropism testing increases X4 tropism detection in individual cases, which may prove to be pivotal when CCR5-inhibitor therapy is applied.
Saumoy, Maria; Llibre, Josep M; Terrón, Alberto; Knobel, Hernando; Arribas, José Ramón; Domingo, Pere; Arroyo-Manzano, David; Rivero, Antonio; Moreno, Santiago; Podzamczer, Daniel
To assess the efficacy and safety of maraviroc (MVC) administered once-daily in routine clinical practice. A retrospective multicenter study (27 centers in Spain) was conducted. Data were collected from the records of patients starting a regimen with MVC. Laboratory and clinical data were recorded every 3 months the first year and every 6 months thereafter. Data are presented as median and interquartile range. Among 667 patients treated with MVC, 142 (21.3%) received MVC once-daily: 108 (76.1%), 150 mg and 34 (23.9%), and 300 mg. Age was 47 (42-45) years, there were 76.1% men, and 81 (57%) patients had baseline HIV-RNA <50 copies/mL. Viral tropism was R5 in 118 (83.1%) patients. Reasons for prescribing MVC: salvage therapy (36.6%), drug toxicity (31.2%), simplification (16.9%), and immunodiscordant response (7.1%). Median follow-up was 13 (9-16) months. In 95.8%, a PI/r was part of the regimen (67% on dual therapy). At months 12 and 24, 73.3% and 68.2% of patients had HIV-RNA <50 copies/mL, respectively (p = .041 and p < .001 vs. baseline). CD4(+) cell count increased by a median of 52 (-36,135) and 84 (-9.5,180) cells/mm(3) at 12 and 24 months, respectively (p < .001 and p = .039 vs. baseline). Twenty-five (17.6%) patients discontinued MVC: virologic failure (6), medical decision (5), and other reasons (14). Two patients presented grade 3 adverse events (hypertransaminasemia, hypertriglyceridemia) without the need for MVC withdrawal, whereas MVC was discontinued in two patients due to gastrointestinal toxicity. In routine clinical practice, MVC once-daily combined with at least PI/r was virologically effective and well tolerated in a high percentage of pretreated patients.
Chalmers, Robert J G
Psoriasis is a complex disease. Dermatologists have not documented psoriasis severity, except in clinical trials; doing so requires tools for assessing psoriasis and an understanding of what changes in those assessments mean in terms of outcome. Two psoriasis assessment tools have dominated: The Psoriasis Area and Severity Index and the Dermatology Life Quality Index. There are advantages and disadvantages to each. Newer instruments may not be more suitable for documenting psoriasis. There may be benefits in terms of patient ownership of disease management from using self-assessment tools for documenting severity, for example, the Self-assessment version of the Simplified Psoriasis Index.
Deibler, A R; Pollock, J M; Kraft, R A; Tan, H; Burdette, J H; Maldjian, J A
Arterial spin-labeled (ASL) perfusion imaging can be implemented successfully into a routine clinical neuroimaging protocol and can accurately demonstrate alterations in brain perfusion. We have observed patterns of focal, regional, and global hyperperfusion in a wide variety of disease processes. The causes of hyperperfusion at clinical ASL have not been previously characterized. Focal lesions such as brain tumors and vascular malformations with increased perfusion can be well depicted by ASL. More global causes of hyperperfusion, including postanoxia vasodilation and hypercapnia, may go undetected on conventional MR images, whereas the regional hyperperfusion, which may occur in reversible encephalopathies and luxury perfusion, has been consistently illustrated on ASL cerebral blood flow maps at our institution.
Baron, Ralf; Eberhart, Leopold; Kern, Kai-Uwe; Regner, Stefan; Rolke, Roman; Simanski, Christian; Tölle, Thomas
Tapentadol prolonged release (PR) for the treatment of moderate to severe chronic pain combines 2 modes of action. These are μ-opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule that allow higher analgesic potency through modulation of different pharmacological targets within the pain transmitting systems. At the same time, this can also serve as a clue for modulation of different pain-generating mechanisms according to nociceptive, neuropathic, or mixed pain conditions. Tapentadol PR has now been on the market for 5 years, with over 4.6 million people treated worldwide. A panel of pain specialists convened in Germany to review the clinical program and to discuss the role of tapentadol PR in the management of chronic pain. The clinical study program demonstrated effective and generally well-tolerated treatment for up to 2 years in a broad range of chronic pain conditions, including those with neuropathic pain components. This was confirmed in routine clinical practice observations. Head-to-head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate-to-severe musculoskeletal pain. Rotation from poorly tolerated WHO III opioids to tapentadol PR provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. Functionality, health status and quality of life also improved under tapentadol PR treatment. The gastrointestinal tolerability profile was more favorable compared to other tested WHO III opioids. Tapentadol PR has a good safety profile and no evidence of acquired tolerance from the long-term data so far collected. Overall, tapentadol PR represents an effective and generally well-tolerated alternative to "classical" opioidergic drugs.
Introduction Guidelines dealing with severe sepsis and septic shock mostly rely on randomized controlled trials (RCTs) to ensure the best standards of care for patients. However, patients included in high-quality studies may differ from the routine population and alter external validity of recommendations. We aimed to determine to what extent non-inclusion criteria of RCTs dealing with severe sepsis and septic shock may affect application of their conclusions in routine care. Methods In a first step, the MEDLINE database was searched for RCTs treating severe sepsis and septic shock patients between 1992 and 2008, and non-inclusion criteria for these studies were abstracted. Two reviewers independently evaluated the articles, which were checked by a third reviewer. We extracted data on the study design, main intervention, primary endpoint, criteria for inclusion, and criteria for non-inclusion. In a second step, the distribution of the non-inclusion criteria was observed in a prospective multicenter cohort of severe sepsis and septic shock patients (Cub-Rea network, 1992 to 2008). Results We identified 96 articles out of 7,012 citations that met the screening criteria. Congestive heart failure (35%) and cancer (30%) were frequent exclusion criteria in selected studies, as well as other frequent disorders such as gastrointestinal and liver diseases and all causes of immune suppression. Of the 67,717 patients with severe sepsis and septic shock in the Cub-Rea database, 40,325 (60%) experienced at least one of the main exclusion criteria, including 11% of congestive heart failure patients and 11% of cancer patients. In addition, we observed a significant trend for increasing number of patients with these criteria along time. Conclusion Current exclusion criteria for RCTs dealing with severe sepsis and septic shock excluded most patients encountered in daily practice and limit external validity of the results of high-quality studies. PMID:23705948
Dummett, B Alex; Adams, Carmen; Scruth, Elizabeth; Liu, Vincent; Guo, Margaret; Escobar, Gabriel J
Efforts to improve outcomes of patients who deteriorate outside the intensive care unit have included the use of rapid response teams (RRTs) as well as manual and automated prognostic scores. Although automated early warning systems (EWSs) are starting to enter clinical practice, there are few reports describing implementation and the processes required to integrate early warning approaches into hospitalists' workflows. We describe the implementation process at 2 community hospitals that deployed an EWS. We employed the Institute for Healthcare Improvement's iterative Plan-Do-Study-Act approach. Our basic workflow, which relies on having an RRT nurse and the EWS's 12-hour outcome time frame, has been accepted by clinicians and has not been associated with patient complaints. Whereas our main objective was to develop a set of workflows for integrating the electronic medical record EWS into clinical practice, we also uncovered issues that must be addressed prior to disseminating this intervention to other hospitals. One problematic area is that of documentation following an alert. Other areas that must be addressed prior to disseminating the intervention include the need for educating clinicians on the rationale for deploying the EWS, careful consideration of interdepartment service agreements, clear definition of clinician responsibilities, pragmatic documentation standards, and how to communicate with patients. In addition to the deployment of the EWS to other hospitals, a future direction for our teams will be to characterize process-outcomes relationships in the clinical response itself. Journal of Hospital Medicine 2016;11:S25-S31. © 2016 Society of Hospital Medicine.
Kaczorowski, Janusz; Myers, Martin G.; Gelfer, Mark; Dawes, Martin; Mang, Eric J.; Berg, Angelique; Grande, Claudio Del; Kljujic, Dragan
Abstract Objective To describe the techniques currently used by family physicians in Canada to measure blood pressure (BP) for screening for, diagnosing, and treating hypertension. Design A Web-based cross-sectional survey distributed by e-mail. Setting Stratified random sample of family physicians in Canada. Participants Family physician members of the College of Family Physicians of Canada with valid e-mail addresses. Main outcome measures Physicians’ self-reported routine methods for recording BP in their practices to screen for, diagnose, and manage hypertension. Results A total of 774 valid responses were received, for a response rate of 16.2%. Respondents were similar to nonrespondents except for underrepresentation of male physicians. Of 769 respondents, 417 (54.2%) indicated that they used manual office BP measurement with a mercury or aneroid device and stethoscope as the routine method to screen patients for high BP, while 42.9% (330 of 769) reported using automated office BP (AOBP) measurement. The method most frequently used to make a diagnosis of hypertension was AOBP measurement (31.1%, 240 of 771), followed by home BP measurement (22.4%, 173 of 771) and manual office BP measurement (21.4%, 165 of 771). Ambulatory BP monitoring (ABPM) was used for diagnosis by 14.4% (111 of 771) of respondents. The most frequently reported method for ongoing management was home BP monitoring (68.7%, 528 of 769), followed by manual office BP measurement (63.6%, 489 of 769) and AOBP measurement (59.2%, 455 of 769). More than three-quarters (77.8%, 598 of 769) of respondents indicated that ABPM was readily available for their patients. Conclusion Canadian family physicians exhibit overall high use of electronic devices for BP measurement, However, more efforts are needed to encourage practitioners to follow current Canadian guidelines, which advocate the use of AOBP measurement for hypertension screening, ABPM and home BP measurement for making a diagnosis, and both
Légaré, France; Witteman, Holly O
For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.
Del Paggio, J.C.; Nanji, S.; Wei, X.; MacDonald, P.H.; Booth, C.M.
Background Guidelines recommend that 12 or more lymph nodes (lns) be evaluated during surgical resection of colon cancer. Here, we report ln yield and its association with survival in routine practice. Methods Electronic records of treatment were linked to the population-based Ontario Cancer Registry to identify all patients with colon cancer treated during 2002–2008. The study population (n = 5508) included a 25% random sample of patients with stage ii or iii disease. Modified Poisson regression was used to identify factors associated with ln yield; Cox models were used to explore the association between ln yield and overall (os) and cancer-specific survival (css). Results During 2002–2008, median ln yield increased to 17 from 11 nodes (p < 0.001), and the proportion of patients with 12 or more nodes evaluated increased to 86% from 45% (p < 0.001). Lymph node positivity did not change over time (to 53% from 54%, p = 0.357). Greater ln yield was associated with younger age (p < 0.001), less comorbidity (p = 0.004), higher socioeconomic status (p = 0.001), right-sided tumours (p < 0.001), and higher hospital volume (p < 0.001). In adjusted analyses, a ln yield of less than 12 nodes was associated with inferior os and css for stages ii and iii disease [stage ii os hazard ratio (hr): 1.36; 95% confidence interval (ci): 1.19 to 1.56; stage ii css hr: 1.52; 95% ci: 1.26 to 1.83; and stage iii os hr: 1.45; 95% ci: 1.30 to 1.61; stage iii css hr: 1.54; 95% ci: 1.36 to 1.75]. Conclusions Despite a temporal increase in ln yield, the proportion of cases with ln positivity has not changed. Lymph node yield is associated with survival in patients with stages ii and iii colon cancer. The association between ln yield and survival is unlikely to be a result of stage migration. PMID:28270730
Kwak, Nakwon; Choi, Sun Mi; Lee, Jinwoo; Park, Young Sik; Lee, Chang-Hoon; Lee, Sang-Min; Yoo, Chul-Gyu; Kim, Young Whan; Han, Sung Koo; Yim, Jae-Joon
The Xpert MTB/RIF assay was introduced for timely and accurate detection of tuberculosis (TB). The aim of this study was to determine the diagnostic accuracy and turnaround time (TAT) of Xpert MTB/RIF assay in clinical practice in South Korea. We retrospectively reviewed the medical records of patients in whom Xpert MTB/RIF assay using sputum were requested. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of pulmonary tuberculosis (PTB) and detection of rifampicin resistance were calculated. In addition, TAT of Xpert MTB/RIF assay was compared with those of other tests. Total 681 patients in whom Xpert MTB/RIF assay was requested were included in the analysis. The sensitivity, specificity, PPV and NPV of Xpert MTB/RIF assay for diagnosis of PTB were 79.5% (124/156), 100.0% (505/505), 100.0% (124/124) and 94.0% (505/537), respectively. Those for the detection of rifampicin resistance were 57.1% (8/14), 100.0% (113/113), 100.0% (8/8) and 94.9% (113/119), respectively. The median TAT of Xpert MTB/RIF assay to the report of results and results confirmed by physicians in outpatient settings were 0 (0-1) and 6 (3-7) days, respectively. Median time to treatment after initial evaluation was 7 (4-9) days in patients with Xpert MTB/RIF assay, but was 21 (7-33.5) days in patients without Xpert MTB/RIF assay. Xpert MTB/RIF assay showed acceptable sensitivity and excellent specificity for the diagnosis of PTB and detection of rifampicin resistance in areas with intermediate TB burden. Additionally, the assay decreased time to the initiation of anti-TB drugs through shorter TAT.
Qi, Guijie; Yi, Jianping; Han, Baosheng; Liu, Heng; Guo, Wanru; Shi, Chong; Yin, Lirong
Abstract This study aimed to summarize the effects of noninvasive prenatal testing (NIPT) on aneuploidy among high-risk participants in Tangshan Maternal and Children Health Hospital. NIPT or invasive prenatal diagnosis was recommended to patients with a high risk of fetal aneuploidy from February 2013 to February 2014. Patients who exhibited eligibility and applied for NIPT from January 2012 to January 2013 were included in a comparison group. The rates of patients who underwent invasive testing, declined to undergo further testing, and manifested trisomies 21, 18, and 13 were compared between two groups. Follow-up data were obtained from the participants who underwent NIPT from 2013 to 2014. A total of 7223 patients (3018 and 4205 individuals before and after NIPT) were eligible for analysis. After NIPT was introduced in 2013 to 2014, 727 patients (17.3%) underwent invasive testing, 2828 preferred NIPT (67.3%), and 650 declined to undergo further testing (15.5%). A total of 34 cases of trisomies 21, 18, and 13 (0.8%) were found. In 2012 to 2013, 565 patients (18.7%) underwent invasive testing and 2453 declined to undergo further testing (81.3%). A total of 7 cases of trisomies 21, 18, and 13 were documented (0.2%). Of these cases, 24 were found from NIPT and 10 cases were found from invasive testing. The number of participants who declined to undergo further testing significantly decreased after NIPT was introduced (81.3% vs. 15.5%, P < 0.001). The sensitivity and specificity of NIPT for trisomies 21, 18, and 13 were 100% and 99.9%, respectively. The detection rates of NIPT for trisomies 21, 18, and 13 also significantly increased (0.2% vs. 0.8%, P < 0.001). By contrast, the overall rates of invasive testing remained unchanged (18.7% vs. 17.3%, P = 0.12). The positive predictive values of NIPT for trisomies 21, 18, and 13 were 100%, 83.3%, and 50.0%, respectively. The false positive rates of NIPT were 0% and 0.04%. With NIPT implementation in clinical
Nin, Carlos Shuler; Marchiori, Edson; Irion, Klaus Loureiro; Paludo, Artur de Oliveira; Alves, Giordano Rafael Tronco; Hochhegger, Daniela Reis; Hochhegger, Bruno
OBJECTIVE: To assess the routine use of barium swallow study in patients with chronic cough. METHODS: Between October of 2011 and March of 2012, 95 consecutive patients submitted to chest X-ray due to chronic cough (duration > 8 weeks) were included in the study. For study purposes, additional images were obtained immediately after the oral administration of 5 mL of a 5% barium sulfate suspension. Two radiologists systematically evaluated all of the images in order to identify any pathological changes. Fisher's exact test and the chi-square test for categorical data were used in the comparisons. RESULTS: The images taken immediately after barium swallow revealed significant pathological conditions that were potentially related to chronic cough in 12 (12.6%) of the 95 patients. These conditions, which included diaphragmatic hiatal hernia, esophageal neoplasm, achalasia, esophageal diverticulum, and abnormal esophageal dilatation, were not detected on the images taken without contrast. After appropriate treatment, the symptoms disappeared in 11 (91.6%) of the patients, whereas the treatment was ineffective in 1 (8.4%). We observed no complications related to barium swallow, such as contrast aspiration. CONCLUSIONS: Barium swallow improved the detection of significant radiographic findings related to chronic cough in 11.5% of patients. These initial findings suggest that the routine use of barium swallow can significantly increase the sensitivity of chest X-rays in the detection of chronic cough-related etiologies. PMID:24473762
De Placido, S; De Angelis, C; Giuliano, M; Pizzi, C; Ruocco, R; Perrone, V; Bruzzese, D; Tommasielli, G; De Laurentiis, M; Cammarota, S; Arpino, G; Arpino, G
Background: Although guidelines do not recommend computerised tomography (CT), positron emission tomography (PET) or magnetic resonance imaging (MRI) for the staging or follow-up of asymptomatic patients with non-metastatic breast cancer, they are often requested in routine clinical practice. The aim of this study was to determine the staging and follow-up patterns, and relative costs in a large population of breast cancer patients living and treated in a Southern Italian region. Methods: We analysed the clinical computerised information recorded by 567 primary-care physicians assisting about 650 000 inhabitants in the Campania region. Patients with non-metastatic breast cancer were identified and divided into calendar years from 2001 to 2010. The number of diagnostic tests prescribed per 100 patients (N/Pts) and the mean cost per patient was determined 3 months before diagnosis and up to 1 year after diagnosis. Costs are expressed in constant 2011 euros. Results: We identified 4680 newly diagnosed cases of asymptomatic non-metastatic breast cancer. N/Pts increased significantly (P<0.0001) from 2001 to 2010. The mean number of prescribed mammograms, bone scans, abdominal ultrasound and chest X-rays (‘routine tests'), and costs was unchanged. However, the number of CT, PET scans and MRI (‘new tests')prescriptions almost quadrupled and the mean cost per patient related to these procedures significantly increased from €357 in 2001 to €830 in 2010 (P<0.0001). Conclusions: New test prescriptions and relative costs significantly and steadily increased throughout the study period. At present there is no evidence that the delivery of new tests to asymptomatic patients improves breast cancer outcome. Well-designed clinical trials are urgently needed to shed light on the impact of these tests on clinical outcome and overall survival. PMID:28170371
Pineau, Mitchel; Pynes, Mary Kate; Katz, Laurence B.; Ginsberg, Barry
Background: There is a perception that patients with diabetes struggle to produce sufficient blood to fill glucose test strips, including strips with 1-µL fill requirements. The purpose of this study was to determine the volume of blood expressed when these patients perform routine fingersticks using their own lancing device and sampling technique and to evaluate the relationship between blood volume and pain. Methods: Sixty-four patients (type 1 or type 2 diabetes) performed 8 fingersticks using their own lancing device and preferred depth setting and lancing technique. Eight different commercially available lancing systems were used (8 patients/system). Blood volume and perceived pain were recorded after each fingerstick. Results: The mean blood volume across all patients was 3.1 µL (512 fingersticks), with 97% of patients expressing a mean of ≥1.0 µL of blood. There was no correlation between pain response and the volume of blood expressed. Nearly all patients agreed that they could easily and comfortably obtain a 1-µL blood sample, and most patients actually preferred a larger drop size to ease sampling and avoid wasting strips. Conclusion: These results provide evidence across 8 lancing systems that challenge the current perceptions that patients with diabetes struggle to produce sufficient blood samples to fill most test strips, including those with 1-µL fill requirements, and that obtaining larger volumes of blood is more painful. These results are consistent with the previous literature suggesting that patients derive no real benefits from very low strip volumes and generally prefer a blood drop size that enables them to confidently fill their test strip. PMID:24876439
In our society, taking personal responsibility is basically regarded as a key step to adopting a more active lifestyle. In health care, however, personal responsibility is primarily equated with higher levels of financial contribution from patients. Obviously, the individual's responsibility for his or her health and towards the mutually supportive community is a highly emotional and ideological issue, so the debate is usually rather heated. This is, however, at odds with the "empowered patient" concept. In the present paper "personal responsibility in practice" will be understood to include both physician and patient responsibility. Examples will be employed to demonstrate that, on an individual level, physicians are responsible for diagnosing and treating their patients as indicated and that, on a collective level, they are expected to make responsible use of the resources allocated. Here, patient responsibility will be defined as both taking care for one's own health and the individual's obligation to contribute to the maintenance of our solidarity-based health care system. The tensions between solidarity and subsidiarity and personal responsibility, respectively, will be outlined, and a readjustment of the relation between external support and individual strengths, between solidarity and personal responsibility in terms of Sect. 1 of the Social Book Code V will be advocated.
Van Den Hoofdakker, Barbara J.; Van Der Veen-Mulders, Lianne; Sytema, Sjoerd; Emmelkamp, Paul M. G.; Minderaa, Ruud B.; Nauta, Maaike H.
Objective: To investigate the effectiveness of behavioral parent training (BPT) as adjunct to routine clinical care (RCC). Method: After a first phase of RCC, 94 children with attention-deficit/hyperactivity disorder (ADHD) ages 4-12, all referred to a Dutch outpatient mental health clinic, were randomly assigned to 5 months of BPT plus concurrent…
Forbes, Lindsay J. L.; Forster, Alice S.; Dodd, Rachael H.; Tucker, Lorraine; Laming, Rachel; Sellars, Sarah; Patnick, Julietta; Ramirez, Amanda J.
Background. Women over 70 with breast cancer have poorer one-year survival and present at a more advanced stage than younger women. Promoting early symptomatic presentation in older women may reduce stage cost effectively and is unlikely to lead to overdiagnosis. After examining efficacy in a randomised controlled trial, we piloted a brief health professional-delivered intervention to equip women to present promptly with breast symptoms, as an integral part of the final invited mammogram at age ~70, in the English National Health Service Breast Screening Programme. Methods. We trained mammographers, who then offered the intervention to older women in four breast screening services. We examined breast cancer awareness at baseline and one month in women receiving the intervention, and also in a service where the intervention was not offered. Results. We trained 27 mammographers to deliver the intervention confidently to a high standard. Breast cancer awareness increased 7-fold at one month in women receiving the intervention compared with 2-fold in the comparison service (odds ratio 15.2, 95% confidence interval 10.0 to 23.2). Conclusions. The PEP Intervention can be implemented in routine clinical practice with a potency similar to that achieved in a randomised controlled trial. It has the potential to reduce delay in diagnosis for breast cancer in older women. PMID:23213334
Price, David; Wilson, Andrew M; Chisholm, Alison; Rigazio, Anna; Burden, Anne; Thomas, Michael; King, Christine
Purpose Acute, severe asthma exacerbations can be difficult to predict and thus prevent. Patients who have frequent exacerbations are of particular concern. Practical exacerbation predictors are needed for these patients in the primary-care setting. Patients and methods Medical records of 130,547 asthma patients aged 12–80 years from the UK Optimum Patient Care Research Database and Clinical Practice Research Datalink, 1990–2013, were examined for 1 year before (baseline) and 1 year after (outcome) their most recent blood eosinophil count. Baseline variables predictive (P<0.05) of exacerbation in the outcome year were compared between patients who had two or more exacerbations and those who had no exacerbation or only one exacerbation, using uni- and multivariable logistic regression models. Exacerbation was defined as asthma-related hospital attendance/admission (emergency or inpatient) or acute oral corticosteroid (OCS) course. Results Blood eosinophil count >400/µL (versus ≤400/µL) increased the likelihood of two or more exacerbations >1.4-fold (odds ratio [OR]: 1.48 (95% confidence interval [CI]: 1.39, 1.58); P<0.001). Variables that significantly increased the odds by up to 1.4-fold included increasing age (per year), female gender (versus male), being overweight or obese (versus normal body mass index), being a smoker (versus nonsmoker), having anxiety/depression, diabetes, eczema, gastroesophageal reflux disease, or rhinitis, and prescription for acetaminophen or nonsteroidal anti-inflammatory drugs. Compared with treatment at British Thoracic Society step 2 (daily controller ± reliever), treatment at step 0 (none) or 1 (as-needed reliever) increased the odds by 1.2- and 1.6-fold, respectively, and treatment at step 3, 4, or 5 increased the odds by 1.3-, 1.9-, or 3.1-fold, respectively (all P<0.05). Acute OCS use was the single best predictor of two or more exacerbations. Even one course increased the odds by more than threefold (OR: 3.75 [95% CI: 3
Vidi, Venkatesan D; Matheny, Michael E; Agarwal, Vikram; Arora, Nipun; Donnelly, Sharon; Bangalore, Sripal; Resnic, Frederic S
Randomized controlled trials have shown improved short-term bleeding outcomes for bivalirudin compared to unfractionated heparin (UFH) in patients undergoing percutaneous coronary intervention (PCI) for stable angina and acute coronary syndrome. This study analyzed the impact of bivalirudin-based anticoagulation strategy versus UFH-based anticoagulation strategy on long-term bleeding complications and major adverse cardiac events in patients undergoing PCI in routine clinical practice. From September 2005 to April 2009, 3,367 consecutive patients who underwent PCI for stable angina or non-ST-segment elevation acute coronary syndrome at Brigham and Women's Hospital were studied. Of these patients, 2,228 patients (66%) received UFH and 1,139 (34%) received bivalirudin. Bleeding complication and major adverse cardiac event rates were compared at discharge, 30 days, and 1 year. In a propensity-score matched analysis, bivalirudin-based anticoagulation strategy was associated with lower bleeding complications at 30 days (7.0% vs 13.7%, p = 0.001) and 1 year (12.7% vs 18.9%, p = 0.013). Major adverse cardiac event rates were not significantly different between groups at discharge, 30 days, and 1 year (6.4% vs 8.3%, p = 0.103; 9.4% vs 10.9%, p = 0.449; 12.1% vs 14.8%, p = 0.235, respectively). There was no difference in all-cause mortality rates between the 2 groups (0.9% vs 0.8%, p = 0.808, at discharge; 1.9% vs 3.6%, p = 0.112, at 30 days; 3.6% vs 5.5%, p = 0.195, at 1 year). In conclusion, in a real-world cohort of patients undergoing PCI, bivalirudin-based anticoagulation strategy is associated with a significant decrease in risk of bleeding complications after 30 days and 1 year compared to a UFH-based anticoagulation strategy with no increase in risk for major adverse cardiac events.
Vidi, Venkatesan D.; Matheny, Michael E.; Agarwal, Vikram; Arora, Nipun; Donnelly, Sharon; Bangalore, Sripal; Resnic, Frederic S.
Randomized controlled trials have shown improved short-term bleeding outcomes for bivalirudin relative to unfractionated heparin (UFH) in patients undergoing percutaneous coronary intervention (PCI) for stable angina and acute coronary syndrome. This study analyzed the impact of bivalirudin based anticoagulation strategy versus UFH based anticoagulation strategy on long-term bleeding complications and major adverse cardiac events in patients undergoing PCI in routine clinical practice. Between September 2005 and April 2009, 3367 consecutive patients who underwent PCI for stable angina or Non ST-segment elevation acute coronary syndrome at Brigham and Women’s Hospital were studied. Of these patients, 2228 (66%) patients received UFH and 1139 (34%) received bivalirudin. We compared the bleeding complication and major adverse cardiac event rates at discharge, 30-days and 1-year. In a propensity-score matched analysis, bivalirudin based anticoagulation strategy was associated with lower bleeding complications at 30 days (7.0% vs. 13.7%, p=0.001) and 1-year (12.7% vs.18.9%, p=0.013). The major adverse cardiac event rates was not significantly different between the groups at discharge, 30-days and 1-year (6.4% vs. 8.3%, p=0.103; 9.4% vs.10.9%, p=0.449; 12.1% vs.14.8%, p=0.235 respectively). There was no difference in all-cause mortality rates between the two groups (0.9% vs. 0.8%, p=0.808 at discharge; 1.9% vs. 3.6%, p=0.112 at 30-days; 3.6% vs. 5.5%, p=0.195 at 1 year). In conclusion, in a real-world cohort of patients undergoing PCI, Bivalirudin based anticoagulation strategy is associated with significant reduction in the risk of bleeding complications after 30-days and 1-year compared to UFH based anticoagulation strategy with no increase in the risk for major adverse cardiac events. PMID:21029818
Preusser, Matthias; Berghoff, Anna S; Manzl, Claudia; Filipits, Martin; Weinhäusel, Andreas; Pulverer, Walter; Dieckmann, Karin; Widhalm, Georg; Wöhrer, Adelheid; Knosp, Engelbert; Marosi, Christine; Hainfellner, Johannes A
Testing of the MGMT promoter methylation status in glioblastoma is relevant for clinical decision making and research applications. Two recent and independent phase III therapy trials confirmed a prognostic and predictive value of the MGMT promoter methylation status in elderly glioblastoma patients. Several methods for MGMT promoter methylation testing have been proposed, but seem to be of limited test reliability. Therefore, and also due to feasibility reasons, translation of MGMT methylation testing into routine use has been protracted so far. Pyrosequencing after prior DNA bisulfite modification has emerged as a reliable, accurate, fast and easy-to-use method for MGMT promoter methylation testing in tumor tissues (including formalin fixed and paraffin-embedded samples). We performed an intra- and inter-laboratory ring trial which demonstrates a high analytical performance of this technique. Thus, pyrosequencing- based assessment of MGMT promoter methylation status in glioblastoma meets the criteria of high analytical test performance and can be recommended for clinical application, provided that strict quality control is performed. Our article summarizes clinical indications, practical instructions and open issues for MGMT promoter methylation testing in glioblastoma using pyrosequencing.
Beckmann, M. W.; Schlieter, H.; Richter, P.; Wesselmann, S.
Medical guidelines have become established as the standard for the comprehensive synopsis of all available information (scientific trials, expert opinion) on diagnosis and treatment recommendations. The transfer of guidelines to clinical practice and subsequent monitoring has however proven difficult. In particular the potential interaction between guideline developers and guideline users has not been fully utilised. This review article analyses the status quo and existing methodological and technical information solutions supporting the guideline life cycle. It is shown that there are numerous innovative developments that in isolation do not provide comprehensive support. The vision of the “Living Guidelines 2.0” is therefore presented. This outlines the merging of guideline development and implementation on the basis of clinical pathways and guideline-based quality control, and building on this, the generation of information for guideline development and research. PMID:27134291
Asselbergs, Folkert W; Visseren, Frank Lj; Bots, Michiel L; de Borst, Gert J; Buijsrogge, Marc P; Dieleman, Jan M; van Dinther, Baukje Gf; Doevendans, Pieter A; Hoefer, Imo E; Hollander, Monika; de Jong, Pim A; Koenen, Steven V; Pasterkamp, Gerard; Ruigrok, Ynte M; van der Schouw, Yvonne T; Verhaar, Marianne C; Grobbee, Diederick E
Background Cardiovascular disease remains the major contributor to morbidity and mortality. In routine care for patients with an elevated cardiovascular risk or with symptomatic cardiovascular disease information is mostly collected in an unstructured manner, making the data of limited use for structural feedback, quality control, learning and scientific research. Objective The Utrecht Cardiovascular Cohort (UCC) initiative aims to create an infrastructure for uniform registration of cardiovascular information in routine clinical practice for patients referred for cardiovascular care at the University Medical Center Utrecht, the Netherlands. This infrastructure will promote optimal care according to guidelines, continuous quality control in a learning healthcare system and creation of a research database. Methods The UCC comprises three parts. UCC-1 comprises enrolment of all eligible cardiovascular patients in whom the same information will be collected, based on the Dutch cardiovascular management guideline. A sample of UCC-1 will be invited for UCC-2. UCC-2 involves an enrichment through extensive clinical measurements with emphasis on heart failure, cerebral ischaemia, arterial aneurysms, diabetes mellitus and elevated blood pressure. UCC-3 comprises on-top studies, with in-depth measurements in smaller groups of participants typically based on dedicated project grants. All participants are followed up for morbidity and mortality through linkage with national registries. Conclusion In a multidisciplinary effort with physicians, patients and researchers the UCC sets a benchmark for a learning cardiovascular healthcare system. UCC offers an invaluable resource for future high quality care as well as for first-class research for investigators.
Peral, Carmen; Sánchez-Ballester, Francisco; García-Mediero, José M; Ramos, Jaime; Rejas, Javier
Objective To carry out cost-effectiveness analysis from the Spanish National Health System perspective, of treating overactive bladder (OAB), in newly diagnosed patients with two flexible doses of fesoterodine in routine clinical practice. Patients and methods Economic evaluation of flexible-dose fesoterodine in newly diagnosed patients, including two treatment groups: standard escalating from 4 to 8 mg or fast escalating to 8 mg. Costs were estimated from health care resources utilization related to OAB, and were expressed in 2015 Euros. Quality-adjusted life-years (QALYs) were obtained from overactive bladder questionnaire-short form. Univariate and probabilistic sensitivity analyses were carried out. Results Three hundred and ninety symptomatic OAB patients treated with fesoterodine and newly diagnosed (141 in fast escalating group and 249 in standard escalating) were analyzed. Adjusted health care total costs were not statistically different; difference −€4.1 (confidence interval: −153.3; 25.1) P=0.842. QALYs were higher in fast escalating to high dose vs standard escalating group, resulting in a cost of −€16,020/QALY gained for fast escalating vs standard escalating group. Conclusion When the cost-effectiveness threshold is set at a maximum value of €30,000/QALY gained, fesoterodine fast escalating group was cost-effective vs standard escalating group 67.6% of the time. The treatment with fesoterodine, in female patients newly diagnosed, fast escalating to 8 mg was a cost-effective option relative to escalating traditionally from 4 to 8 mg, in the management of OAB in routine clinical practice, from the Spanish National Health System perspective. PMID:27713646
This Guide to Good Practices is written to enhance understanding of, and provide direction for, ``Shift Routines and Operating Practices,`` Chapter 2 of Department of Energy (DOE) Order 5480.19, Conduct of Operations Requirements for DOE Facilities. The practices in this guide should be considered when planning or reviewing shift routines and operating practices. ``Shift Routines and Operating Practices`` is an element of an effective Conduct of Operations program. The complexity and array of activities performed in DOE facilities dictate the necessity for a high standard of professional conduct and sound operating practices to promote safe and efficient operations. Recently, guidance pertaining to this element has been strengthened for nuclear power reactors. This additional guidance is given in Appendix C for information purposes. Though this guidance and good practices pertain to nuclear power reactors, DOE sites may choose to use a graded approach for implementing these in nuclear facilities.
Augustine, Kurt E.; Walsh, Timothy J.; Beltran, Chris J.; Stoker, Joshua B.; Mundy, Daniel W.; Parry, Mark D.; Bues, Martin; Fatyga, Mirek
The use of radiation therapy for the treatment of cancer has been carried out clinically since the late 1800's. Early on however, it was discovered that a radiation dose sufficient to destroy cancer cells can also cause severe injury to surrounding healthy tissue. Radiation oncologists continually strive to find the perfect balance between a dose high enough to destroy the cancer and one that avoids damage to healthy organs. Spot scanning or "pencil beam" proton radiotherapy offers another option to improve on this. Unlike traditional photon therapy, proton beams stop in the target tissue, thus better sparing all organs beyond the targeted tumor. In addition, the beams are far narrower and thus can be more precisely "painted" onto the tumor, avoiding exposure to surrounding healthy tissue. To safely treat patients with proton beam radiotherapy, dose verification should be carried out for each plan prior to treatment. Proton dose verification systems are not currently commercially available so the Department of Radiation Oncology at the Mayo Clinic developed its own, called DOSeCHECK, which offers two distinct dose simulation methods: GPU-based Monte Carlo and CPU-based analytical. The three major components of the system include the web-based user interface, the Linux-based dose verification simulation engines, and the supporting services and components. The architecture integrates multiple applications, libraries, platforms, programming languages, and communication protocols and was successfully deployed in time for Mayo Clinic's first proton beam therapy patient. Having a simple, efficient application for dose verification greatly reduces staff workload and provides additional quality assurance, ultimately improving patient safety.
Kato, Masaki; Kimura, Toshifumi; Kimura, Takeshi; Hara, Terufumi
Objective Selective serotonin reuptake inhibitors are commonly used in the pharmacotherapy of depression. However, adverse events can lead to their early discontinuation. This study evaluated the safety and effectiveness of paroxetine controlled-release (CR) tablets in Japanese patients with depression/depressive state (hereafter referred to as depression) in routine clinical practice in Japan. Patients and methods This was an open-label, noninterventional, prospective, postmarketing surveillance study. A total of 3,213 patients aged 12–92 years with depression were prescribed paroxetine CR for 8 weeks at the physician’s discretion. Safety was evaluated on the basis of the reporting of adverse drug reactions. Effectiveness was evaluated on the basis of the physician’s assessment using the Clinical Global Impression-Global Improvement (CGI-GI) and the Clinical Global Impression-Severity of Illness (CGI-SI) scales, as well as on the basis of the patients’ self-reported satisfaction. The primary effectiveness outcome was the improvement rate based on the physician’s assessment using the CGI-GI. Results The incidence of adverse drug reactions was 11.2% (359/3,213; 95% confidence interval [CI]: 10.1%–12.3%). The common adverse drug reactions that accounted for 1.0% or more of the incidence were nausea (3.5%) and somnolence (2.7%). The proportion of patients who continued paroxetine CR at week 8 was 80.2% (2,577/3,213; 95% CI: 78.8%–81.6%). The improvement rate at week 8 (last observation carried forward) was 72.8% (2,132/2,927; 95% CI: 71.2%–74.4%). The proportion of patients with CGI-SI scores of moderately or severely ill decreased from 63.6% at baseline to 17.9% at week 8. The proportion of patients who were satisfied with paroxetine CR treatment was 69.8% (2,040/2,921; 95% CI: 68.1%–71.5%). Conclusion The results of this study suggest that paroxetine CR is a well-tolerated and efficacious treatment for depression in routine clinical practice. PMID
Background The objective of this study is to perform an independent evaluation of the feasibility and effectiveness of an educational programme for the primary prevention of type 2 diabetes (DM2) in high risk populations in primary care settings, implanted within the Basque Health Service - Osakidetza. Methods/design This is a prospective phase IV cluster clinical trial conducted under routine conditions in 14 primary health care centres of Osakidetza, randomly assigned to an intervention or control group. We will recruit a total sample of 1089 individuals, aged between 45 and 70 years old, without diabetes but at high risk of developing the condition (Finnish Diabetes Risk Score, FINDRISC ≥ 14) and follow them up for 2 years. Primary health care nursing teams of the intervention centres will implement DE-PLAN, a structured educational intervention program focused on changing healthy lifestyles (diet and physical activity); while the patients in the control centres will receive the usual care for the prevention and treatment of DM2 currently provided in Osakidetza. The effectiveness attributable to the programme will be assessed by comparing the changes observed in patients exposed to the intervention and those in the control group, with respect to the risk of developing DM2 and lifestyle habits. In terms of feasibility, we will assess indicators of population coverage and programme implementation. Discussion The aim of this study is to provide the scientific basis for disseminate the programme to the remaining primary health centres in Osakidetza, as a novel way of addressing prevention of DM2. The study design will enable us to gather information on the effectiveness of the intervention as well as the feasibility of implementing it in routine practice. Trial registration ClinicalTrials.gov NCT01365013 PMID:23158830
Ruiz, Miguel A; Álvarez, Enrique; Carrasco, Jose L; Olivares, José M; Pérez, María; Rejas, Javier
Background Anxiety disorders are among the most common psychiatric illnesses, with generalized anxiety disorder (GAD) being one of the most common. Sleep disturbances are highly prevalent in GAD patients. While treatment with pregabalin has been found to be associated with significant improvement in GAD-related sleep disturbance across many controlled clinical trials, mediational analysis has suggested that a substantial portion of this effect could be the result of a direct effect of pregabalin. Thus, the objective of this study was to model the longitudinal latent effect of pregabalin or usual care (UC) therapies on changes in sleep in outpatients with GAD under routine clinical practice. Methods Male and female GAD outpatients, aged 18 years or above, from a 6-month prospective noninterventional trial were analyzed. Direct and indirect effects of either pregabalin or UC changes in anxiety symptoms (assessed with Hamilton Anxiety Scale) and sleep disturbances (assessed with Medical Outcomes Study-Sleep Scale [MOS-S]) were estimated by a conditional latent curve model applying structural equation modeling. Results A total of 1,546 pregabalin-naïve patients were analyzed, 984 receiving pregabalin and 562 UC. Both symptoms of anxiety and sleep disturbances were significantly improved in both groups, with higher mean (95% confidence interval) score reductions in subjects receiving pregabalin: −15.9 (−15.2; −16.6) vs −14.5 (−13.5; −15.5), P=0.027, in Hamilton Anxiety Scale; and −29.7 (−28.1; −31.3) vs −24.0 (−21.6; −26.4), P<0.001, in MOS-S. The conditional latent curve model showed that the pregabalin effect on sleep disturbances was significant (γ =−3.99, P<0.001), after discounting the effect on reduction in anxiety symptoms. A mediation model showed that 70% of the direct effect of pregabalin on sleep remained after discounting the mediated effect of anxiety improvement. Conclusion A substantial proportion of the incremental
Antinori, Andrea; Meraviglia, Paola; Monforte, Antonella d’Arminio; Castagna, Antonella; Mussini, Cristina; Bini, Teresa; Gianotti, Nicola; Rusconi, Stefano; Colella, Elisa; Airoldi, Giuseppe; Mancusi, Daniela; Termini, Roberta
Current antiretroviral (ARV) therapy for the treatment of human immunodeficiency virus (HIV-1)-infected patients provides long-term control of viral load (VL). Darunavir (DRV) is a nonpeptidomimetic protease inhibitor approved for use with a ritonavir booster (DRV/r). This study evaluated the effectiveness of DRV/r in combination with other ARV agents in routine clinical practice in Italy. In this descriptive observational study, data on utilization of DRV/r, under the conditions described in the marketing authorization, were collected from June 2009 to December 2012. Effectiveness (VL <50 copies/mL), tolerability, and durability in four patient groups (two DRV/r-experienced, one ARV-experienced DRV/r-naïve, and one ARV-naïve) were analyzed. Secondary objectives included immunological response, safety, and persistence/discontinuation rates. In total, 875 of 883 enrolled patients were included in the analysis: of these, 662 (75.7%) completed the follow-up until the end of 2012 and 213 (24.3%) withdrew from the study earlier. Initial DRV dose was 600 mg twice daily (67.1%) or 800 mg once daily (32.9%). Only 16 patients (1.8%) withdrew from the study due to virological failure. Virological response proportions were higher in patients virologically suppressed at study entry versus patients with baseline VL ≥50 copies/mL in each ARV-experienced group, while there was no consistent difference across study groups and baseline VL strata according to baseline CD4+ cell count. CD4+ cell count increased from study entry to last study visit in all the four groups. DRV/r was well tolerated, with few discontinuations due to study-emergent nonfatal adverse events (3.0% overall, including 2.1% drug-related) or deaths (3.0% overall, all non-drug-related); 35.3% of patients reported ≥1 adverse events. These observational data show that DRV/r was effective and well tolerated in the whole patient population described here. The DRV/r-containing regimen provided viral suppression
Puiggros, Anna; Puigdecanet, Eulàlia; Salido, Marta; Ferrer, Ana; Abella, Eugènia; Gimeno, Eva; Nonell, Lara; Herranz, María José; Galván, Ana Belén; Rodríguez-Rivera, María; Melero, Carme; Pairet, Silvia; Bellosillo, Beatriz; Serrano, Sergi; Florensa, Lourdes; Solé, Francesc; Espinet, Blanca
Chronic lymphocytic leukemia (CLL) is characterized by a highly variable clinical course. Del(11q) and del(17p), routinely studied by conventional G-banding cytogenetics (CGC) and fluorescence in situ hybridization (FISH), have been related to progression and shorter overall survival. Recently, array-based karyotyping has gained acceptance as a high-resolution new tool for detecting genomic imbalances. The aim of the present study was to compare genomic arrays with CGC and FISH to ascertain whether the current techniques could be substituted in routine procedures. We analyzed 70 patients with CLL using the Cytogenetics Whole-Genome 2.7M Array and CytoScan HD Array (Affymetrix), CGC and FISH with the classical CLL panel. Whereas 31.4% and 68.6% of patients presented abnormalities when studied by CGC and FISH, respectively, these rates increased when arrays were also analyzed (78.6% and 80%). Although abnormality detection is higher when arrays are applied, one case with del(11q) and three with del(17p) were missed by genomic arrays due to their limited sensitivity. We consider that the complete substitution of CGC and FISH by genomic arrays in routine laboratories could negatively affect the management of some patients harboring 11q or 17p deletions. In conclusion, genomic arrays are valid to detect known and novel genomic imbalances in CLL, but should be maintained as a complementary tool to the current techniques.
Sturgeon, Catharine; Hill, Robert; Hortin, Glen L; Thompson, Douglas
There is increasing pressure to provide cost-effective healthcare based on “best practice.” Consequently, new biomarkers are only likely to be introduced into routine clinical biochemistry departments if they are supported by a strong evidence base and if the results will improve patient management and outcome. This requires convincing evidence of the benefits of introducing the new test, ideally reflected in fewer hospital admissions, fewer additional investigations and/or fewer clinic visits. Carefully designed audit and cost-benefit studies in relevant patient groups must demonstrate that introducing the biomarker delivers an improved and more effective clinical pathway. From the laboratory perspective, pre-analytical requirements must be thoroughly investigated at an early stage. Good stability of the biomarker in relevant physiological matrices is essential to avoid the need for special processing. Absence of specific timing requirements for sampling and knowledge of the effect of medications that might be used to treat the patients in whom the biomarker will be measured is also highly desirable. Analytically, automation is essential in modern high-throughput clinical laboratories. Assays must therefore be robust, fulfilling standard requirements for linearity on dilution, precision and reproducibility, both within- and between-run. Provision of measurements by a limited number of specialized reference laboratories may be most appropriate, especially when a new biomarker is first introduced into routine practice. PMID:21137030
Kishida, Ken; Funahashi, Tohru; Shimomura, Iichiro
Adiponectin is a protein synthesized and secreted predominantly by adipocytes into the peripheral blood. However, circulating adiponectin level is inversely related with body weight, especially visceral fat accumulation. The mechanism of this paradoxical relation remains obscure. Low circulating adiponectin concentrations (hypoadiponectinemia; <4 μg/mL) are associated with a variety of diseases, including dysmetabolism (type 2 diabetes, insulin resistance, hypertension, dyslipidemia, metabolic syndrome, hyperuricemia), atherosclerosis (coronary artery disease, stroke, peripheral artery disease), sleep apnea, non-alcoholic fatty liver disease, gastritis and gastro-esophageal reflux disease, inflammatory bowel diseases, pancreatitis, osteoporosis, and cancer (endometrial cancer, postmenopausal breast cancer, leukemia, colon cancer, gastric cancer, prostate cancer). On the other hand, hyperadiponectinemia is associated with cardiac, renal and pulmonary diseases. This review article focuses on the significance of adiponectin as a clinical biomarker of obesity-related diseases. Routine measurement of adiponectin in patients with lifestyle-related diseases is highly recommended.
Cho, Won-Hyung; Won, Eun-Jeong; Choi, Hyun-Jung; Kee, Seung-Jung; Shin, Jong-Hee; Ryang, Dong-Wook; Suh, Soon-Pal
The AdvanSure tuberculosis/non-tuberculous mycobacterium (TB/NTM) PCR (LG Life Science, Korea) and COBAS TaqMan Mycobacterium tuberculosis (MTB) PCR (Roche Diagnostics, USA) are commonly used in clinical microbiology laboratories. We aimed to evaluate these two commercial real-time PCR assays for detection of MTB in a large set of clinical samples over a two-year period. AdvanSure TB/NTM PCR and COBAS TaqMan MTB PCR were performed on 9,119 (75.2%) and 3,010 (24.8%) of 12,129 (9,728 respiratory and 2,401 non-respiratory) MTB specimens, with 361 (4.0%) and 102 (3.4%) acid-fast bacilli (AFB)-positive results, respectively. In MTB culture, 788 (6.5%) MTB and 514 (4.2%) NTM were identified. The total sensitivity and specificity of the AdvanSure assay were 67.8% (95% confidence interval [CI], 63.9-71.6) and 98.3% (95% CI, 98.0-98.6), while those of the COBAS TaqMan assay were 67.2% (95% CI, 60.0-73.8) and 98.4% (95% CI, 97.9-98.9), respectively. The sensitivities and specificities of the AdvanSure and COBAS TaqMan assays for AFB-positive and AFB-negative samples were comparable. Furthermore, the AdvanSure assay showed fewer invalid results compared with the COBAS TaqMan assay (5.0 vs. 20.4 invalid results/1,000 tests, P<0.001). AdvanSure assay represents a comparable yet more reliable method than COBAS TaqMan for the identification of mycobacteria in routine clinical microbiology.
Clark, Andrew E; Kaleta, Erin J; Arora, Amit; Wolk, Donna M
Within the past decade, clinical microbiology laboratories experienced revolutionary changes in the way in which microorganisms are identified, moving away from slow, traditional microbial identification algorithms toward rapid molecular methods and mass spectrometry (MS). Historically, MS was clinically utilized as a high-complexity method adapted for protein-centered analysis of samples in chemistry and hematology laboratories. Today, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) MS is adapted for use in microbiology laboratories, where it serves as a paradigm-shifting, rapid, and robust method for accurate microbial identification. Multiple instrument platforms, marketed by well-established manufacturers, are beginning to displace automated phenotypic identification instruments and in some cases genetic sequence-based identification practices. This review summarizes the current position of MALDI-TOF MS in clinical research and in diagnostic clinical microbiology laboratories and serves as a primer to examine the "nuts and bolts" of MALDI-TOF MS, highlighting research associated with sample preparation, spectral analysis, and accuracy. Currently available MALDI-TOF MS hardware and software platforms that support the use of MALDI-TOF with direct and precultured specimens and integration of the technology into the laboratory workflow are also discussed. Finally, this review closes with a prospective view of the future of MALDI-TOF MS in the clinical microbiology laboratory to accelerate diagnosis and microbial identification to improve patient care.
Clark, Andrew E.; Kaleta, Erin J.; Arora, Amit
SUMMARY Within the past decade, clinical microbiology laboratories experienced revolutionary changes in the way in which microorganisms are identified, moving away from slow, traditional microbial identification algorithms toward rapid molecular methods and mass spectrometry (MS). Historically, MS was clinically utilized as a high-complexity method adapted for protein-centered analysis of samples in chemistry and hematology laboratories. Today, matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) MS is adapted for use in microbiology laboratories, where it serves as a paradigm-shifting, rapid, and robust method for accurate microbial identification. Multiple instrument platforms, marketed by well-established manufacturers, are beginning to displace automated phenotypic identification instruments and in some cases genetic sequence-based identification practices. This review summarizes the current position of MALDI-TOF MS in clinical research and in diagnostic clinical microbiology laboratories and serves as a primer to examine the “nuts and bolts” of MALDI-TOF MS, highlighting research associated with sample preparation, spectral analysis, and accuracy. Currently available MALDI-TOF MS hardware and software platforms that support the use of MALDI-TOF with direct and precultured specimens and integration of the technology into the laboratory workflow are also discussed. Finally, this review closes with a prospective view of the future of MALDI-TOF MS in the clinical microbiology laboratory to accelerate diagnosis and microbial identification to improve patient care. PMID:23824373
Yin, Robert K.; And Others
The goal of this report is to describe the process by which new service practices in urban bureaucracies become routinized. The routinization process is studied by examining the life histories of six types of innovations: computer-assisted instruction; police computer systems; mobile intensive care units; closed circuit television systems; breath…
The question of practical knowledge and its teaching has arisen more perceptibly since the appearance of the aim to professionalize teachers. How can imperceptible knowledge such as professional routines be taught? To establish a social fabric and effective class management, it is essential to call on creative and adaptive professional routines.…
Pagliarini, Sergio; Beatty, Stephen; Lipkova, Blandina; Perez-Salvador Garcia, Eduardo; Reynders, Stefaan; Gekkieva, Margarita; Si Bouazza, Abdelkader; Pilz, Stefan
Purpose. To assess the safety profile of ranibizumab 0.5 mg in patients with neovascular age-related macular degeneration (nAMD) in routine clinical practice. Methods. This 2-year, multicentre, observational study was conducted to capture real-world early practice and outcomes across Europe, shortly after European licensing of ranibizumab for nAMD. Being observational in nature, the study did not impose diagnostic/therapeutic interventions/visit schedule. Patients were to be treated as per the EU summary of product characteristics (SmPC) in effect during the study. Key outcome measures were incidence of selected adverse events (AEs), treatment exposure, bilateral treatment, compliance to the EU SmPC, and best-corrected visual acuity (BCVA) over 2 years. Results. 755 of 770 patients received treatment. Ranibizumab was generally well tolerated with low incidence of selected AEs (0%-1.9%). Patients received 6.2 (mean) injections and 133 patients received bilateral treatment over 2 years. Protocol deviation to treatment compliance was reported in majority of patients. The observed decline in mean BCVA (Month 12, +1.5; Month 24, -1.3 letters) may be associated with undertreatment as suggested by BCVA subgroup analysis. Conclusion. The EPICOHORT study conducted in routine clinical practice reinforces the well-established safety profile of ranibizumab in nAMD. In early European practice it appeared that the nAMD patients were undertreated.
Background According to some studies, almost 40% of depressive patients – half of them previously undetected – are diagnosed of bipolar II disorder when systematically assessed for hypomania. Thus, instruments for bipolar disorder screening are needed. The Mood Disorder Questionnaire (MDQ) is a self-reported questionnaire validated in Spanish in stable patients with a previously known diagnosis. The purpose of this study is to evaluate in the daily clinical practice the usefulness of the Spanish version of the MDQ in depressive patients. Methods Patients (n = 87) meeting DSM-IV-TR criteria for a major depressive episode, not previously known as bipolar were included. The affective module of the Structured Clinical Interview (SCID) was used as gold standard. Results MDQ screened 24.1% of depressive patients as bipolar, vs. 12.6% according to SCID. For a cut-off point score of 7 positive answers, sensitivity was 72.7% (95% CI = 63.3 – 82.1) and specificity 82.9% (95% CI = 74.9–90.9). Likelihood ratio of positive and negative tests were 4,252 y 0,329 respectively. Limitations The small sample size reduced the power of the study to 62%. Conclusion Sensitivity and specificity of the MDQ were high for screening bipolar disorder in patients with major depression, and similar to the figures obtained in stable patients. This study confirms that MDQ is a useful instrument in the daily clinical assessment of depressive patients. PMID:18498637
Bonora, Stefano; Madeddu, Giordano; Maggiolo, Franco; Antinori, Andrea; Galli, Massimo; Di Perri, Giovanni; Viale, Pierluigi; d’Arminio Monforte, Antonella; Gori, Andrea
Background In clinical trials, toxicity leading to tenofovir disoproxil fumarate (TDF) discontinuation is rare (3% by 2 years); however in clinical practice it seems to be higher, particularly when TDF is co-administered with ritonavir-boosted protease inhibitors (PI/r). Aims of this study were to assess the rate of TDF discontinuations in clinical practice and to identify factors associated with the risk of stopping TDF. Methods All antiretroviral treatment (ART)-naive patients initiating a TDF-based regimen were selected from the ICONA Foundation Study cohort. The primary outcome was TDF discontinuation regardless of the reason; secondary outcome measures were TDF discontinuation due to toxicity and selective TDF discontinuation (that is, TDF discontinuation or substitution, maintaining unchanged the remaining antiretroviral treatment). Results 3,618 ART-naïve patients were included: 54% started a PI/r-based and 46% a NNRTI-based based regimen. Two-hundred-seventy-seven patients discontinued TDF and reintroduced ART within 30 days without TDF. The probability of TDF discontinuation regardless of the reason was of 7.4% (95%CI:6.4–8.5) by 2 years and 14.1% (95%CI:12.2–16.1) by 5 years. The 5-year KM estimates in the PI/r vs. NNRTI group were 20.4% vs. 7.6%, respectively (log-rank p = 0.0001), for the outcome of stopping regardless of the reason, and 10.7% vs. 4.7% (p = 0.0001) for discontinuation due to toxicity. PI/r use and lower eGFR were associated with an increased risk of discontinuing TDF. Conclusion In our cohort, the frequency of TDF discontinuations was higher than that observed in clinical trials. Co-administration of TDF with PI/r was associated with an increased rate of TDF discontinuations. Further studies are needed to clarify the mechanisms that might have led to this outcome. PMID:27716843
Cost analysis of bivalirudin versus reference anticoagulants without GP IIb/IIIa inhibitors in patients undergoing percutaneous coronary intervention for acute coronary syndrome in routine clinical practice. Pompidou registry.
Puymirat, E; Cohen, S; Védrenne, G; Caruba, T; Sabatier, B; Danchin, N; Durand, E
Randomized controlled trials have shown improved short-term bleeding outcomes for bivalirudin compared to other anticoagulant in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). This study analyzed the cost/efficacy profile of bivalirudin-based anticoagulation strategy versus non bivalirudin-based anticoagulant strategy without use of GP IIb/IIIa inhibitors in routine clinical practice. From January 2009 to December 2010, 216 patients who underwent PCI for ACS at hospital Georges-Pompidou without GP IIb/IIIa inhibitors were studied. Of these patients, 24 (11%) received bivalirudin and 192 (88%) received others anticoagulants (mainly unfractionated heparin or low molecular weight heparin). Ischemic events and bleeding or transfusion were slightly lower in bivalirudin group (0 vs. 4.2%, P=0.60 and 4.2 vs. 8.9%, P=0.70, respectively). In spite of a higher cost of the medication, the overall cost of the bivalirudin strategy was slightly lower (9167±3688 € vs. 14,016±14,749 €, P=0.23), in relation with a shorter average duration of the hospital stay. In conclusion, in this limited, single-center, population of patients with ACS, the clinical efficacy and safety of bivalirudin appeared at least as good as that of reference anticoagulants in real world clinical practice, with no increase in overall costs.
Kleine-Tebbe, Jörg; Jakob, Thilo
Allergen molecules (synonyms: single allergens, allergen components) open up new horizons for the targeted allergen-specific diagnostics of immunoglobulin E (IgE) in singleplex determination. The following rationales support the targeted use of allergen molecules and, more importantly, improve test properties: (1) increased test sensitivity ("analytical sensitivity"), particularly when important allergens are under-represented or lacking in the extract; (2) improved test selectivity (analytical specificity), particularly when the selected IgE repertoire against an allergen yields additional information on: (a) potential risk, (b) possible cross-reactivity, or (c) primary (species-specific) sensitization. However, the appropriate indication for the use of single allergens can only be established on a case-by-case basis (depending on the clinical context and previous history) and in an allergen-specific manner (depending on the allergen source and the single allergens available), rather than in a standardized way. Numerous investigations on suspected food allergy, insect venom allergy, or sensitization to respiratory allergens have meanwhile demonstrated the successful use of defined molecules for allergen-specific singleplex IgE diagnosis. Specific IgE to single allergens is limited in its suitability to predict the clinical relevance of sensitivity on an individual basis. In food allergies, one can at best identify the relative risk of a clinical reaction on the basis of an IgE profile, but no absolutely reliable prediction on (future) tolerance can be made. Ultimately, the clinical relevance of all IgE findings depends on the presence of corresponding symptoms and can only be assessed on an individual basis (previous history, symptom log, and provocation testing with the relevant allergen source where appropriate). Thus, also in molecular allergology, the treating physician and not the test result should determine the clinical relevance of diagnostic findings.
Finning, Kirstin; Bhandari, Radhika; Sellers, Fiona; Revelli, Nicoletta; Villa, Maria Antonietta; Muñiz-Díaz, Eduardo; Nogués, Núria
Background High-throughput genotyping platforms enable simultaneous analysis of multiple polymorphisms for blood group typing. BLOODchip® ID is a genotyping platform based on Luminex® xMAP technology for simultaneous determination of 37 red blood cell (RBC) antigens (ID CORE XT) and 18 human platelet antigens (HPA) (ID HPA XT) using the BIDS XT software. Materials and methods In this international multicentre study, the performance of ID CORE XT and ID HPA XT, using the centres’ current genotyping methods as the reference for comparison, and the usability and practicality of these systems, were evaluated under working laboratory conditions. DNA was extracted from whole blood in EDTA with Qiagen methodologies. Ninety-six previously phenotyped/genotyped samples were processed per assay: 87 testing samples plus five positive controls and four negative controls. Results Results were available for 519 samples: 258 with ID CORE XT and 261 with ID HPA XT. There were three “no calls” that were either caused by human error or resolved after repeating the test. Agreement between the tests and reference methods was 99.94% for ID CORE XT (9,540/9,546 antigens determined) and 100% for ID HPA XT (all 4,698 alleles determined). There were six discrepancies in antigen results in five RBC samples, four of which (in VS, N, S and Doa) could not be investigated due to lack of sufficient sample to perform additional tests and two of which (in S and C) were resolved in favour of ID CORE XT (100% accuracy). The total hands-on time was 28–41 minutes for a batch of 16 samples. Compared with the reference platforms, ID CORE XT and ID HPA XT were considered simpler to use and had shorter processing times. Discussion ID CORE XT and ID HPA XT genotyping platforms for RBC and platelet systems were accurate and user-friendly in working laboratory settings. PMID:26674823
Rink, M; Kluth, L A; Shariat, S F; Chun, F K; Fisch, M; Dahm, P
Applying evidence-based medicine in daily clinical practice is the basis of patient-centered medicine and knowledge of accurate literature acquisition skills is necessary for informed clinical decision-making. PubMed is an easy accessible, free bibliographic database comprising over 21 million citations from the medical field, life-science journals and online books. The article summarizes the effective use of PubMed in routine urological clinical practice based on a common case scenario. This article explains the simple use of PubMed to obtain the best search results with the highest evidence. Accurate knowledge about the use of PubMed in routine clinical practice can improve evidence-based medicine and also patient treatment.
Margolin, David A.; Beck, David E.
A multispecialty clinic practice is a common practice arrangement for colorectal surgeons. This type of practice has a variety of features, both positive and negative. The authors explore location, practice patterns, lifestyles, compensation, and academic opportunities associated with a multispecialty clinic practice. This information can assist younger surgeons in choosing a practice opportunity and guide experienced surgeons through their career progression. PMID:22654568
de Bont, Antoinette; Bal, Roland
Background Information systems can play a key role in care innovations including task redesign and shared care. Many demonstration projects have presented evidence of clinical and cost effectiveness and high levels of patient satisfaction. Yet these same projects often fail to become part of everyday clinical routines. The aim of the paper is to gain insight into a common paradox that a technology can meet the criteria for success set out at the start of the project yet fail to become part of everyday clinical routines. Methods We evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were further assessed by trained technicians in the hospital. Over a period of three years, we conducted interviews with the project team and the users about the workability of the system and its integration in practice. Beside the interviews, we analyzed record data to measure the quality of the images. We compared the qualitative accounts with these measurements. Results According to our measurements, the quality of the images was at least satisfactory in 90% of the cases, i.e. the images could be used to screen the patients – reducing the workload of the ophthalmologist considerably. However, both the ophthalmologist and the optometrists became increasingly dissatisfied respectively with the perceived quality of the pictures and the perceived workload. Through a detailed analysis of how the professionals discussed the quality of the pictures, we re-constructed how the notion of quality of the images and being a good professional were constructed and linked. The IT system transformed into a quality system and, at the same time, transformed the notions of being a good professional. While a continuous dialogue about the quality of the pictures became an emblem for the quality of care, this dialogue was hindered by the system and the way the care
Less than 5% of colorectal adenomas will become malignant, but we do not have sufficient knowledge about their natural course to target removal of these 5% only. Thus, 95% of polypectomies are a waste of time exposing patients to a small risk of complications. Recently, a new type of polyps, sessile serrated polyps, has attracted attention. Previously considered innocuous, they are now found to have molecular similarities to cancer and some guidelines recommend to have them removed. These lesions are often flat, covered by mucous, not easily seen and situated in the proximal colon where the bowel wall is thinner. Thus, polypectomy carries a higher risk of perforation than predominantly left-sided, stalked adenomas - and we do not know what is gained in terms of cancer prevention. Screening is a neat balance between harms and benefit for presumptively healthy participants not interested in risk exposure to obtain confirmation of being healthy. The situation is quite different for patient worried about symptom. Thus, the standards set for evidence-based practice may be higher for screening than for routine clinics - a mechanism which may benefit patients in the long run.
In routine practice neuroimaging has been applied as an adjunct technique for early and differential diagnosis of Alzheimer disease in routine practice. Of the several neuroimaging modalities, magnetic resonance imaging (MRI) and brain perfusion single-photon emission computed tomography (SPECT) have been commonly used in Japan; further software programs are used to aid statistical analysis of the imaging results. For example voxel-based specific regional analysis system for Alzheimer disease (VSRAD) for MRI and easy Z-score imaging system (eZIS) are used for the analysis of MRI and SPECT. In the early stage of Alzheimer disease, specific findings of regional atrophy and perfusion reduction are observed in some areas. In the posterior cingulate gyrus precuneus and parietal cortex, perfusion reduction was more frequently observed than atrophy. On the other hand, in the medial temporal structures, perfusion reduction was less frequently observed than atrophy. Perfusion reduction in the the posterior cingulate gyrus precuneus and in the parietal cortex was more prominent in the case of patients with early-onset Alzheimer disease than in the case of patients with late-onset Alzheimer disease. Further, atrophy in the medial temporal structures was more prominent in the case of patients with late-onset Alzheimer disease than in the case of those with early-onset Alzheimer disease. These findings are helpful for differentiating of Alzheimer disease from other diseases characterized by dementia.
Greenhalgh, Trisha; Voisey, Christopher; Robb, Nadia
UK general practices operate in an environment of high linguistic diversity, because of recent large-scale immigration and of the NHS's commitment to provide a professional interpreter to any patient if needed. Much activity in general practice is co-ordinated and patterned into organisational routines (defined as repeated patterns of interdependent actions, involving multiple actors, bound by rules and customs) that tend to be stable and to persist. If we want to understand how general practices are responding to pressures to develop new routines, such as interpreted consultations, we need to understand how existing organisational routines change. This will then help us to address a second question, which is how the interpreted consultation itself is being enacted and changing as it becomes routinised (or not) in everyday general practice. In seeking answers to these two questions, we undertook a qualitative study of narratives of interpreted primary care consultations in three London boroughs with large minority ethnic populations. In 69 individual interviews and two focus groups, we sought accounts of interpreted consultations from service users, professional interpreters, family member interpreters, general practitioners, practice nurses, receptionists, and practice managers. We asked participants to tell us both positive and negative stories of their experiences. We analysed these data by searching for instances of concepts relating to the organisational routine, the meaning of the interpreted consultation to the practice, and the sociology of medical work. Our findings identified a number of general properties of the interpreted consultation as an organisational routine, including the wide variation in the form of adoption, the stability of the routine, the adaptability of the routine, and the strength of the routine. Our second key finding was that this variation could be partly explained by characteristics of the practice as an organisation, especially
Dolan, Michelle; Snover, Dale
Because HER-2 expression in invasive carcinoma of the breast has well-documented ramifications for treatment and prognosis, accurate assessment of HER-2 status is critical. Comparative studies have shown high concordance rates between immunohistochemical analysis and fluorescence in situ hybridization (FISH) in cases with immunohistochemical scores of 0 or 1+ (negative) and 3+ (strongly positive) and low concordance rates among cases with immunohistochemical scores of 2+. The present study was performed to determine concordance rates in a setting more representative of routine clinical practice, in which multiple pathologists submit specimens to a single cytogenetics referral laboratory. We found a higher rate of discordance between immunohistochemical analysis and FISH (approximately 92%) in the groups with immunohistochemical scores of 2+ than reported in other studies. These results strongly support the practice of performing FISH in all cases with immunohistochemical scores of 2+, particularly in routine practice, in which interobserver variability in immunohistochemical scoring among multiple pathologists is likely to be high.
Desai, A K; Jaiyesimi, R A K
The practice of undertaking routine intimate examinations in the management of subfertile couples varies among clinicians. An anonymous self-administered mailed questionnaire survey was carried out to determine the current practices followed by clinicians and the rationale supporting their practice. In the absence of large comparative studies, this survey provides expert opinion regarding this practice. The questionnaire was mailed to the Fellows and members of the Royal College of Obstetricians and Gynaecologists in the Northern, Yorkshire, West Midlands and Wales regions in the UK. A total of 802 questionnaires were posted, of which 516 were returned, giving an overall response rate of 64%. The responses and comments varied. Some 62% of respondents would routinely perform a pelvic examination on all women presenting with subfertility; 23% would do so only in selected cases and 63% of the clinicians would perform a routine transvaginal ultrasound. The male partners are examined by only 19% of the clinicians. A total of 83% of the respondents were of the opinion that the survey made them think about the role and justification of intimate examinations in greater detail. The practice of intimate examination of subfertile couples varies among clinicians in the survey group. There is a need for large prospective comparative studies to study the value of this examination and related practices in the management of subfertile couples. In the absence of comparative trials, this survey provides expert opinion. It may be suggested that an intimate examination should not be carried out routinely in all subfertile couples. It could be done when it has potential to add value to the management of the patient. A pragmatic approach should be adopted in every clinical situation.
Wolberg, Rochelle Ibanez; Goff, Allison
This article describes thinking routines as tools to guide and support young children's thinking. These learning strategies, developed by Harvard University's Project Zero Classroom, actively engage students in constructing meaning while also understanding their own thinking process. The authors discuss how thinking routines can be used in both…
Belgaied, Wael; Samp, Jennifer; Vimont, Alexandre; Rémuzat, Cécile; Aballéa, Samuel; El Hammi, Emna; Kooli, Amna; Toumi, Mondher; Akhras, Kasem
As more evidence points to the association of cognitive dysfunction with mental health disorders, the assessment of cognitive function in routine clinical care of these disorders is increasingly important. Despite this, it remains unknown how cognitive function is measured in routine clinical practice. The objective of this study was to assess psychiatrists' awareness of cognitive dysfunction in mental health disorders and their methods of cognitive assessment. An online survey was disseminated to psychiatrists in Europe, Asia, Australia and the United States. The survey asked about their perceptions of cognitive dysfunction in several mental health disorders, knowledge of cognitive assessment, method of cognitive assessment, and instruments used to measure cognitive function. Among the 61 respondents, most perceived that schizophrenia was associated with the greatest cognitive dysfunction. Many were unaware whether guidelines were available on cognitive assessment. In schizophrenia, 59% of psychiatrists reportedly used cognitive instruments, while the remainder relied solely on patient history interviews. The use of instruments to assess cognition in major depressive disorder (MDD) and bipolar disorder (BPD) was lower, 38% and 37% respectively. Of the reported instruments used, only a few were actually appropriate for use in the diseases of interest (12% in schizophrenia, 3% in MDD and 0% in BPD). Other instruments reported were clinical measures that did not assess cognition. These findings reveal some inconsistencies in psychiatrists' routine clinical evaluation of cognitive function. There appeared to be low use of true cognitive assessment instruments in clinical practice and confusion regarding what constituted a cognitive assessment instrument.
Bukowski, Mark; Kühn, Martin; Zhao, Xiaoqing; Bettermann, Ralf; Jonas, Stephan
Gamification is used in clinical context in the health care education. Furthermore, it has shown great promises to improve the performance of the health care staff in their daily routine. In this work we focus on the medication sorting task, which is performed manually in hospitals. This task is very error prone and needs to be performed daily. Nevertheless, errors in the medication are crucial and lead to serious complications. In this work we present a real world gamification approach of the medication sorting task in a patient's daily pill organizer. The player of the game needs to sort the correct medication into the correct dispenser slots and is rewarded or punished in real time. At the end of the game, a score is given and the user can register in a leaderboard.
Sánchez-Gonzaléz, Miguel; Herreros, Benjamín
Bioethics has grown exponentially in recent decades. Its most important schools include principlism, casuistry, virtue ethics and the ethics of care. These schools are not exclusive. Within bioethics, clinical ethics addresses the inherent clinical practice ethical problems, problems which are many and very varied. Bioethics training is essential for clinicians to address these bioethics' problems. But even the professionals are trained, there are problems that cannot be solved individually and require advisory groups in clinical ethics: clinical ethics committees. These committees are also responsible for education in bioethics in health institutions. Clinical bioethics is a practical discipline, oriented to address specific problems, so its development is necessary to improve the decision making in such complex problems, inevitable problems in healthcare.
Holland, Patricia E.
Clinical supervision remained grounded in empirical inquiry as late as Morris Cogan's writings on the subject in 1973. With the acknowledgment of Thomas Kuhn's (1962) paradigm shift, educational theory and practice developed interpretive methodologies. An interpretive reflection on Cogan's rationale offers insights into the current, matured…
Arango, Jaime; Chuck, Tina; Ellenberg, Susan S.; Foltz, Bridget; Gorman, Colleen; Hinrichs, Heidi; McHale, Susan; Merchant, Kunal; Shapley, Stephanie; Wild, Gretchen
Good Clinical Practice (GCP) is an international standard for the design, conduct, performance, monitoring, auditing, recording, analyses, and reporting of clinical trials. The goal of GCP is to ensure the protection of the rights, integrity, and confidentiality of clinical trial participants and to ensure the credibility and accuracy of data and reported results. In the United States, trial sponsors generally require investigators to complete GCP training prior to participating in each clinical trial to foster GCP and as a method to meet regulatory expectations (ie, sponsor’s responsibility to select qualified investigators per 21 CFR 312.50 and 312.53(a) for drugs and biologics and 21 CFR 812.40 and 812.43(a) for medical devices). This training requirement is often extended to investigative site staff, as deemed relevant by the sponsor, institution, or investigator. Those who participate in multiple clinical trials are often required by sponsors to complete repeated GCP training, which is unnecessarily burdensome. The Clinical Trials Transformation Initiative convened a multidisciplinary project team involving partners from academia, industry, other researchers and research staff, and government to develop recommendations for streamlining current GCP training practices. Recommendations drafted by the project team, including the minimum key training elements, frequency, format, and evidence of training completion, were presented to a broad group of experts to foster discussion of the current issues and to seek consensus on proposed solutions. PMID:27390628
Liraglutide effect and action in diabetes-In (LEAD-In): A prospective observational study assessing safety and effectiveness of liraglutide in patients with type 2 diabetes mellitus treated under routine clinical practice conditions in India
Wangnoo, Subhash Kumar; Kumar, Surender; Bhattacharyya, Arpandev; Tripathi, Sudhir; Akhtar, Shahid; Shetty, Raman; Ghosal, Samit
Background: This 26-week, open-label observational study assessed the incidence and type of adverse events (AEs) associated with liraglutide use according to the standard clinical practice settings and the local label in India. Materials and Methods: A total of 1416 adults with type 2 diabetes (T2D) treated with liraglutide in 125 sites across India were included in the study. Participants were newly diagnosed or already receiving antidiabetic medications. Safety and efficacy data were collected at baseline and at approximately weeks 13 and 26. The primary outcome was incidence and type of AEs while using liraglutide, with events classified by Medical Dictionary for Regulatory Activities system organ class and preferred term. The secondary objective was to assess other clinical parameters related to effective T2D management. Results: Twenty AEs, predominately gastrointestinal, were reported in 1.3% of the study population in scheduled visits up to week 26. No serious AEs, including death, were reported. Hypoglycemic episodes were reported in 7.3% of participants at baseline and 0.7% at week 26. No major hypoglycemic events were reported up to week 26 (baseline: 0.4%). Glycated hemoglobin was reduced from baseline (8.8 ± 1.3%) to week 26 by 1.6 ± 1.1% (P < 0.0001); significant improvements in fasting blood glucose, and 2-h postprandial blood glucose (post-breakfast, -lunch, and -dinner) were also observed. Mean body weight decreased by 8.1 ± 6.5 kg from baseline (92.5 ± 14.6 kg; P < 0.0001). Conclusions: From the number of AEs reported, it is suggested that liraglutide was well tolerated in subjects with T2D treated under standard clinical practice conditions in India. Liraglutide was effective, and no new safety concerns were identified. PMID:27867889
Francis, J; Barrett, S P; Ogilvie, M M; Sutherland, S
Viral examination is routinely carried out in most routine diagnostic microbiology laboratories. Most often, this comprises the detection of viral antigens and antibodies, and less commonly the isolation of viruses and the detection of viral nucleic acids. However, there are no standards or guidelines available for processing these specimens in routine diagnostic laboratories or for referral to specialist virology centres or units. Clinical Pathology Accreditation (CPA) has defined standards for assessing the quality of service provided by laboratories, but these do not include the scientific and technical aspects of provision of service. The Association of Medical Microbiologists has recently published Standards for Laboratory practice in medical microbiology, which covers scientific and technical aspects of provision of microbiology service, mainly bacteriological examination of specimens in routine diagnostic microbiology laboratories. These guidelines are complementary to the CPA guidelines and aim to ensure a consistent and high quality service. This article presents guidelines for the examination of specimens for the diagnosis of viral infections.
The clinical, computed tomography, cytological, and histological aspects of interstitial lung disease complicating an autoimmune disease lack specificity. Search for autoantibodies in the serum is thus warranted once the essentially clinical diagnosis has been established. An exhaustive history taking should aim at identifying extrathoracic elements of a possible systemic autoimmune disease. The battery of the biological tests which can be useful are discussed here in light of the diagnostic, prognostic, therapeutic, and even conceptual aspects of the disease. For the clinician, a simplified analysis of the main methods and the interpretation of immunological tests is discussed together with new tools currently under development.
Much more is known about attitudes toward mental illness and social stigma, the viscious cycle of its consequences and how to fight the social stigma in public, but much less is known about how to combat the stigma and self stigma in clinical practice. Stigma theories have not been enough to understand the feelings and experience of people with mental illness. Conceptual framework that understands stigma as consisting of difficulties of knowledge (ignorance or misinformation), problems of attitudes (prejudice), and problems of behaviour (discrimination) have not o been enough to understand stigma dynamics in the patient therapist interaction. Understanding the psychodynamic aspects of internalized stereotype of mental illness in the patient- therapist relationship may improve our competency to deal with stigma and self stigma in clinical practice.
Sheu-Grabellus, S-Y; Schmid, K W
The diagnostic histopathology of parathyroid glands comprises mostly benign diseases associated with primary, secondary and rarely tertiary hyperparathyroidism. Parathyroid adenoma and hyperplasia are the most common diagnoses, whereas parathyroid carcinomas and atypical adenomas are exceptional causes of hyperparathyroidism, the latter being purely a diagnosis by exclusion. This article deals with the major histopathological criteria of the various diagnoses with special emphasis on the clinical manifestation.
Vleugels, A M
Clinical practice guidelines are systematically developed statements that are intended to support medical decision making in well-defined clinical situations. Essentially, their object is to reduce the variability in medical practice, to improve quality, and to make appropriated control of the financial resources possible. Internationally, ever more organisations, associations, and institutions are concerned with the development of guidelines in many different areas of care. Making implicit knowledge explicit is one of the associated advantages of guidelines: they have a potential utility in training, in process evaluation, and in the reevaluation of outcome studies. In liability issues, their existence has a double effect: they can be used to justify medical behaviour, and they constitute a generally accepted reference point. A derivative problem is the legal liability of the compilers of the guidelines. The principle of the guideline approach can be challenged academically: science cannot give a definition of optimal care with absolute certainty. What is called objectivity often rests on methodologically disputable analyses; also the opinion of opinion leaders is not always a guarantee for scientific soundness. Moreover, patients are not all identical: biological variability, situational factors, patient expectations, and other elements play a role in this differentiation. Clinicians are often hesitant with respect to clinical guidelines: they are afraid of cookbook medicine and curtailment of their professional autonomy. Patients fear reduction of individualization of care and the use of guidelines as a rationing instrument. The effects of the introduction of clinical practice guidelines on medical practice, on the results and on the cost of care vary but are generally considered to be favourable. The choice of appropriate strategies in development, dissemination, and implementation turns out to be of critical importance. The article ends with concrete
In recent years the ability of neuroscience to identify and intervene in mental functions has progressed immensely, which raises several anthropologic and ethical questions. Meanwhile neuroethics arose as a new interdisciplinary field for critical analysis of neuroscientific actions and ethical reflection on the increasing knowledge of the human brain, with regard to society and politics. This article provides a survey of neuroethical implications for clinical practice.
Gridelli, Cesare; Ardizzoni, Andrea; Barni, Sandro; Crinò, Lucio; Caprioli, Alberto; Piazza, Elena; Lorusso, Vito; Barbera, Santi; Zilembo, Nicoletta; Gebbia, Vittorio; Adamo, Vincenzo; Pela, Riccardo; Marangolo, Maurizio; Morena, Raffaella; Filippelli, Gianfranco; Buscarino, Calogero; Alabiso, Oscar; Maione, Paolo; Venturino, Paola; De Marinis, Filippo
Lung cancer is the most common cancer in the world today, in terms of both incidence and mortality. Non-small cell lung cancer (NSCLC) accounts for about 85% of all lung cancers, and the majority of people diagnosed with NSCLC have locally advanced or metastatic disease. Treatment algorithms have rapidly changed in the last 10 years because of the introduction of new chemotherapeutic and targeted agents in clinical practice. SUN is a 1-year longitudinal observational multicenter study that has consecutively enrolled patients affected by stage IIIB or IV NSCLC with the aim to describe the pattern of care and evolving approaches in the treatment of advanced NSCLC. 987 consecutive NSCLC patients were enrolled between January 2007 and March 2008 at the 74 participating centers throughout Italy and a 12-month follow-up was performed. Cyto-histological diagnosis was performed mainly by broncoscopy with only 24% by CT-scan guided fine-needle aspiration biopsy. 91.4% of the patients received a first-line medical treatment and 8.6% supportive care only. Median age of patients receiving first-line treatment was 66 years. First-line chemotherapy consisted of a single agent in 20% of patients and combination chemotherapy in 80%. The most frequently used chemotherapy regimens were cisplatin plus gemcitabine and carboplatin plus gemcitabine. Median survival of patients receiving first-line chemotherapy was 9.1 months. 32% percent of patients received a second-line treatment that consisted of chemotherapy in 71% of cases and erlotinib in 29%. Overall third-line treatment was given to 7.3% of patients. These results showed a pattern of care for advanced NSCLC that reflects the current clinical practice in Italy at the study time with a high adherence to the International guidelines by the Italian Oncologists.
Whereas alchemy postulated the unity of body and soul as early as in the 15th century, René Descartes developed an artificial separation of the body from the soul in the 17th century, a challenge that today's doctors continue to face. This problematic nature of dualism seems to be suitable for complicating the doctor's relationship with patients of different age groups. With the help of a screening technique and a semi-standardized interview 100 patients (25 women with RA aged > 65; 25 women with RA aged < 55; 25 women aged < 65 without RA and 25 women aged < 55 without RA) were examined with regard to their basic needs in the relationships with their doctor. The patients older than 65 showed characteristic psychophysical particularities and, as compared with patients younger than 55, 86% of them articulated the needs for security as primary need in the relationship with their doctor. Seventy-six percent of the younger patients articulated the need for passing on of information as primary need. To understand the world of the elderly means the handling of pseudo-morbidity, reduced capability, social death and disease as normality, means the acceptance of the need for a mainly emotional doctor-patient relationship. From the results efficient psycho-therapeutical findings can be recommended for the doctor's practical work with regard to "pitfalls," as well as for use as the basis for talks and for a method to use in dealing with elderly people.
Jones, Robert E
Background Surveying patients is increasingly important for evaluating and improving health care delivery, but practical survey strategies during routine care activities have not been available. Objective We examined the feasibility of conducting routine patient surveys in a primary care clinic using commercially available technology (Web-based survey creation, deployment on tablet computers, cloud-based management of survey data) to expedite and enhance several steps in data collection and management for rapid quality improvement cycles. Methods We used a Web-based data management tool (survey creation, deployment on tablet computers, real-time data accumulation and display of survey results) to conduct four patient surveys during routine clinic sessions over a one-month period. Each survey consisted of three questions and focused on a specific patient care domain (dental care, waiting room experience, care access/continuity, Internet connectivity). Results Of the 727 available patients during clinic survey days, 316 patients (43.4%) attempted the survey, and 293 (40.3%) completed the survey. For the four 3-question surveys, the average time per survey was overall 40.4 seconds, with a range of 5.4 to 20.3 seconds for individual questions. Yes/No questions took less time than multiple choice questions (average 9.6 seconds versus 14.0). Average response time showed no clear pattern by order of questions or by proctor strategy, but monotonically increased with number of words in the question (<20 words, 21-30 words, >30 words)—8.0, 11.8, 16.8, seconds, respectively. Conclusions This technology-enabled data management system helped capture patient opinions, accelerate turnaround of survey data, with minimal impact on a busy primary care clinic. This new model of patient survey data management is feasible and sustainable in a busy office setting, supports and engages clinicians in the quality improvement process, and harmonizes with the vision of a learning health
Sinagra, Gianfranco; Anzini, Marco; Pereira, Naveen L; Bussani, Rossana; Finocchiaro, Gherardo; Bartunek, Jozef; Merlo, Marco
Myocarditis is a polymorphic disease characterized by great variability in clinical presentation and evolution. Patients presenting with severe left ventricular dysfunction and life-threatening arrhythmias represent a demanding challenge for the clinician. Modern techniques of cardiovascular imaging and the exhaustive molecular evaluation of the myocardium with endomyocardial biopsy have provided valuable insight into the pathophysiology of this disease, and several clinical registries have unraveled the disease's long-term evolution and prognosis. However, uncertainties persist in crucial practical issues in the management of patients. This article critically reviews current information for evidence-based management, offering a rational and practical approach to patients with myocarditis. For this review, we searched the PubMed and MEDLINE databases for articles published from January 1, 1980, through December 31, 2015, using the following terms: myocarditis, inflammatory cardiomyopathy, and endomyocardial biopsy. Articles were selected for inclusion if they represented primary data or were review articles published in high-impact journals. In particular, a risk-oriented approach is proposed. The different patterns of presentation of myocarditis are classified as low-, intermediate-, and high-risk syndromes according to the most recent evidence on prognosis, clinical findings, and both invasive and noninvasive testing, and appropriate management strategies are proposed for each risk class.
Giesinger, Johannes; Kemmler, Georg; Meraner, Verena; Gamper, Eva-Maria; Oberguggenberger, Anne; Sperner-Unterweger, Barbara; Holzner, Bernhard
Summary Quality of life (QOL) has become a widely used outcome parameter in the evaluation of treatment modalities in clinical oncology research. By now, many of the practical problems associated with measuring QOL in clinical practice can be overcome by the use of computer-based assessment methods. QOL assessment in oncology is dominated by two measurement systems, the FACT scales and the EORTC QLQ-C30 with its modules. The amount of human resources required to implement routine data collection has been reduced significantly by advanced computer technology allowing data collection in busy clinical practice. Monitoring of QOL can contribute to oncologic care by facilitating detection of physical and psychological problems and tracking the course of disease and treatment over time. Furthermore, the integration of screening for psychosocial problems into QOL monitoring contributes to the identification of patients who are in need of psychooncologic interventions. Computer-based QOL monitoring does not replace the direct physician-patient communication but enables to identify specific impairments and symptoms including psychological problems. Beyond clinical practice, QOL data can be used for research purposes and may help health care planners to determine those patient services that should be maintained or ones that should be developed. PMID:20847874
Giesinger, Johannes; Kemmler, Georg; Meraner, Verena; Gamper, Eva-Maria; Oberguggenberger, Anne; Sperner-Unterweger, Barbara; Holzner, Bernhard
Quality of life (QOL) has become a widely used outcome parameter in the evaluation of treatment modalities in clinical oncology research. By now, many of the practical problems associated with measuring QOL in clinical practice can be overcome by the use of computer-based assessment methods. QOL assessment in oncology is dominated by two measurement systems, the FACT scales and the EORTC QLQ-C30 with its modules. The amount of human resources required to implement routine data collection has been reduced significantly by advanced computer technology allowing data collection in busy clinical practice. Monitoring of QOL can contribute to oncologic care by facilitating detection of physical and psychological problems and tracking the course of disease and treatment over time. Furthermore, the integration of screening for psychosocial problems into QOL monitoring contributes to the identification of patients who are in need of psychooncologic interventions. Computer-based QOL monitoring does not replace the direct physician-patient communication but enables to identify specific impairments and symptoms including psychological problems. Beyond clinical practice, QOL data can be used for research purposes and may help health care planners to determine those patient services that should be maintained or ones that should be developed.
Biswas, M; Davies, J S
Hyponatraemia is defined as a serum sodium concentration below 135 mmol/l. It causes major diagnostic and management problems in practice. Hyponatraemic disorders are divided into euvolaemic, hypervolaemic and hypovolaemic. In the evaluation of the hyponatraemic patient, history taking should focus on identifying the potential cause, duration and symptomatology. Clinical examination should include assessment of volume status. Acute hyponatraemia of less than 48 h duration requires prompt correction. Treatment may involve hypertonic saline, isotonic saline and appropriate hormone replacement therapy depending on the aetiology. Chronic hyponatraemia should be treated with caution because of the risk of central pontine myelinolysis. PMID:17551067
Frank, Laura L
Thiamin is a water-soluble vitamin also known as vitamin B1. Its biologically active form, thiamin pyrophosphate (TPP), is a cofactor in macronutrient metabolism. In addition to its coenzyme roles, TPP plays a role in nerve structure and function as well as brain metabolism. Signs and symptoms of thiamin deficiency (TD) include lactic acidosis, peripheral neuropathy, ataxia, and ocular changes (eg, nystagmus). More advanced symptoms include confabulation and memory loss and/or psychosis, resulting in Wernicke's encephalopathy and/or Wernicke's Korsakoff syndrome, respectively. The nutrition support clinician should be aware of patients who may be at risk for TD. Risk factors include those patients with malnutrition due to 1 or more nutrition-related etiologies: decreased nutrient intake, increased nutrient losses, or impaired nutrient absorption. Clinical scenarios such as unexplained heart failure or lactic acidosis, renal failure with dialysis, alcoholism, starvation, hyperemesis gravidarum, or bariatric surgery may increase the risk for TD. Patients who are critically ill and require nutrition support may also be at risk for TD, especially those who are given intravenous dextrose void of thiamin repletion. Furthermore, understanding thiamin's role as a potential therapeutic agent for diabetes, some inborn errors of metabolism, and neurodegenerative diseases warrants further research. This tutorial describes the absorption, digestion, and metabolism of thiamin. Issues pertaining to thiamin in clinical practice will be described, and evidence-based practice suggestions for the prevention and treatment of TD will be discussed.
Rahi, J.; Lynn, R.
A survey of a sample of UK paediatricians was carried out to identify the practices and determine the training of those involved in routine surveillance examinations to detect ophthalmic disorders in infants. The findings indicate important variation in current practices and raise concerns about both undergraduate and postgraduate training in ophthalmic assessment of infants. PMID:9623402
Fuertes de Vega, I; Iranzo-Fernández, P; Mascaró-Galy, J M
Bullous pemphigoid (BP) is an autoimmune subepidermal bullous disease in which autoantibodies are directed against components of the basement membrane. Most of these antibodies belong to the immunoglobulin G class and bind principally to 2 hemidesmosomal proteins: the 180-kD antigen (BP180) and the 230-kD antigen (BP230). It is the most common blistering disease in the adult population in developed countries, with an estimated incidence in Spain of 0.2 to 3 cases per 100,000 inhabitants per year. The disease primarily affects older people, although it can also occur in young people and even in children. In recent years, advances in clinical practice have led to a better understanding and improved management of this disorder. These advances include new diagnostic techniques, such as enzyme-linked immunosorbent assay for BP180 and new drugs for the treatment of BP, with diverse therapeutic targets. There is, however, still no international consensus on guidelines for the management of BP. This article is an updated review of the scientific literature on the treatment of BP. It focuses primarily on evidence-based recommendations and is written from a practical standpoint based on experience in the routine management of this disease.
Longo, Caterina; Piana, Simonetta; Lallas, Aimilios; Moscarella, Elvira; Lombardi, Mara; Raucci, Margherita; Pellacani, Giovanni; Argenziano, Giuseppe
Background Several studies have demonstrated the benefit of integrating clinical with pathologic information, to obtain a confident diagnosis for melanocytic tumors. However, all those studies were conducted retrospectively and no data are currently available about the role of a clinical-pathologic correlation approach on a daily basis in clinical practice. Aim of the Study In our study, we evaluated the impact of a routine clinical-pathologic correlation approach for difficult skin tumors seen over 3 years in a tertiary referral center. Results Interestingly, a re-appraisal was requested for 158 out of 2015 (7.7%) excised lesions because clinical-pathologic correlation was missing. Of note, in 0.6% of them (13 out of 2045) the first histologic diagnosis was revised in the light of clinical information that assisted the Pathologist to re-evaluate the histopathologic findings that might be bland or inconspicuous per se. Conclusion In conclusion, our study demonstrated that an integrated approach involving clinicians and pathologists allows improving management of selected patients by shifting from a simply disease-focused management (melanoma versus nevus) to a patient-centered approach. PMID:26325678
Dekker, Andre; Vinod, Shalini; Holloway, Lois; Oberije, Cary; George, Armia; Goozee, Gary; Delaney, Geoff P.; Lambin, Philippe; Thwaites, David
Background and purpose A rapid learning approach has been proposed to extract and apply knowledge from routine care data rather than solely relying on clinical trial evidence. To validate this in practice we deployed a previously developed decision support system (DSS) in a typical, busy clinic for non-small cell lung cancer (NSCLC) patients. Material and methods Gender, age, performance status, lung function, lymph node status, tumor volume and survival were extracted without review from clinical data sources for lung cancer patients. With these data the DSS was tested to predict overall survival. Results 3919 lung cancer patients were identified with 159 eligible for inclusion, due to ineligible histology or stage, non-radical dose, missing tumor volume or survival. The DSS successfully identified a good prognosis group and a medium/poor prognosis group (2 year OS 69% vs. 27/30%, p < 0.001). Stage was less discriminatory (2 year OS 47% for stage I–II vs. 36% for stage IIIA–IIIB, p = 0.12) with most good prognosis patients having higher stage disease. The DSS predicted a large absolute overall survival benefit (~40%) for a radical dose compared to a non-radical dose in patients with a good prognosis, while no survival benefit of radical radiotherapy was predicted for patients with a poor prognosis. Conclusions A rapid learning environment is possible with the quality of clinical data sufficient to validate a DSS. It uses patient and tumor features to identify prognostic groups in whom therapy can be individualized based on predicted outcomes. Especially the survival benefit of a radical versus non-radical dose predicted by the DSS for various prognostic groups has clinical relevance, but needs to be prospectively validated. PMID:25241994
Etienne-Grimaldi, Marie-Christine; Boyer, Jean-Christophe; Thomas, Fabienne; Quaranta, Sylvie; Picard, Nicolas; Loriot, Marie-Anne; Narjoz, Céline; Poncet, Delphine; Gagnieu, Marie-Claude; Ged, Cécile; Broly, Franck; Le Morvan, Valérie; Bouquié, Régis; Gaub, Marie-Pierre; Philibert, Laurent; Ghiringhelli, François; Le Guellec, Chantal
Irinotecan is a major drug in the treatment of advanced colorectal cancer. Its active form is the SN38 metabolite, which is cleared by the biliary route after glucuronidation by uridine diphosphate-glucuronosyltransferase 1A1 (UGT1A1). UGT1A1 activity exhibits a wide intersubject variability, in part related to UGT1A1 gene polymorphisms. The present review on the impact of the deficient UGT1A1*28 variant on irinotecan efficacy and toxicity was produced by a French joint workgroup comprising the Group of Clinical Onco-pharmacology (GPCO-Unicancer) and the National Pharmacogenetics Network (RNPGx). It clearly emerges that for irinotecan doses at least equal to 180 mg/m(2) , patients homozygous for the UGT1A1*28 allele are at increased risk of developing hematological and/or digestive toxicities. Irinotecan dose reduction is thus recommended in homozygous *28/*28 patients. In addition, this personalized medicine strategy aims to secure high-dose irinotecan administration (≥240 mg/m(2) ) that have proven to be safe in homozygous *1/*1 patients only. The clinical relevance of this test is discussed in terms of treatment efficacy improvement, as increasing the irinotecan dose appears to be safe in patients not bearing a deficient allele. Best execution practices, cost-effectiveness, and result interpretation are discussed with the aim of facilitating the implementation of this analysis in clinical practice. The existence of networks of laboratories performing this test in routine hospital treatment, as in France, offers the prospect of widespread screening, thus guaranteeing equal access to safe treatment and optimized therapy for patients receiving irinotecan-based therapy in advanced colorectal cancer.
Benhorin, Jesaia; Bodenheimer, Monty; Brown, Mary; Case, Robert; Dwyer, Edward M; Eberly, Shirley; Francis, Charles; Gillespie, John A; Goldstein, Robert E; Greenberg, Henry; Haigney, Mark; Krone, Ronald J; Klein, Helmut; Lichstein, Edgar; Locati, Emanuela; Marcus, Frank I; Moss, Arthur J; Oakes, David; Ryan, Daniel H; Bloch Thomsen, Poul E; Zareba, Wojciech
Cardiac-related clinical practice guidelines have become an integral part of the practice of cardiology. Unfortunately, these guidelines are often long, complex, and difficult for practicing cardiologists to use. Guidelines should be condensed and their format upgraded, so that the key messages are easier to comprehend and can be applied more readily by those involved in patient care. After presenting the historical background and describing the guideline structure, we make several recommendations to make clinical practice guidelines more user-friendly for clinical cardiologists. Our most important recommendations are that the clinical cardiology guidelines should focus exclusively on (1) class I recommendations with established benefits that are supported by randomized clinical trials and (2) class III recommendations for diagnostic or therapeutic approaches in which quality studies show no benefit or possible harm. Class II recommendations are not evidence based but reflect expert opinions related to published clinical studies, with potential for personal bias by members of the guideline committee. Class II recommendations should be published separately as "Expert Consensus Statements" or "Task Force Committee Opinions," so that both majority and minority expert opinions can be presented in a less dogmatic form than the way these recommendations currently appear in clinical practice guidelines.
Harricharan, Michelle; Gemen, Raymond; Celemín, Laura Fernández; Fletcher, David; de Looy, Anne E; Wills, Josephine; Barnett, Julie
The field of Mobile health (mHealth), which includes mobile phone applications (apps), is growing rapidly and has the potential to transform healthcare by increasing its quality and efficiency. The present paper focuses particularly on mobile technology for body weight management, including mobile phone apps for weight loss and the available evidence on their effectiveness. Translation of behaviour change theory into weight management strategies, including integration in mobile technology is also discussed. Moreover, the paper presents and discusses the myPace platform as a case in point. There is little clinical evidence on the effectiveness of currently available mobile phone apps in enabling behaviour change and improving health-related outcomes, including sustained body weight loss. Moreover, it is unclear to what extent these apps have been developed in collaboration with health professionals, such as dietitians, and the extent to which apps draw on and operationalise behaviour change techniques has not been explored. Furthermore, presently weight management apps are not built for use as part of dietetic practice, or indeed healthcare more widely, where face-to-face engagement is fundamental for instituting the building blocks for sustained lifestyle change. myPace is an innovative mobile technology for weight management meant to be embedded into and to enhance dietetic practice. Developed out of systematic, iterative stages of engagement with dietitians and consumers, it is uniquely designed to complement and support the trusted health practitioner-patient relationship. Future mHealth technology would benefit if engagement with health professionals and/or targeted patient groups, and behaviour change theory stood as the basis for technology development. Particularly, integrating technology into routine health care practice, rather than replacing one with the other, could be the way forward.
Maristany, Cleofé Pérez-Portabella; Segurola Gurruchaga, Hegoi
Water is an essential foundation for life, having both a regulatory and structural function. The former results from active and passive participation in all metabolic reactions, and its role in conserving and maintaining body temperature. Structurally speaking it is the major contributer to tissue mass, accounting for 60% of the basis of blood plasma, intracellular and intersticial fluid. Water is also part of the primary structures of life such as genetic material or proteins. Therefore, it is necessary that the nurse makes an early assessment of patients water needs to detect if there are signs of electrolyte imbalance. Dehydration can be a very serious problem, especially in children and the elderly. Dehydrations treatment with oral rehydration solution decreases the risk of developing hydration disorders, but even so, it is recommended to follow preventive measures to reduce the incidence and severity of dehydration. The key to having a proper hydration is prevention. Artificial nutrition encompasses the need for precise calculation of water needs in enteral nutrition as parenteral, so the nurse should be part of this process and use the tools for calculating the patient's requirements. All this helps to ensure an optimal nutritional status in patients at risk. Ethical dilemmas are becoming increasingly common in clinical practice. On the subject of artificial nutrition and hydration, there isn't yet any unanimous agreement regarding hydration as a basic care. It is necessary to take decisions in consensus with the health team, always thinking of the best interests of the patient.
Dorée, Suzanne Ingrid
How can we teach inquiry? In this paper, I offer practical techniques for teaching inquiry effectively using activities built from routine textbook exercises with minimal advanced preparation, including rephrasing exercises as questions, creating activities that inspire students to make conjectures, and asking for counterexamples to reasonable,…
Nunn, Adrian D
The objective of this study was to estimate the financial cost of developing new imaging agents for clinical use and to discuss the effects of these costs on the future clinical imaging agent environment. Publicly available financial data from the annual reports of major companies developing and selling imaging agents were examined and the data used to develop cost estimates. These estimates were compared with the in-depth data and analyses available for the development costs of therapeutic drugs. The cost of developing a drug for diagnostic imaging to commercialization is in the 100 dollars to 200 million dollars range, whereas a blockbuster imaging drug has current sales of 200 dollars to 400 million dollars. Most of these blockbuster imaging agents have been on the market for some time. The majority provide morphologic images with general indications in a slowly changing section of the market. Future agents will most likely address smaller markets and be in the rapidly developing molecular imaging field. The costs are high and are a significant brake on the development of imaging agents for commercialization. If new imaging agents are to realize their commercial potential, ways must be found to make the financials more attractive. The prices per dose are currently low so they must either be greatly increased for new imaging agents, with a corresponding increase in the value of the information they provide, or the use of imaging agents must be widened and/or their development made less costly in time and money. Without addressing these issues, the commercialization of new imaging agents will continue to be slow and may get slower. This will impact the progress of imaging agents toward use as validated biomarkers.
Walter, Hauke; Pfeifer, Nico; Knops, Elena; Lübke, Nadine; Büch, Joachim; Di Giambenedetto, Simona; Kaiser, Rolf; Lengauer, Thomas
Background: HIV-1 drug resistance can be measured with phenotypic drug-resistance tests. However, the output of these tests, the resistance factor (RF), requires interpretation with respect to the in vivo activity of the tested variant. Specifically, the dynamic range of the RF for each drug has to be divided into a suitable number of clinically meaningful intervals. Methods: We calculated a susceptible-to-intermediate and an intermediate-to-resistant cutoff per drug for RFs predicted by geno2pheno[resistance]. Probability densities for therapeutic success and failure were estimated from 10,444 treatment episodes. The density estimation procedure corrects for the activity of the backbone drug compounds and for therapy failure without drug resistance. For estimating the probability of therapeutic success given an RF, we fit a sigmoid function. The cutoffs are given by the roots of the third derivative of the sigmoid function. Results: For performance assessment, we used geno2pheno[resistance] RF predictions and the cutoffs for predicting therapeutic success in 2 independent sets of therapy episodes. HIVdb was used for performance comparison. On one test set (n = 807), our cutoffs and HIVdb performed equally well receiver operating characteristic curve [(ROC)–area under the curve (AUC): 0.68]. On the other test set (n = 917), our cutoffs (ROC–AUC: 0.63) and HIVdb (ROC–AUC: 0.65) performed comparatively well. Conclusions: Our method can be used for calculating clinically relevant cutoffs for (predicted) RFs. The method corrects for the activity of the backbone drug compounds and for therapy failure without drug resistance. Our method's performance is comparable with that of HIVdb. RF cutoffs for the latest version of geno2pheno[resistance] have been estimated with this method. PMID:27787339
Alarcão, Violeta; Ribeiro, Sofia; Almeida, Joana; Giami, Alain
Few studies explore the clinicians' knowledge, attitudes, and practices regarding sexuality, despite their role in the sexual-health socialization process. This study focuses on Portuguese sexologists engaged in clinical practice. It aims to characterize sexologists' sex education and training and their clinical practices, including diagnostic and therapeutic approaches. This research followed the methodology of an European survey on sexology as a profession (Euro-Sexo). From the 91 respondents who completed questionnaires, 51 (56%) were active in clinical practice. Results indicate that the Portuguese clinical sexologist is significantly older, predominantly male, has had training in sexology, performs more scientific research, and is more engaged in teaching activities when compared to nonclinical working sexologists. This article describes the main sexual problems presented by patients to Portuguese clinical sexologists and highlights differences in the professional groups and approaches toward treating these problems by medical doctors and nonmedical professionals. Results reinforce the idea that there are intra-European differences in the educational background of sexologists and reveal important variations in Portuguese sexologists' education, training, and clinical practice. The representations and practices of the sexologists in Portugal, as in other European countries, are embedded in cultural scenarios and sexual cultures, with implications for the clinical practice.
Zöllner, Frank G; Weisser, Gerald; Reich, Marcel; Kaiser, Sven; Schoenberg, Stefan O; Sourbron, Steven P; Schad, Lothar R
To develop a generic Open Source MRI perfusion analysis tool for quantitative parameter mapping to be used in a clinical workflow and methods for quality management of perfusion data. We implemented a classic, pixel-by-pixel deconvolution approach to quantify T1-weighted contrast-enhanced dynamic MR imaging (DCE-MRI) perfusion data as an OsiriX plug-in. It features parallel computing capabilities and an automated reporting scheme for quality management. Furthermore, by our implementation design, it could be easily extendable to other perfusion algorithms. Obtained results are saved as DICOM objects and directly added to the patient study. The plug-in was evaluated on ten MR perfusion data sets of the prostate and a calibration data set by comparing obtained parametric maps (plasma flow, volume of distribution, and mean transit time) to a widely used reference implementation in IDL. For all data, parametric maps could be calculated and the plug-in worked correctly and stable. On average, a deviation of 0.032 ± 0.02 ml/100 ml/min for the plasma flow, 0.004 ± 0.0007 ml/100 ml for the volume of distribution, and 0.037 ± 0.03 s for the mean transit time between our implementation and a reference implementation was observed. By using computer hardware with eight CPU cores, calculation time could be reduced by a factor of 2.5. We developed successfully an Open Source OsiriX plug-in for T1-DCE-MRI perfusion analysis in a routine quality managed clinical environment. Using model-free deconvolution, it allows for perfusion analysis in various clinical applications. By our plug-in, information about measured physiological processes can be obtained and transferred into clinical practice.
Wilk, Joshua; West, Joyce C; Rae, Donald S; Regier, Darrel A
The primary aim of this study was to present data on the relationship of mental and comorbid substance use disorders to work disability and functioning in routine psychiatric practice in the United States. Data were used from the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network Study of Psychiatric Patients and Treatments, totaling 754 psychiatrists and 3,088 patients. Results found patients with comorbid substance use disorders had significantly higher rates of work disability. These findings highlight the critical need to address the disturbing lack of substance use treatment and rehabilitation services for this population.
Routman, Justin S.; Willig, James H.; Westfall, Andrew O.; Abroms, Sarah R.; Varshney, Mohit; Adusumilli, Sunil; Allison, Jeroan J.; Savage, Karen G.; Saag, Michael S.; Mugavero, Michael J.
Summary The generalizability of clinical trial findings (efficacy) to routine care (effectiveness) may be limited. The present study found similar first year virologic and CD4 outcomes among antiretroviral-naïve patients treated through routine care vs. those participating in clinical trials. Background The generalizability of clinical trial findings (efficacy) to routine care (effectiveness) may be limited due to study eligibility criteria and volunteer bias. While well chronicled in many conditions, the efficacy vs. effectiveness of antiretroviral therapy (ART) remains understudied. Methods A retrospective study of the UAB 1917 Clinic Cohort evaluated naïve patients starting ART between 1/1/00–12/31/06. Patients received ART through clinical trials or routine care. Multivariable logistic and linear regression models were fit to evaluate factors associated with virologic failure (VF=VL>50 copies/mL) and change from baseline CD4 count 6 and 12 months after ART initiation. Sensitivity analyses evaluated the impact of missing data on outcomes. Results Among 570 patients starting ART during the study period, 121 (21%) enrolled in clinical trials vs. 449 (79%) receiving ART via routine care. ART receipt through routine care was not associated with VF at either 6 (OR=1.00;95%CI=0.54–1.86) or 12 (OR=1.56;95%CI=0.80–3.05) months in primary analyses. No significant differences in CD4 count responses at 6 and 12 months were observed. Conclusions Though marked differences in efficacy vs. effectiveness have been observed in the therapeutic outcomes of other conditions, our analyses found no evidence of such divergence among our patients initiating antiretroviral therapy for HIV. PMID:20067423
Reutter, Claudius A.; Robra, Bernt-Peter; Walther, Winfried
Background. Little is known about the clinical impact of new root canal preparation systems in general dental practice under routine care conditions. Therefore, we compared hand instrumentation (H) with Reciproc (R) (VDW, Munich, Germany) preparation. The outcomes were endodontic related pain and oral health related quality of life (OHRQoL), evaluation of the procedures by the patients and the strain felt by the dentists during root canal therapy. Methods. Six dentists participated in the trial as practitioner–investigators. In the first phase of the trial they prepared root canals with H and in the second phase with R. The patients documented their pain felt with a visual analogue scale (VAS 100) and OHRQoL with the German short version of the oral health impact profile (OHIP-G-14) before treatment and before the completion of therapy and answered questions about how they experienced the treatment. The dentists documented their physical strain during treatment. Results. A total of 137 patients were included in the evaluation. 66 patients were treated with H, 71 with R. Pain reduction was 32.6 (SD 32.9) VAS (H) vs. 29.4 (SD 26.9) VAS (R) (p = 0.550), and the improvement of the OHIP-14 score was 5.5 (SD 9.2) (H) vs. 6.7 (SD 7.4) (R) (p = 0.383). There were no statistical differences in both groups. Significantly fewer patients felt stressed by the duration of treatment with R as with H (p = 0.018). Significantly more dentists reported that their general physical strain and the strain on their fingers were less severe with R than with H (p = 0.013 and p < 0.001). Discussion. H as well as R effectively reduced endodontic related pain and OHRQoL without statistical differences. R has advantages in terms of how patients experience the treatment and regarding the physical strain felt by the dentists. PMID:27375972
Peters, Remco P H; Savelkoul, Paul H M; Simoons-Smit, Alberdina M; Danner, Sven A; Vandenbroucke-Grauls, Christina M J E; van Agtmael, Michiel A
Rapid identification of microorganisms in blood cultures is required to optimize empirical treatment at an early stage. Fluorescence in situ hybridization (FISH) can reduce the time to identification of microorganisms in growth-positive blood cultures. In this study, we evaluated the performance, time to identification, and potential clinical benefits of FISH compared to those of conventional culture methods in routine practice. After Gram staining, blood culture fluids were simultaneously further identified with FISH and with conventional culture methods. Results and points in time of FISH and culture identification (provisional and final identifications) were collected and compared. For 91% of microorganisms, the genus or family name was identified, and for 79%, the species name could be attributed. The sensitivity and specificity of the individual probes exceeded 95%, except for the Enterobacteriaceae probe (sensitivity, 89%). Cross-hybridization was obtained with the Klebsiella pneumoniae probe for Klebsiella oxytoca. The time gains of FISH and final culture identification were more than 18 h for bacteria and 42 h for yeasts. With FISH, Staphylococcus aureus was differentiated from coagulase-negative staphylococci 1.4 h faster than by provisional identification (P < 0.001). In conclusion, FISH allows rapid and reliable identification of the majority of microorganisms in growth-positive blood cultures. The substantial time gain of identification with FISH may allow same-day adjustment of antimicrobial therapy, and FISH is especially useful if no provisional identification is obtained. With further extension of the number of probes and a reduction in turnaround time, FISH will become a very useful diagnostic tool in the diagnosis of bloodstream infections.
Moorin, Rachael E.; Gibson, David A. J.; Forsyth, Rene K.; Fox, Richard
Purpose To evaluate the effect of introduction of iterative reconstruction as a mandated software upgrade on radiation dosimetry in routine clinical practice over a range of computed tomography examinations. Methods Random samples of scanning data were extracted from a centralised Picture Archiving Communication System pertaining to 10 commonly performed computed tomography examination types undertaken at two hospitals in Western Australia, before and after the introduction of iterative reconstruction. Changes in the mean dose length product and effective dose were evaluated along with estimations of associated changes to annual cancer incidence. Results We observed statistically significant reductions in the effective radiation dose for head computed tomography (22–27%) consistent with those reported in the literature. In contrast the reductions observed for non-contrast chest (37–47%); chest pulmonary embolism study (28%), chest/abdominal/pelvic study (16%) and thoracic spine (39%) computed tomography. Statistically significant reductions in radiation dose were not identified in angiographic computed tomography. Dose reductions translated to substantial lowering of the lifetime attributable risk, especially for younger females, and estimated numbers of incident cancers. Conclusion Reduction of CT dose is a priority Iterative reconstruction algorithms have the potential to significantly assist with dose reduction across a range of protocols. However, this reduction in dose is achieved via reductions in image noise. Fully realising the potential dose reduction of iterative reconstruction requires the adjustment of image factors and forgoing the noise reduction potential of the iterative algorithm. Our study has demonstrated a reduction in radiation dose for some scanning protocols, but not to the extent experimental studies had previously shown or in all protocols expected, raising questions about the extent to which iterative reconstruction achieves dose
OʼLaughlin, Kelli N; Kasozi, Julius; Walensky, Rochelle P; Parker, Robert A; Faustin, Zikama M; Doraiswamy, Sathyanarayanan; Owino, Chris Omara; Bassett, Ingrid V
We implemented and evaluated a clinic-based routine voluntary HIV testing intervention in Nakivale Refugee Settlement in Uganda. Comparing the standard of care period (40 d) with the intervention period (168 d), the mean HIV-infected clients identified per week increased from 0.9 to 5.6, and there was no significant difference between the HIV prevalence in the 2 periods (standard of care: 3.3%; intervention: 4.5%; P > 0.5). Clinic-based routine HIV testing in a refugee settlement is effective and should be considered for implementation in refugee settlements in other high-prevalence regions in sub-Saharan Africa.
Akkermans, Reinier; Bourbeau, Jean; van Weel, Chris; Vercoulen, Jan H; Schermer, Tjard R J
interval 1.16 to 6.82) and with prednisolone, antibiotics, or both (3.98, 1.10 to 15.58). Conclusions Comprehensive self management or routine monitoring did not show long term benefits in terms of quality of life or self efficacy over usual care alone in COPD patients in general practice. Patients in the self management group seemed to be more capable of appropriately managing exacerbations than did those in the usual care group. Trial registration Clinical trials NCT00128765. PMID:23190905
Laux, Gunter; Walther, Winfried
Background Little is known about the differences of rotary multiple file endodontic therapy and single-file reciprocating endodontic treatment under routine care conditions in dental practice. This multicenter study was performed to compare the outcome of multiple-file (MF) and single-file (SF) systems for primary root canal treatment under conditions of general dental practice regarding reduction of pain with a visual analogue scale (VAS 100), improvement of oral-health-related quality of life (OHRQoL) with the german short version of the oral health impact profile (OHIP-G-14) and the speed of root canal preparation. Materials and Methods Ten general dental practitioners (GDPs) participated in the study as practitioner-investigators (PI). In the first five-month period of the study, the GDPs treated patients with MF systems. After that, the GDPs treated the patients in the second five-month period with a SF system (WaveOne). The GDPs documented the clinical findings at the beginning and on completion of treatment. The patients documented their pain and OHRQoL before the beginning and before completion of treatment. Results A total of 599 patients were included in the evaluation. 280 patients were in the MF group, 319 were in the SF WaveOne group. In terms of pain reduction and improvement in OHIP-G-14, the improvement in both study groups (MF and SF) was very similar based on univariate analysis methods. Pain reduction was 34.4 (SD 33.7) VAS (MF) vs. 35.0 (SD 35.4) VAS (SF) (p = 0.840) and the improvement in OHIP-G-14 score was 9.4 (SD 10.3) (MF) vs. 8.5 (SD 10.2) (SF) (p = 0.365). The treatment time per root canal was 238.9 s (SD 206.2 s) (MF) vs. 146.8 sec. (SD 452.8 sec) (SF) (p = 0.003). Discussion Regarding improvement of endodontic pain and OHRQoL measure with OHIP-G-14, there were no statistical significant differences between the SF und the MF systems. WaveOne-prepared root canals significantly faster than MF systems. PMID:27957398
Aphasia is a central language impairment with word finding and comprehension deficit and paraphasias. The highlights of the essential language tests and the classification based on a scorable assessment are presented. The clinical syndromes of Broca's, global, Wernicke, conduction, anomic and transcortical aphasias are detailed with definition, localization, and prognosis. Modality specific disorders associated with aphasic syndromes are discussed. The management of the aphasic patient, consisting of informed support and coordination of available services, is often the responsibility of the family physician. ImagesFig. 1Fig. 2 PMID:21286589
Funabiki, K; Naito, Y; Matsuda, K; Honjo, I
A new vestibulo-ocular reflex (VOR) recording system was developed, which consists of an infrared eye camera, a small velocity sensor and a frequency modulator. Using this system, the head velocity signal was frequency modulated and simultaneously recorded as a sound signal on the audio track of a Hi8 video recorder with eye images. This device enabled recording of the VOR response in routine vestibular clinical practice. The reliability and effectiveness of this system were estimated by recording and analysing the VOR response against manually controlled rotation in normal subjects (n = 22) and in patients with unilateral severe vestibular hypofunction (n = 11). VOR gain on clockwise rotation viewed from the top was defined as R gain, and counterclockwise rotation as L gain. Directional preponderance (DP%) was also calculated. VOR gain towards the diseased side was significantly lower than that towards the intact side, and also significantly lower than that of normal subjects. DP% of unilateral vestibular hypofunction cases was significantly larger than that of normal subjects. These findings indicate that this VOR recording system reliably detects severe unilateral vestibular hypofunction.
Hollon, Steven D; Areán, Patricia A; Craske, Michelle G; Crawford, Kermit A; Kivlahan, Daniel R; Magnavita, Jeffrey J; Ollendick, Thomas H; Sexton, Thomas L; Spring, Bonnie; Bufka, Lynn F; Galper, Daniel I; Kurtzman, Howard
Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, high-quality guidelines can facilitate shared decision making and identify gaps in knowledge.
Black, Dennis M; Rosen, Clifford J
Key Clinical Points Postmenopausal Osteoporosis Fractures and osteoporosis are common, particularly among older women, and hip fractures can be devastating. Treatment is generally recommended in postmenopausal women who have a bone mineral density T score of -2.5 or less, a history of spine or hip fracture, or a Fracture Risk Assessment Tool (FRAX) score indicating increased fracture risk. Bisphosphonates (generic) and denosumab reduce the risk of hip, nonvertebral, and vertebral fractures; bisphosphonates are commonly used as first-line treatment in women who do not have contraindications. Teriparatide reduces the risk of nonvertebral and vertebral fractures. Osteonecrosis of the jaw and atypical femur fractures have been reported with treatment but are rare. The benefit-to-risk ratio for osteoporosis treatment is strongly positive for most women with osteoporosis. Because benefits are retained after discontinuation of alendronate or zoledronic acid, drug holidays after 5 years of alendronate therapy or 3 years of zoledronic acid therapy may be considered for patients at lower risk for fracture.
Leung, Kai Yan Eugene; van der Lijn, Fedde; Vrooman, Henri A; Sturkenboom, Miriam C J M; Niessen, Wiro J
We propose an infrastructure for the automated anonymization, extraction and processing of image data stored in clinical data repositories to make routinely acquired imaging data available for research purposes. The automated system, which was tested in the context of analyzing routinely acquired MR brain imaging data, consists of four modules: subject selection using PACS query, anonymization of privacy sensitive information and removal of facial features, quality assurance on DICOM header and image information, and quantitative imaging biomarker extraction. In total, 1,616 examinations were selected based on the following MRI scanning protocols: dementia protocol (246), multiple sclerosis protocol (446) and open question protocol (924). We evaluated the effectiveness of the infrastructure in accessing and successfully extracting biomarkers from routinely acquired clinical imaging data. To examine the validity, we compared brain volumes between patient groups with positive and negative diagnosis, according to the patient reports. Overall, success rates of image data retrieval and automatic processing were 82.5 %, 82.3 % and 66.2 % for the three protocol groups respectively, indicating that a large percentage of routinely acquired clinical imaging data can be used for brain volumetry research, despite image heterogeneity. In line with the literature, brain volumes were found to be significantly smaller (p-value <0.001) in patients with a positive diagnosis of dementia (915 ml) compared to patients with a negative diagnosis (939 ml). This study demonstrates that quantitative image biomarkers such as intracranial and brain volume can be extracted from routinely acquired clinical imaging data. This enables secondary use of clinical images for research into quantitative biomarkers at a hitherto unprecedented scale.
Simmons, Emma; Roberts, Mary; Ma, Mindy; Beckwith, Curt; Carpenter, Charles; Flanigan, Timothy
The purpose of this study was to examine the current practices of family practice (FP) providers and their allied staff with regard to routine HIV testing in Rhode Island (RI) and Mississippi (MS). Anonymous experimenter-derived surveys were mailed to both groups of providers in 2002. The questionnaire contained five questions about their current practices and attitudes toward HIV testing as well as patient demographics. Five hundred twenty-one questionnaires were sent to American Academy of Family Practitioners (AAFP) members in RI and MS and to FPs with listings in the phone book in RI. The response rate was 52% in RI and 41% in MS. The vast majority of providers (93%) tested their high-risk patients for HIV, but less tested pregnant (57%) and other sexually active (37%) patients. The FPs in this survey wanted HIV testing to be done in the primary care setting, yet only 7% recommended HIV testing to their sexually active patients aged 18-50 in the previous year. In order not to stigmatize any specific risk group, nor to miss any patients who are unable to be identified as being "at high risk," routine testing in the primary care setting should be encouraged.
Despotović, Nebojsa; Zdravković, Mihajlo
Multiple arterial disease is presented by coexistence of ischaemic heart disease, carotid disease and peripheral obliterate arterial disease. Atherosclerosis is the main factor for onset of the disease. Among 150 patients with clinical manifestations of obliterate disease of at least two aforementioned arterial systems, we examined by many noninvasive and invasive procedures the existence and degree of obliterate arterial disease of coronary, carotid and peripheral arteries of the lower extremities. The results revealed the statistically significant correlation among: ischaemic heart disease and carotid disease (r = 0.939; p < 0.01); ischaemic heart disease and peripheral arterial disease (r = 0.834; p < 0.05); ischaemic heart disease, peripheral arterial disease and carotid disease (r = 0.986; p < 0.01). The results pointed out that whenever clinical manifestations of obliterate disease of peripheral arteries are present, there is also need for routine examination of existent coronary artery disease.
Metzger-Filho, Otto; Catteau, Aurélie; Michiels, Stefan; Buyse, Marc; Ignatiadis, Michail; Saini, Kamal S.; de Azambuja, Evandro; Fasolo, Virginie; Naji, Sihem; Canon, Jean Luc; Delrée, Paul; Coibion, Michel; Cusumano, Pino; Jossa, Veronique; Kains, Jean Pierre; Larsimont, Denis; Richard, Vincent; Faverly, Daniel; Cornez, Nathalie; Vuylsteke, Peter; Vanderschueren, Brigitte; Peyro-Saint-Paul, Hélène; Piccart, Martine; Sotiriou, Christos
Purpose Genomic Grade Index (GGI) is a 97-gene signature that improves histologic grade (HG) classification in invasive breast carcinoma. In this prospective study we sought to evaluate the feasibility of performing GGI in routine clinical practice and its impact on treatment recommendations. Methods Patients with pT1pT2 or operable pT3, N0-3 invasive breast carcinoma were recruited from 8 centers in Belgium. Fresh surgical samples were sent at room temperature in the MapQuant Dx™ PathKit for centralized genomic analysis. Genomic profiles were determined using Affymetrix U133 Plus 2.0 and GGI calculated using the MapQuant Dx® protocol, which defines tumors as low or high Genomic Grade (GG-1 and GG-3 respectively). Results 180 pts were recruited and 155 were eligible. The MapQuant test was performed in 142 cases and GGI was obtained in 78% of cases (n=111). Reasons for failures were 15 samples with <30% of invasive tumor cells (11%), 15 with insufficient RNA quality (10%), and 1 failed hybridization (<1%). For tumors with an available representative sample (≥ 30% inv. tumor cells) (n=127), the success rate was 87.5%. GGI reclassified 69% of the 54 HG2 tumors as GG-1 (54%) or GG-3 (46%). Changes in treatment recommendations occurred mainly in the subset of HG2 tumors reclassified into GG-3, with increased use of chemotherapy in this subset. Conclusion The use of GGI is feasible in routine clinical practice and impacts treatment decisions in early-stage breast cancer. Trial Registration ClinicalTrials.gov NCT01916837, http://clinicaltrials.gov/ct2/show/NCT01916837 PMID:23990869
Fogelman, I. )
The topics covered in this book include the history of bone scanning, mechanisms of uptake of diphosphonate in bone, the normal bone scan, and the role of bone scanning in clinical practice. The aim of this book is to provide a source of reference relating to bone scan imaging for all those who are interested in the skeleton.
Trujillo, Adriana; Feixas, Guillem; Bados, Arturo; García-Grau, Eugeni; Salla, Marta; Medina, Joan Carles; Montesano, Adrián; Soriano, José; Medeiros-Ferreira, Leticia; Cañete, Josep; Corbella, Sergi; Grau, Antoni; Lana, Fernando; Evans, Chris
Objective The objective of this paper is to assess the reliability and validity of the Spanish translation of the Clinical Outcomes in Routine Evaluation – Outcome Measure, a 34-item self-report questionnaire that measures the client’s status in the domains of Subjective well-being, Problems/Symptoms, Life functioning, and Risk. Method Six hundred and forty-four adult participants were included in two samples: the clinical sample (n=192) from different mental health and primary care centers; and the nonclinical sample (n=452), which included a student and a community sample. Results The questionnaire showed good acceptability and internal consistency, appropriate test–retest reliability, and acceptable convergent validity. Strong differentiation between clinical and nonclinical samples was found. As expected, the Risk domain had different characteristics than other domains, but all findings were comparable with the UK referential data. Cutoff scores were calculated for clinical significant change assessment. Conclusion The Spanish version of the Clinical Outcomes in Routine Evaluation – Outcome Measure showed acceptable psychometric properties, providing support for using the questionnaire for monitoring the progress of Spanish-speaking psychotherapy clients. PMID:27382288
Vaginal ultrasound probes are semi-critical Group A medical products which must be disinfected following the manufacturer's instructions after every patient examination. According to the "Essential Requirements for Medical Devices (Directive 93/42/EEC, Annex I, paragraph 13)" the manufacturer's instructions for use for reusable products must contain suitable instructions for preparation processes. This presumes both an effective and material-compatible method. Evidence of effectiveness must be validated.In the Editorial in issue 1 Ultraschall in der Medizin/European Journal of Ultrasound 2005 we discussed the topic of transducer hygiene and stated that proper handling and cleaning as well as disinfection of probes in daily use are indispensable. This applies particularly to vaginal ultrasound probes routinely used in gynecological and obstetrical clinics, gynecological practices as well as IVF centers Normally the probe used in a transvaginal ultrasound examination is covered with a latex protective cover (with CE marking) which contains a certain amount of ultrasound gel. After the examination, the cover is removed and disposed of, and the gel is removed from the transducer. Since handling of the probe, ultrasound gel and cover can result in smear infections and cross-contamination with various pathogens (e. g. MRSA, HBV, HCV, HIV, herpes papilloma and cytomegalic viruses), after the protective cover is removed, the probe must be cleaned and subjected to disinfection with a bactericidal, fungicidal and virucidal effect. This is especially important in the event the cover ruptures during the vaginal examination, and the probe comes into direct contact with vaginal secretions or blood. The same likewise applies if the sterile protective cover is perforated during a follicular puncture. Usually special bactericidal, levurocidal and virucidal wipes or special submersion disinfection methods are available for disinfecting the vaginal ultrasound probes 11. Using
Asheervath, J.; Blevins, D.R.
Written in outline format, this reference will help nurses further their understanding of advanced nursing procedures. Information is provided on the physiological, psychological, environmental, and safety considerations of nursing activities associated with diagnostic and therapeutic procedures. Special consideration is given to the areas of pediatric nursing, nursing assessment, and selected radiologic and nuclear medicine procedures for each system. Contents: Clinical Introduction. Clinical Nursing Practice: Focus on Basics. Focus on Cardiovascular Function. Focus on Respiratory Function. Focus on Gastrointestinal Function. Focus on Renal and Genito-Urological Function. Focus on Neuro-Skeletal and Muscular Function. Appendices.
Rovelli, Francesca; Mercuri, Santo Raffaele; Naldi, Luigi
Seborrheic dermatitis is a chronic relapsing inflammatory skin condition characterized by scaling and poorly defined erythematous patches in areas rich in sebaceous glands. It is one of the most frequent skin disorders and may be socially embarrassing. Fungi of the genus Malassezia, lipid-dependent, ubiquitous skin residents, play a pathogenic role. Topical antifungal agents (e.g., ketoconazole) are the mainstay of treatment, and if used intermittently they can maintain remission. The vehicle itself may also play a relevant role. Improvements in diagnostic criteria, severity measures and outcome variables are needed to better design clinical trials and inform clinical practice.
Ng, T; Marx, G; Littlewood, T; Macdougall, I
The introduction of recombinant human erythropoietin (RHuEPO) has revolutionised the treatment of patients with anaemia of chronic renal disease. Clinical studies have demonstrated that RHuEPO is also useful in various non-uraemic conditions including haematological and oncological disorders, prematurity, HIV infection, and perioperative therapies. Besides highlighting both the historical and functional aspects of RHuEPO, this review discusses the applications of RHuEPO in clinical practice and the potential problems of RHuEPO treatment. PMID:12897214
Borrell-Carrió, F; Hernández-Clemente, J C
The purpose of this article is to analyze some models of expert decision and their impact on the clinical practice. We have analyzed decision-making considering the cognitive aspects (explanatory models, perceptual skills, analysis of the variability of a phenomenon, creating habits and inertia of reasoning and declarative models based on criteria). We have added the importance of emotions in decision making within highly complex situations, such as those occurring within the clinical practice. The quality of the reflective act depends, among other factors, on the ability of metacognition (thinking about what we think). Finally, we propose an educational strategy based on having a task supervisor and rectification scenarios to improve the quality of medical decision making.
Wasfy, Meagan M; Baggish, Aaron L
There is wide variability in the physical activity patterns of the patients in contemporary clinical cardiovascular practice. This review is designed to address the impact of exercise dose on key cardiovascular risk factors and on mortality. We begin by examining the body of literature that supports a dose-response relationship between exercise and cardiovascular disease risk factors, including plasma lipids, hypertension, diabetes mellitus, and obesity. We next explore the relationship between exercise dose and mortality by reviewing the relevant epidemiological literature underlying current physical activity guideline recommendations. We then expand this discussion to critically examine recent data pertaining to the impact of exercise dose at the lowest and highest ends of the spectrum. Finally, we provide a framework for how the key concepts of exercise dose can be integrated into clinical practice.
Leal, Sixto M; Jones, Melissa; Gilligan, Peter H
Commensal bacteria from the skin and mucosal surfaces are routinely isolated from patient samples and considered contaminants. The majority of these isolates are catalase-positive Gram-positive rods from multiple genera routinely classified as diphtheroids. These organisms can be seen upon Gram staining of clinical specimens or can be isolated as the predominant or pure species in culture, raising a priori suspicion of a possible involvement in infection. With the development and adoption of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), suspicious isolates are now routinely identified to the species level. In this study, we performed a retrospective data review (2012 to 2015) and utilized site-specific laboratory criteria and chart reviews to identify species within the diphtheroid classification representative of true infection versus contamination. Our data set included 762 isolates from 13 genera constituting 41 bacterial species. Only 18% represented true infection, and 82% were deemed contaminants. Clinically significant isolates were identified in anaerobic wounds (18%), aerobic wounds (30%), blood (5.5%), urine (22%), cerebrospinal fluid (24%), ophthalmologic cultures (8%), and sterile sites (20%). Organisms deemed clinically significant included multiple Actinomyces species in wounds, Propionibacterium species in joints and cerebrospinal fluid associated with central nervous system hardware, Corynebacterium kroppenstedtii (100%) in breast, and Corynebacterium striatum in multiple sites. Novel findings include clinically significant urinary tract infections by Actinomyces neuii (21%) and Corynebacterium aurimucosum (21%). Taken together, these findings indicate that species-level identification of diphtheroids isolated with a priori suspicion of infection is essential to accurately determine whether an isolate belongs to a species associated with specific types of infection.
Clinical research implies advancing current knowledge about health care by continually developing and testing new ideas about diseases, products, procedures, and strategies. Although this trait is inherent in human nature, it needs to be encouraged, nurtured, groomed, and channelized by creating a suitable atmosphere for it, providing the necessary resources, inculcating the necessary conceptual and manual skills, and rewarding the efforts and achievements suitably. Language, logic, statistics, and psychology play an important role in acquiring and developing research capability. To be socially relevant and economically viable, clinical research will need to partner with patients and their doctors in identifying what their goals of health care are, what they value, and what they are willing to "buy" in terms of goods and services. Besides, clinical research will need to bring on one platform the sponsors, the researchers, the patients, the payers, and the regulators to ensure that they do not work at cross purposes, that the cost of developing health care measures is scaled down through innovative approaches such as large simple trials, sequential trials, early marketing conditional on post-marketing surveillance, and so on. All these will be possible if day-to-day practice is slowly and systemically transformed into the largest laboratory of clinical research, which it ought to be, by forming networks of research-oriented practices, and popularizing the use of data collection and analysis tools such as Epi Info which are in the public domain.
Bensenor, Isabela M; Griep, Rosane H; Pinto, Karina Araújo; Faria, Carolina Perim de; Felisbino-Mendes, Mariana; Caetano, Edna I; Albuquerque, Liliane da Silva; Schmidt, Maria Inês
The ELSA-Brasil (Estudo Longitudinal de Saúde do Adulto - Brazilian Longitudinal Study for Adult Health) is a prospective cohort study with extensive assessments throughout time. This article describes the routine of clinical tests and interviews performed with participants and the structuring of the Research Center physical space and teams. The ELSA-Brasil assumes that participants will be present at the Research Center to have the tests and interviews performed, according to standard protocols developed by this study. Considering the multiplicity of activities involved, each with specific needs for standardization, several predetermined orders of clinical tests and interviews were created. This ensured a high standard of quality in data collection without harm to participants' comfort. Each participant was previously assigned to a specific sequence of clinical tests and interviews with a predefined arrival time, mean length of stay of five to six hours and departure time.
Talkowski, Michael E; Ernst, Carl; Heilbut, Adrian; Chiang, Colby; Hanscom, Carrie; Lindgren, Amelia; Kirby, Andrew; Liu, Shangtao; Muddukrishna, Bhavana; Ohsumi, Toshiro K; Shen, Yiping; Borowsky, Mark; Daly, Mark J; Morton, Cynthia C; Gusella, James F
The contribution of balanced chromosomal rearrangements to complex disorders remains unclear because they are not detected routinely by genome-wide microarrays and clinical localization is imprecise. Failure to consider these events bypasses a potentially powerful complement to single nucleotide polymorphism and copy-number association approaches to complex disorders, where much of the heritability remains unexplained. To capitalize on this genetic resource, we have applied optimized sequencing and analysis strategies to test whether these potentially high-impact variants can be mapped at reasonable cost and throughput. By using a whole-genome multiplexing strategy, rearrangement breakpoints could be delineated at a fraction of the cost of standard sequencing. For rearrangements already mapped regionally by karyotyping and fluorescence in situ hybridization, a targeted approach enabled capture and sequencing of multiple breakpoints simultaneously. Importantly, this strategy permitted capture and unique alignment of up to 97% of repeat-masked sequences in the targeted regions. Genome-wide analyses estimate that only 3.7% of bases should be routinely omitted from genomic DNA capture experiments. Illustrating the power of these approaches, the rearrangement breakpoints were rapidly defined to base pair resolution and revealed unexpected sequence complexity, such as co-occurrence of inversion and translocation as an underlying feature of karyotypically balanced alterations. These findings have implications ranging from genome annotation to de novo assemblies and could enable sequencing screens for structural variations at a cost comparable to that of microarrays in standard clinical practice.
Allen, Sarah; Lowe, Derek; Harris, Rebecca V; Brown, Steve; Rogers, Simon N
Oral cancer has a higher incidence in the lower social strata, and these patients are less likely to engage in supportive interventions and report a poorer quality of life (QoL). The aim of this paper is to compare the Patient Concerns Inventory (PCI) responses across social groups attending routine oral cancer follow-up clinics with particular focus on the deprivation lower quartile. The PCI package is completed by patients as part of their routine review consultation with SNR. Patients were those diagnosed between 2008 and 2012. Deprivation was stratified using the IMD 2010 from postcode. Of the 106 eligible patients, 85 % used the PCI. Just over half (54 %) were living in the most deprived quartile, with two-thirds (68 %) of males in the most deprived quartile, compared with 35 % of females (p = 0.004). In regard to number and type of PCI items selected by patients at their first PCI clinic, there were no notable differences in respect of IMD classification. The two commonest concerns were fear of recurrence (43 %) and sore mouth (43 %). The most deprived quartile reported significant problems in regard to mood (p = 0.004) and recreation (p = 0.02), and a non-significant trend (36 vs 18 %, p = 0.09) in stating their overall QoL as being less than good. It is possible to identify the concerns of patients from lower socioeconomic strata as part of routine follow-up clinics. This allows for targeted multi-professional intervention and supports to improve the outcome in this hard to reach group.
Noordhoek, G T; Kaan, J A; Mulder, S; Wilke, H; Kolk, A H
AIM--To investigate the use of the polymerase chain reaction (PCR) in the routine laboratory for the detection of Mycobacterium tuberculosis in clinical samples. METHODS--Samples were divided and processed separately for the detection of M tuberculosis by microscopy, culture and PCR. After DNA extraction, PCR was performed with primers specific for the insertion element IS6110 and the product was analysed by agarose gel electrophoresis, Southern blotting or dot blotting and hybridisation with a digoxigenin labelled internal probe. Each sample was tested for inhibitors of Taq polymerase with the aid of an internal control. Multiple negative and positive controls were used to monitor each step of the procedure. RESULTS--The data from two laboratories, using the same operating procedures, were combined. Of 1957 specimens, 79 (4%) were culture and PCR positive, while 1839 (93.9%) were negative in both tests. Thirty specimens (1.5%) were PCR positive only and nine (0.5%) were culture positive but PCR negative. CONCLUSION--Using culture and clinical history as the gold standard, sensitivity and specificity for PCR were 92.1% and 99.8%, respectively. With elaborate precautions, PCR is a suitable and reliable method for the detection of M tuberculosis in clinical samples in a routine microbiology laboratory. Images PMID:7490312
Rice, E W
This communication describes and evaluates an improved routine methodology for quantitating clinical proteinuria. Based on investigations of Piscator and of Savory et al., a modified Tsuchiya's reagent (ethanolic HCI-phosphotungstic acid) is used to precipitate proteins at 56 degrees C, followed by biuret spectrophotometry at 540 nm. The accuracy of the proposed procedure was assessed by comparisons with results obtained by using an ultrafiltration membrane that retains solutes with an average molecular weight in excess of 10 000 for separating of urinary proteins before they are measured with the biuret reaction. Precision of the method (coefficient of variation) is typically 2-3%.
de Boer, Lisanne L; Spliethoff, Jarich W; Sterenborg, Henricus J C M; Ruers, Theo J M
Innovations in optical spectroscopy have helped the technology reach a point where performance previously seen only in laboratory settings can be translated and tested in real-world applications. In the field of oncology, spectral tissue sensing (STS) by means of optical spectroscopy is considered to have major potential for improving diagnostics and optimizing treatment outcome. The concept has been investigated for more than two decades and yet spectral tissue sensing is not commonly employed in routine medical practice. It is therefore important to understand what is needed to translate technological advances and insights generated through basic scientific research in this field into clinical practice. The aim of the discussion presented here is not to provide a comprehensive review of all work published over the last decades but rather to highlight some of the challenges found in literature and encountered by our group in the quest to translate optical technologies into useful clinical tools. Furthermore, an outlook is proposed on how translational researchers could proceed to eventually have STS incorporated in the process of clinical decision-making.
Summary of the proceedings of the international forum 2016: "Imaging referral guidelines and clinical decision support - how can radiologists implement imaging referral guidelines in clinical routine?"
The International Forum is held once a year by the ESR and its international radiological partner societies with the aim to address and discuss selected subjects of global relevance in radiology. In 2016, the issue of implementing imaging referral guidelines in clinical routine was analysed. The legal environment in the USA requires that after January 1, 2017, physicians must consult government-approved, evidence-based appropriate-use criteria through a clinical decision support system when ordering advanced diagnostic imaging exams. The ESR and the National Decision Support Company are developing "ESR iGuide", a clinical decision support system for European imaging referral guidelines using ESR imaging referral guidelines based on ACR Appropriateness Criteria. In many regions of the world, the situation is different and quite diverse, depending on the specific features of health care systems in different countries, but there are, unlike in the USA and EU, no legal obligations to implement imaging referral guidelines into the clinical practice. Imaging referral guidelines and clinical decision support implementation is a complex issue everywhere and the legal environment surrounding it even more so; how they will be implemented into the clinical practice in different areas of the world needs yet to be decided.
Liu, Hui; Chang, Joe Y.
Radiation dose escalation and acceleration improves local control but also increases toxicity. Proton radiation is an emerging therapy for localized cancers that is being sought with increasing frequency by patients. Compared with photon therapy, proton therapy spares more critical structures due to its unique physics. The physical properties of a proton beam make it ideal for clinical applications. By modulating the Bragg peak of protons in energy and time, a conformal radiation dose with or without intensity modulation can be delivered to the target while sparing the surrounding normal tissues. Thus, proton therapy is ideal when organ preservation is a priority. However, protons are more sensitive to organ motion and anatomy changes compared with photons. In this article, we review practical issues of proton therapy, describe its image-guided treatment planning and delivery, discuss clinical outcome for cancer patients, and suggest challenges and the future development of proton therapy. PMID:21527064
Thwaites, D; Holloway, L; Bailey, M; Carolan, M; Miller, A; Barakat, S; Field, M; Delaney, G; Vinod, S; Dekker, A; Lustberg, T; Soest, J van; Walsh, S
Purpose: Large amounts of routine radiotherapy (RT) data are available, which can potentially add clinical evidence to support better decisions. A developing collaborative Australian network, with a leading European partner, aims to validate, implement and extend European predictive models (PMs) for Australian practice and assess their impact on future patient decisions. Wider objectives include: developing multi-institutional rapid learning, using distributed learning approaches; and assessing and incorporating radiomics information into PMs. Methods: Two initial standalone pilots were conducted; one on NSCLC, the other on larynx, patient datasets in two different centres. Open-source rapid learning systems were installed, for data extraction and mining to collect relevant clinical parameters from the centres’ databases. The European DSSs were learned (“training cohort”) and validated against local data sets (“clinical cohort”). Further NSCLC studies are underway in three more centres to pilot a wider distributed learning network. Initial radiomics work is underway. Results: For the NSCLC pilot, 159/419 patient datasets were identified meeting the PM criteria, and hence eligible for inclusion in the curative clinical cohort (for the larynx pilot, 109/125). Some missing data were imputed using Bayesian methods. For both, the European PMs successfully predicted prognosis groups, but with some differences in practice reflected. For example, the PM-predicted good prognosis NSCLC group was differentiated from a combined medium/poor prognosis group (2YOS 69% vs. 27%, p<0.001). Stage was less discriminatory in identifying prognostic groups. In the good prognosis group two-year overall survival was 65% in curatively and 18% in palliatively treated patients. Conclusion: The technical infrastructure and basic European PMs support prognosis prediction for these Australian patient groups, showing promise for supporting future personalized treatment decisions
duCret, R.P.; Boudreau, R.J.; Gonzalez, R.; Carpenter, R.; Tennison, J.; Kuni, C.C.
99m-Technetium mercaptoacetylglycine is a promising new renal radiopharmaceutical undergoing phase III trials in the United States. In a preliminary investigation of the efficacy and safety of mercaptoacetylglycine in 30 adult patients with suspected renal disease we used simultaneous imaging with orthoiodohippurate as the physiological ''gold standard''. Of these patients 11 had undergone renal transplantation. Factors, such as time to peak renal activity, clearance half-life and regional functional comparison, were similar by orthoiodohippurate and mercaptoacetylglycine imaging. Visual and quantitative analysis of angiograms and renograms was markedly facilitated with the use of mercaptoacetylglycine. Several morphological abnormalities were apparent only during mercaptoacetylglycine evaluation. No adverse effects, changes in vital signs or significant changes in clinical laboratory status were encountered. Since mercaptoacetylglycine combined an excellent technetium image with the pharmacokinetics of orthoiodohippurate, mercaptoacetylglycine may supplant all other agents for routine clinical use.
Vernillo, Anthony T; Caplan, Arthur L
The latest Centers for Disease Control and Prevention (CDC) guidelines recommend routine HIV screening for a large segment of the population, given that the individual understands that an HIV test will be performed unless he or she declines testing (opt-out testing). The CDC recommendation calls for the elimination of formalized requirements for written consent and pretest counseling to encourage more Americans to voluntarily accept testing. Knowledge of HIV infection can increase early access to care and treatment and reduce further transmission. A rapid non-invasive test for HIV infection (OraQuick Advance) from oral fluid has recently become available. It offers two distinct advantages: 1) results are available within twenty minutes, thereby eliminating a long waiting period; and 2) it has high sensitivity and specificity comparable to blood testing. A preliminary positive test result must be confirmed with a Western Blot by an outside laboratory or physician. Important ethical and legal issues must be resolved before the successful implementation of HIV testing in the dental setting. An educational emphasis on broader coverage of HIV testing is also needed within the dental school curriculum. The integration of HIV testing into dental practice is discussed as well. A policy of screening patients in dental offices will contribute to a major advance in public health.
Richardson, Alice; Signor, Ben M; Lidbury, Brett A; Badrick, Tony
Big Data is having an impact on many areas of research, not the least of which is biomedical science. In this review paper, big data and machine learning are defined in terms accessible to the clinical chemistry community. Seven myths associated with machine learning and big data are then presented, with the aim of managing expectation of machine learning amongst clinical chemists. The myths are illustrated with four examples investigating the relationship between biomarkers in liver function tests, enhanced laboratory prediction of hepatitis virus infection, the relationship between bilirubin and white cell count, and the relationship between red cell distribution width and laboratory prediction of anaemia.
Kim, Sollip; Yun, Yeo-Min; Chae, Hyo-Jin; Cho, Hyun-Jung; Ji, Misuk; Kim, In-Suk; Wee, Kyung-A; Lee, Woochang; Song, Sang Hoon; Woo, Hye In
Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings. PMID:28029011
Kim, Sollip; Yun, Yeo Min; Chae, Hyo Jin; Cho, Hyun Jung; Ji, Misuk; Kim, In Suk; Wee, Kyung A; Lee, Woochang; Song, Sang Hoon; Woo, Hye In; Lee, Soo Youn; Chun, Sail
Pharmacogenetic testing for clinical applications is steadily increasing. Correct and adequate use of pharmacogenetic tests is important to reduce unnecessary medical costs and adverse patient outcomes. This document contains recommended pharmacogenetic testing guidelines for clinical application, interpretation, and result reporting through a literature review and evidence-based expert opinions for the clinical pharmacogenetic testing covered by public medical insurance in Korea. This document aims to improve the utility of pharmacogenetic testing in routine clinical settings.
Maheshwari, Gaurav; Maheshwari, Namrata
Surgery as a discipline has perhaps been slower than other specialties to embrace evidence based principles. Today, surgeons all over Asia are prepared to challenge the dogma of yesterday. Surgical science which rests on a strong foundation of laboratory and clinical research can now be broadened to include the armamentarium of evidence based practice to advance surgical knowledge. The sheer volume of easily accessed information creates a new challenge. This article discusses keeping up with new information and finding the best available answers to specific questions amidst all the other information. PMID:22359733
Rishniw, Mark; Bicalho, Rodrigo
Evidence suggests that apparently healthy cats presenting for routine evaluation should have a randomly sampled urine specific gravity (USG) >1.035. A USG <1.035 might reflect inappropriate concentrating ability warranting further investigation. We measured the USG of 1040 apparently healthy cats presenting to first opinion practice in an observational study, using either in-clinic refractometers or measurements provided by reference laboratories, and examined factors that might affect USG. In-clinic refractometers were calibrated using distilled water (specific gravity = 1.000). The USG was >1.030 in 91% of cats and >1.035 in 88% of cats; 121 adult cats (⩾6 months old) and five young cats (<6 months old) had USGs of <1.035. Of these 126 cats, a pathological cause was identified in 27 adult cats - of these, 26 were >9 years old - but no young cats. No cause was identified in 43 adult cats, and further investigation was not pursued in 51 adult cats. Factors that affected USG included age, diet type, sex, fasting status, drinking avidity, refractometer type, and the interaction between sex and diet - increasing dietary moisture content lowered USG only in female cats. Most factors minimally affected USG. The odds of having a USG <1.035 without apparent pathology included age and dietary moisture content. Drinking avidity decreased with increasing dietary moisture content. Our results show that most apparently healthy cats presenting to first-opinion practice should have a USG >1.035. Dietary management strategies to lower USG might be less effective than anticipated, and warrant monitoring of USG to determine efficacy. Older cats with USG <1.035 are more likely to have pathological causes identified, although clinicians are more likely to examine these cats for possible pathology. A lack of stringent refractometer calibration could have caused some errors in estimates of USG by some observers, but would be unlikely to alter markedly the findings.
Pearson, Sallie-Anne; Schaffer, Andrea
Introduction After medicines have been subsidised in Australia we know little about their use in routine clinical practice, impact on resource utilisation, effectiveness or safety. Routinely collected administrative health data are available to address these issues in large population-based pharmacoepidemiological studies. By bringing together cross-jurisdictional data collections that link drug exposure to real-world outcomes, this research programme aims to evaluate the use and impact of cancer medicines in a subset of elderly Australians in the real-world clinical setting. Methods and analysis This ongoing research programme involves a series of retrospective cohort studies of Australian Government Department of Veterans’ Affairs (DVA) clients. The study population includes 104 635 veterans who reside in New South Wales, Australia, and were aged 65 years and over as of 1 July 2004. We will investigate trends in cancer medicines use according to cancer type and other sociodemographic characteristics as well as predictors of the initiation of cancer medicines and other treatment modalities, survival and adverse outcomes among patients with cancer. The programme is underpinned by the linkage of eight health administrative databases under the custodianship of the DVA and the New South Wales Ministry of Health, including cancer notifications, medicines dispensing data, hospitalisation data and health services data. The cancer notifications database is available from 1994 with all other databases available from 2005 onwards. Ethics and dissemination Ethics approval has been granted by the DVA and New South Wales Population and Health Service Research Ethics Committees. Results Results will be reported in peer-reviewed publications, conference presentations and policy forums. The programme has high translational potential, providing invaluable evidence about cancer medicines in an elderly population who are under-represented in clinical trials. PMID:24793244
Yap, Shui-Jean; Watts, Jared C; Faithfull, Tiffany J; Wong, Sabrina Z; Wylde, Kate L; McGurgan, Paul M
An anonymous questionnaire-based survey was used to determine current practices and opinions of senior health professionals working in Western Australian (WA) hospitals performing gynaecological procedures, regarding the routine use of histopathology for products of conception (POC) obtained either from the surgical management of miscarriage or termination of pregnancy. Sixty-one senior health professionals completed the survey. Tissue histopathology on POC was routinely requested for miscarriage and termination of pregnancy (TOP) by 87 and 59% of respondents, respectively. Respondents listed the main reasons for requesting routine histopathology as avoidance of misdiagnosis, medico-legal and quality assurance. There were inconsistent practices among WA health professionals regarding sending POC for histopathology; 63% of gynaecology head of departments recommend the introduction of state or national guidelines for the use of histopathology in the surgical management of miscarriages or terminations of pregnancy.
Kim, Doo-Youp; Choi, Jung-Hyun; Rim, Se-Joong; Kim, Jang-Young; Lee, Sang-Chol; Sohn, Il-Suk; Chung, Wook-Jin; Seo, Hye-Sun; Yoon, Se-Jung; Cho, Kyoung-Im; Choi, Si-Wan; Lee, Kyung-Jin
Background Fundamental echocardiography has some drawbacks in patients with difficult-to-image echocardiograms. The aim of this study is to evaluate impact of contrast echocardiography (CE) on ventricular function assessment and clinical diagnosis in routine clinical echocardiography. Methods Two hundred sixty patients were prospectively enrolled over 3 years in 12 medical centers in Korea. General image quality, the number of distinguishable segments, ability to assess regional wall motion, left ventricular (LV) apex and right ventricle (RV) visualization, LV ejection fraction, changes in diagnostic or treatment plan were documented after echocardiography with and without ultrasound contrast agent. Results Poor or uninterpretable general image was 31% before contrast use, and decreased to 2% (p<0.05) after contrast use. The average number of visualized LV segments was 9.53 before contrast use, and increased to 14.46 (p<0.001) after contrast use. The percentage of poor or not seen LV regional wall motion was decreased from 28.4% to 3.5% (p<0.001). The percentage of poor or not seen LV apex and RV was decreased from 49.4% to 2.4% (p<0.001), from 30.5% to 10.5% (p<0.001), respectively. Changes in diagnostic procedure and treatment plan after CE were 30% and 29.6%, respectively. Conclusion Compared to fundamental echocardiography, CE impacted LV function assessment and clinical decision making in Korean patients who undergo routine echocardiography.
Colloca, Luana; Miller, Franklin G.
Negative expectations deriving from the clinical encounter can produce negative outcomes, known as nocebo effects. Specifically, research on the nocebo effect indicates that information disclosure about potential side effects can itself contribute to producing adverse effects. Neurobiological processes play a role in the nocebo effect and this paper provides a selective review of mechanistic research on the nocebo effect. Comparatively little attention has been directed to clinical studies and their implications for daily clinical practice. The nocebo response is influenced by the content and the way information is presented to patients in clinical trials in both the placebo as well as active treatment conditions. Nocebo effect adversely influences quality of life and therapy adherence, emphasizing the need for minimizing these responses to the extent possible. Evidence further indicates that the informed consent process in clinical trials may induce nocebo effects. This paper concludes with ethical directions for future patient-oriented research and routine practice. PMID:21862825
de Oliveira, Reinaldo Ayer; Jorge Filho, Isac
To think about ethics means to go into the Bioethics universe. If it is understood that medical ethics deals with doctors within an organized society under legal purposes, consensus and ethics in the exercise of medicine it is observed that Bioethics came up due to the need to debate and decide on the ethic questions related mainly to research and scientific advances as well as conquests concerning human rights and social-cultural development: it is the critical expression of our interest in conveniently using the development of medical art and science. Within Medicine, clinical Bioethics arouse as a possibility of thinking and discussing the practice of medicine in the different social institutions which deal with health and with professionals in health area.
Yehia, Baligh R; Long, Judith A; Stearns, Cordelia R; French, Benjamin; Tebas, Pablo; Frank, Ian
Participation in antiretroviral therapy clinical trials (ART-RCTs) offers many advantages including access to new drugs, close monitoring, and cost savings. These same benefits may pose a risk to patients ending ART-RCTs and returning to routine care; as they may experience changes to their drug regimen, decreased monitoring, and new out-of-pocket costs. We aimed to evaluate this transition and determine its effects on viral outcomes and patient perceptions. A retrospective cohort was assembled from participants of naïve ART-RCTs at the University of Pennsylvania between 1 January 2000 and 31 December 2009. Data were collected in the 12 months prior to and after trial completion. Multivariable logistic regression was used to evaluate viral failure rates and to identify factors associated with viral failure. Qualitative interviews were held with a subset of patients. Content analysis was used to identify thematic differences between patients with viral failure and those with viral suppression. In total, 116 patients enrolled in 5 ART-RCTs from 2000 to 2009. Viral failure was observed in 39 patients (34%). Nonwhites, high enrollment CD4 count, and trial completion in 1999-2002 were risk factors for failure. Patients transitioning from ART-RCTs to routine care had a 20% increased odds of failure (Adjusted Odds Ratio 1.20 (95% CI [0.37, 3.88])). Nine patients with viral suppression and three with viral failure in the year after trail completion were interviewed. Suppressed patients were more eager to continue trial participation, nervous about leaving the trial, and felt prepared to return to routine care. In contrast, those with viral failure were less concerned about the transition. These findings suggest that the posttrial period may be a vulnerable time for patients. Patients without a healthy fear of transitioning from ART-RCTs to routine care may be at increased risk of viral failure. Focus should be given to assisting patients during this transition.
Wang, Yingying; Hunt, Kate; Nazareth, Irwin; Freemantle, Nick; Petersen, Irene
Objective To examine whether gender differences in primary care consultation rates (1) vary by age and deprivation status and (2) diminish when consultation for reproductive reasons or common underlying morbidities are accounted for. Design Cross-sectional study of a cohort of patients registered with general practice. Setting UK primary care. Subjects Patients (1 869 149 men and 1 916 898 women) registered with 446 eligible practices in 2010. Primary outcome measures Primary care consultation rate. Results This study analyses routinely collected primary care consultation data. The crude consultation rate was 32% lower in men than women. The magnitude of gender difference varied across the life course, and there was no ‘excess’ female consulting in early and later life. The greatest gender gap in primary care consultations was seen among those aged between 16 and 60 years. Gender differences in consulting were higher in people from more deprived areas than among those from more affluent areas. Accounting for reproductive-related consultations diminished but did not eradicate the gender gap. However, consultation rates in men and women who had comparable underlying morbidities (as assessed by receipt of medication) were similar; men in receipt of antidepressant medication were only 8% less likely to consult than women in receipt of antidepressant medication (relative risk (RR) 0.916, 95% CI 0.913 to 0.918), and men in receipt of medication to treat cardiovascular disease were just 5% less likely to consult (RR=0.950, 95% CI 0.948 to 0.952) than women receiving similar medication. These small gender differences diminished further, particularly for depression (RR=0.950, 95% CI 0.947 to 0.953), after also taking account of reproductive consultations. Conclusions Overall gender differences in consulting are most marked between the ages of 16 and 60 years; these differences are only partially accounted for by consultations for reproductive reasons
Moss, Taryn G; Carney, Colleen E; Haynes, Patricia; Harris, Andrea L
Social rhythms, also known as daily routines (e.g. exercise, of school or work, recreation, social activities), have been identified as potential time cues to help to regulate the biological clock. Past research has shown links between regularity and healthy sleep. This study examined the regularity and frequency of daytime activities in a clinical insomnia population and a good sleeper comparison group. Participants (N = 69) prospectively monitored their sleep and daily activities for a 2-week period. Although participants with insomnia and good sleepers had similar levels of activity, relative to good sleepers, those with insomnia were less regular in their activities. Findings from this study add to the growing number of studies that highlight the relative importance of the regularity of daytime activities on sleep. Accordingly, future research should test treatment components that focus on regulating daytime activities, which would likely improve treatment outcomes.
Kim, Myeong Seong
Background Pulsed radiofrequency (RF) magnetic fields, required to produce magnetic resonance imaging (MRI) signals from tissue during the MRI procedure have been shown to heat tissues. Objectives To investigate the relationship between body temperature rise and the RF power deposited during routine clinical MRI procedures, and to determine the correlation between this effect and the body’s physiological response. Patients and Methods We investigated 69 patients from the Korean national cancer center to identify the main factors that contribute to an increase in body temperature (external factors and the body’s response) during a clinical brain MRI. A routine protocol sequence of MRI scans (1.5 T and 3.0 T) was performed. The patient’s tympanic temperature was recorded before and immediately after the MRI procedure and compared with changes in variables related to the body’s physiological response to heat. Results Our investigation of the physiological response to RF heating indicated a link between increasing age and body temperature. A higher increase in body temperature was observed in older patients after a 3.0-T MRI (r = 0.07, P = 0.29 for 1.5-T MRI; r = 0.45, P = 0.002 for 3.0-T MRI). The relationship between age and body heat was related to the heart rate (HR) and changes in HR during the MRI procedure; a higher RF power combined with a reduction in HR resulted in an increase in body temperature. Conclusion A higher magnetic field strength and a decrease in the HR resulted in an increase in body temperature during the MRI procedure. PMID:27895872
Morrow, Angela M; Quine, Susan; Heaton, Maria D; Craig, Jonathan C
The rising prevalence of children with chronic conditions has made quality of life an increasingly important outcome measure in paediatric practice. The discrepancy between doctors' and patients' perceptions of quality of life makes formal assessment necessary. In this paper we use a case scenario to answer commonly asked questions. What is quality of life and who can assess it? Why assess quality of life in the clinical setting? Is it feasible to measure in routine clinical practice? How is quality of life formally assessed? We provide a basic outline of the language and methods of quality of life assessment and use the case scenario to discuss the process of choosing an appropriate instrument. We conclude that quality of life assessment in clinical practice is feasible and provides benefits for both patients and doctors. The benefits include better informed doctors, improved patient doctor communication and a means to effectively monitor quality of life as a treatment outcome.
Zygourakis, Corinna C; Winkler, Ethan; Pitts, Lawrence; Hannegan, Lisa; Franc, Benjamin; Lawton, Michael T
OBJECTIVE Postoperative head CT scanning is performed routinely at the authors' institution on all neurosurgical patients after elective aneurysm clippings. The goal of this study was to determine how often these scans influence medical management and to quantify the associated imaging costs. METHODS The authors reviewed the medical records and accounting database of 304 patients who underwent elective (i.e., nonruptured) aneurysm clipping performed by 1 surgeon (M.T.L.) from 2010 to 2014 at the University of California, San Francisco. Specifically, the total number of postoperative head CT scans, radiographic findings, and the effect of these studies on patient management were determined. The authors obtained the total hospital costs for these patients, including the cost of imaging studies, from the hospital accounting database. RESULTS Overall, postoperative CT findings influenced clinical management in 3.6% of cases; specifically, they led to permissive hypertension in 4 patients for possible ischemia, administration of mannitol for edema and high-flow oxygen for pneumocephalus in 2 patients each, seizure prophylaxis in 1 patient, Plavix readjustment in 1 patient, and return to the operating room for an asymptomatic epidural hematoma evacuation in 1 patient. When patients were stratified on the basis of postoperative neurological examination, findings on CT scans altered management in 1.1%, 4.8%, and 9.0% of patients with no new neurological deficits, a nonfocal examination, and focal deficits, respectively. The mean total hospital cost for treating patients who undergo elective aneurysm clipping was $72,227 (± $53,966) (all values are US dollars), and the cost of obtaining a noncontrast head CT scan was $292. Neurologically intact patients required 99 head CT scans, at a cost of $28,908, to obtain 1 head CT scan that influenced medical management. In contrast, patients with a focal neurological deficit required only 11 head CT scans, at a cost of $3212, to
Mosser, Hans M.; Paertan, Gerald; Hruby, Walter
This paper communicates the operational implementation of filmless digital radiology in clinical routine, its feasibility and its effect on the radiology profession, based on the three years clinical experience from the filmless digital radiology department of the Danube Hospital, a major teaching hospital in Vienna, Austria, with currently 850 acute-care beds. Since April 1992 all radiological modalities are reported from the monitors of 16 reporting consoles in the radiology department. Images and reports are distributed by the hospital-wide network (Sienet, Siemens Medical Systems, Erlangen), and can be viewed on 60 display consoles throughout the hospital. Filmless radiology primarily is an efficient hospital-wide infrastructure to deliver radiological services along with other medical information, providing safe and fast access to this information anytime and anywhere, necessary for the conduct of the diagnostic and therapeutic task of patient care. In a comparative study of the Danube Hospital with the film based Rudolfstiftung Hospital in Vienna, we found a significant decrease of the mean patient length of hospital stay (1.99 to 3.72 days) that partially might be attributed to the implementation of filmless radiology.
Jayadev, Chaitra; Vinekar, Anand; Bauer, Noel; Mangalesh, Shwetha; Mahendradas, Padmamalini; Kemmanu, Vasudha; Mallipatna, Ashwin; Shetty, Bhujang
Purpose: The purpose of this study was to report the spectrum of anterior and posterior segment diagnoses in Asian Indian premature infants detected serendipitously during routine retinopathy of prematurity (ROP) screening during a 1 year period. Methods: A retrospective review of all Retcam (Clarity MSI, USA) imaging sessions during the year 2011 performed on infants born either <2001 g at birth and/or <34.1 weeks of gestation recruited for ROP screening was performed. All infants had a minimum of seven images at each session, which included the dilated anterior segment, disc, and macula center and the four quadrants using the 130° lens. Results: Of the 8954 imaging sessions of 1450 new infants recruited in 2011, there were 111 (7.66%) with a diagnosis other than ROP. Anterior segment diagnoses seen in 31 (27.9%) cases included clinically significant cataract, lid abnormalities, anophthalmos, microphthalmos, and corneal diseases. Posterior segment diagnoses in 80 (72.1%) cases included retinal hemorrhages, cherry red spots, and neonatal uveitis of infective etiologies. Of the 111 cases, 15 (13.5%) underwent surgical procedures and 24 (21.6%) underwent medical procedures; importantly, two eyes with retinoblastoma were detected which were managed timely. Conclusions: This study emphasizes the importance of ocular digital imaging in premature infants. Visually significant, potentially life-threatening, and even treatable conditions were detected serendipitously during routine ROP screening that may be missed or detected late otherwise. This pilot data may be used to advocate for a possible universal infant eye screening program using digital imaging. PMID:26139795
Issa, Victor Sarli; Dinardi, Layara Fernanda Lipari; Pereira, Thiago Vicente; de Almeida, Lyna Kyria Rodrigues; Barbosa, Thaisa Silveira; Benvenutti, Luiz Alberto; Ayub-Ferreira, Silvia Moreira; Bocchi, Edimar Alcides
Abstract Autopsies are the gold standard for diagnostic accuracy; however, no recent study has analyzed autopsies in heart failure (HF). We reviewed 1241 autopsies (January 2000–May 2005) and selected 232 patients with HF. Clinical and autopsy diagnoses were analyzed and discrepancies categorized according to their importance regarding therapy and prognosis. Mean age was 63.3 ± 15.9 years; 154 (66.4%) patients were male. The causes of death at autopsy were end-stage HF (40.9%), acute myocardial infarction (17.2%), infection (15.9), and pulmonary embolism 36 (15.5). Diagnostic discrepancies occurred in 191 (82.3%) cases; in 56 (24.1%), discrepancies were related to major diagnoses with potential influence on survival or treatment; pulmonary embolism was the cause of death for 24 (42.9%) of these patients. In 35 (15.1%), discrepancies were related to a major diagnosis with equivocal influence on survival or treatment; in 100 (43.1%), discrepancies did not influence survival or treatment. In multivariate analysis, age (OR: 1.03, 95% CI: 1.008–1.052, P = 0.007) and presence of diabetes mellitus (OR: 0.359, 95% CI: 0.168–0.767, P = 0.008) influenced the occurrence discrepancies. Diagnostic discrepancies with a potential impact on prognosis are frequent in HF. These findings warrant reconsideration in diagnostic and therapeutic practices with HF patients. PMID:28121951
Sison, Nathan; Yolken, Annajane; Poceta, Joanna; Mena, Leandro; Chan, Philip A; Barnes, Arti; Smith, Erin; Nunn, Amy
The Mississippi Delta region is one of the communities most heavily impacted by HIV/AIDS in the United States. To understand local provider attitudes and practices regarding HIV testing and care, we conducted 25 in-depth qualitative interviews with local primary care providers and infectious disease specialists. Interviews explored attitudes and practices regarding HIV testing and linkage to care. Most providers did not routinely offer HIV testing, noting financial barriers, financial disincentives to offer routine screening, misperceptions about local informed consent laws, perceived stigma among patients, and belief that HIV testing was the responsibility of the health department. Barriers to enhancing treatment and care included stigma, long distances, lack of transportation, and paucity of local infectious disease specialists. Opportunities for enhancing HIV testing and care included provider education programs regarding billing, local HIV testing guidelines, and informed consent, as well as telemedicine services for underserved counties. Although most health care providers in our study did not currently offer routine HIV testing, all were willing to provide more testing and care services if they were able to bill for routine testing. Increasing financial reimbursement and access to care, including through the Affordable Care Act, may provide an opportunity to enhance HIV/AIDS services in the Mississippi Delta.
Ehlers, Anke; Grey, Nick; Wild, Jennifer; Stott, Richard; Liness, Sheena; Deale, Alicia; Handley, Rachel; Albert, Idit; Cullen, Deborah; Hackmann, Ann; Manley, John; McManus, Freda; Brady, Francesca; Salkovskis, Paul; Clark, David M.
Objective Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area. Method A consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects. Results CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience. Conclusions The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services
Levin, Iris; Aram, Dorit
The present study compared the effects of different mediation routines provided to kindergartners from families of low socioeconomic status on the students' invented spelling attempts and on their gains obtained on spelling and other early literacy skills (letter naming, sounds of letters, word segmentation, and word decoding). The effects of the…
Goer, Henci; Sagady Leslie, Mayri; Romano, Amy
Step 6 of the Ten Steps of Mother-Friendly Care addresses two issues: 1) the routine use of interventions (shaving, enemas, intravenous drips, withholding food and fluids, early rupture of membranes, and continuous electronic fetal monitoring; and 2) the optimal rates of induction, episiotomy, cesareans, and vaginal births after cesarean. Rationales for compliance and systematic reviews are presented. PMID:18523680
Wolery, Mark; Brashers, Margaret Sigalove; Neitzel, Jennifer C.
This article explains how educators can use the ecological congruence assessment process for identifying functional goals for young children with disabilities. Process steps include: teacher collects information about functioning in usual classroom activities, routines, and transitions; summarizes the collected information; and shares the…
Background Modern clinical-research practice favors placebo controls over usual-care controls whenever a credible placebo exists. An unrecognized consequence of this preference is that clinicians are more limited in their ability to provide the benefits of the non-specific healing effects of placebos in clinical practice. Methods We examined the issues in choosing between placebo and usual-care controls. We considered why placebo controls place constraints on clinicians and the trade-offs involved in the choice of control groups. Results We find that, for certain studies, investigators should consider usual-care controls, even if an adequate placebo is available. Employing usual-care controls would be of greatest value for pragmatic trials evaluating treatments to improve clinical care and for which threats to internal validity can be adequately managed without a placebo-control condition. Conclusions Intentionally choosing usual-care controls, even when a satisfactory placebo exists, would allow clinicians to capture the value of non-specific therapeutic benefits that are common to all interventions. The result could be more effective, patient-centered care that makes the best use of both specific and non-specific benefits of medical interventions. PMID:22540350
Charnot-Katsikas, Angella; Tesic, Vera; Boonlayangoor, Sue; Bethel, Cindy; Frank, Karen M
This study assessed the accuracy of bacterial and yeast identification using the VITEK MS, and the time to reporting of isolates before and after its implementation in routine clinical practice. Three hundred and sixty-two isolates of bacteria and yeast, consisting of a variety of clinical isolates and American Type Culture Collection strains, were tested. Results were compared with reference identifications from the VITEK 2 system and with 16S rRNA sequence analysis. The VITEK MS provided an acceptable identification to species level for 283 (78 %) isolates. Considering organisms for which genus-level identification is acceptable for routine clinical care, 315 isolates (87 %) had an acceptable identification. Six isolates (2 %) were identified incorrectly, five of which were Shigella species. Finally, the time for reporting the identifications was decreased significantly after implementation of the VITEK MS for a total mean reduction in time of 10.52 h (P<0.0001). Overall, accuracy of the VITEK MS was comparable or superior to that from the VITEK 2. The findings were also comparable to other studies examining the accuracy of the VITEK MS, although differences exist, depending on the diversity of species represented as well as on the versions of the databases used. The VITEK MS can be incorporated effectively into routine use in a clinical microbiology laboratory and future expansion of the database should provide improved accuracy for the identification of micro-organisms.
Donay, J-L; Mathieu, D; Fernandes, P; Prégermain, C; Bruel, P; Wargnier, A; Casin, I; Weill, F X; Lagrange, P H; Herrmann, J L
A comparative study was designed to evaluate the identification (ID) and antimicrobial susceptibility testing (AST) performances of the BD Phoenix Automated Microbiology System (Becton Dickinson Diagnostic Systems [BD], Pont de Claix, France). A total of 305 single clinical isolates were collected, and comparisons were made with routine manual methods in use in our microbiology laboratories. The percentages of correct IDs were 93.3, 89.4, 91.8, and 85.7% for enterobacteria, nonfermenting gram-negative bacilli, staphylococci, and streptococci-enterococci, respectively. The median ID time was 3 h, and the median time for AST was 10 h 30 min. AST results showed variable percentages of errors for the different antibiotics. None of the enterobacteria and 0.3% of Pseudomonas aeruginosa isolates showed a very major error (VME). Only one strain of Staphylococcus aureus showed a VME with oxacillin. We demonstrate here the efficiency of the Phoenix system, which can be used for the majority of strains encountered in a university-based laboratory, for ID and AST.
Hanson, Jon M.; Harrison, David K.; Hawthorn, Ian E.
About 5% of British males over 50 years develop peripheral arterial occlusive disease. Of these about 2% ultimately require lower limb amputation. In 1995 we proposed a new technique using lightguide spectrophotometry to measure the oxygen saturation level of haemoglobin (SO2) in the skin as a method for predicting tissue viability. This technique, in combination with thermographic imaging, was compared with skin blood flow measurements using the I125)4- Iodoantipyrine (IAP) clearance technique. The optical techniques gave a sensitivity and selectivity of 1.0 for the prediction of successful outcome of a below knee amputation compared with a specificity of 93% using the traditional IAP technique at a below knee to above knee amputation ratio (BKA:AKA) of 75%. The present study assesses the routine clinical application of these optical techniques. The study is ongoing, but the data to date comprises 22 patients. 4 patients were recommended for above knee amputation (AKA) and 18 patients for below knee amputation on the basis of thermographic and tissue SO2 measurements. All but one of the predicted BKA amputations healed. The study to date produces evidence of 94% healing rate (specificity) for a BKA:AKA ratio of 82%. This compares favorably with the previous figures given above.
Stadlbauer, Andreas; Zimmermann, Max; Heinz, Gertraud; Oberndorfer, Stefan; Doerfler, Arnd; Buchfelder, Michael; Rössler, Karl
Knowledge about the topological and structural heterogeneity of the microvasculature is important for diagnosis and monitoring of glioma. A vessel caliber and type-dependent temporal shift in the magnetic resonance imaging signal forms the basis for vascular architecture mapping. This study introduced a clinically feasible approach for assessment of vascular pathologies in gliomas using vascular architecture mapping. Sixty consecutive patients with known or suspected gliomas were examined using vascular architecture mapping as part of the routine magnetic resonance imaging protocol. Maps of microvessel radius and density, which adapted to the vasculature-dependent temporal shift phenomenon, were calculated using a costume-made software tool. Microvessel radius and density were moderately to severely elevated in a heterogeneous, inversely correlated pattern within high-grade gliomas. Additionally, three new imaging biomarkers were introduced: Microvessel type indicator allowing differentiation between supplying arterial and draining venous microvasculature in high-grade gliomas. Vascular-induced bolus peak time shift may presumably be sensitive for early neovascularization in the infiltration zone. Surprisingly, curvature showed significant changes in peritumoral vasogenic edema which correlated with neovascularization in the tumor core of high-grade gliomas. These new magnetic resonance imaging biomarkers give insights into complexity and heterogeneity of vascular changes in glioma; however, histological validations in more well-defined patient populations are required.
Gardner, Greg; Sexton, Patrick; Guyer, M. Susan; Willeford, K. Sean; Levy, Linda S.; Barnum, Mary G.; Fincher, A. Louise
Objective: To present the principles of adult learning and mentoring to help clinical instructors better educate athletic training students (ATSs) during their clinical experiences, with the end result being a better prepared, competent entry-level practitioner. Background: The principles of adult learning must be applied to ATS clinical education…
Koturović, Zoran; Knežević, Miroslav; Rašić, Dejan M.
The main purpose of this paper is to provide the information about the incidence and types of pathology of secondary acquired obstructions of the lacrimal excretory outflow system caused by primary lacrimal sac non-neoplastic and neoplastic lesions. After a thorough literature search, 17 case-control studies were found and selected, data were extracted and categorized, to evaluate specific lacrimal sac pathology mimicking inflammation. A total of 3865 histopathologically examined lacrimal sac wall biopsy specimens from 3662 patients, taken during dacryocystorhinostomy for clinically presumed primary chronic dacryocystitis, were analyzed. The most common reported histopathological finding was non-specific chronic inflammation with or without fibrosis (94.15% of cases). Lacrimal sac-specific pathologies were present in 226 (5.85%) cases. Unsuspected lacrimal sac-specific pathologies were present in 55/226 (24.34%) cases. Almost 45% of primary lacrimal sac malignant neoplasms were not suspected, preoperatively and intraoperatively. Tumor-like lesions of the lacrimal sac were the most common pathology found: (1) lacrimal stones-dacryoliths, (2) pyogenic granuloma, (3) granulation tissues, (4) reactive lymphoid hyperplasia, and (5) lacrimal sac-specific inflammation (Wegener’s granulomatosis and sarcoidosis). Neoplastic pathology was found in 55/3865 (1.42%) lacrimal sac wall biopsy specimens; of those, malignant cases were 2.24 times more frequent than benign. Lymphoma was the most common preoperatively unsuspected or intraoperatively unexpected neoplastic pathology. This analysis of the relevant literature highlights the value of routine lacrimal sac biopsy during surgery for clinically presumed primary acquired nasolacrimal duct obstruction. PMID:27754826
Koturović, Zoran; Knežević, Miroslav; Rašić, Dejan M
The main purpose of this paper is to provide the information about the incidence and types of pathology of secondary acquired obstructions of the lacrimal excretory outflow system caused by primary lacrimal sac non-neoplastic and neoplastic lesions. After a thorough literature search, 17 case-control studies were found and selected, data were extracted and categorized, to evaluate specific lacrimal sac pathology mimicking inflammation. A total of 3865 histopathologically examined lacrimal sac wall biopsy specimens from 3662 patients, taken during dacryocystorhinostomy for clinically presumed primary chronic dacryocystitis, were analyzed. The most common reported histopathological finding was non-specific chronic inflammation with or without fibrosis (94.15% of cases). Lacrimal sac-specific pathologies were present in 226 (5.85%) cases. Unsuspected lacrimal sac-specific pathologies were present in 55/226 (24.34%) cases. Almost 45% of primary lacrimal sac malignant neoplasms were not suspected, preoperatively and intraoperatively. Tumor-like lesions of the lacrimal sac were the most common pathology found: (1) lacrimal stones-dacryoliths, (2) pyogenic granuloma, (3) granulation tissues, (4) reactive lymphoid hyperplasia, and (5) lacrimal sac-specific inflammation (Wegener's granulomatosis and sarcoidosis). Neoplastic pathology was found in 55/3865 (1.42%) lacrimal sac wall biopsy specimens; of those, malignant cases were 2.24 times more frequent than benign. Lymphoma was the most common preoperatively unsuspected or intraoperatively unexpected neoplastic pathology. This analysis of the relevant literature highlights the value of routine lacrimal sac biopsy during surgery for clinically presumed primary acquired nasolacrimal duct obstruction.
Hargrove, Patricia; Griffer, Mona; Lund, Bonnie
Purpose: This article provides information about clinical practice guidelines (CPGs) to facilitate their application to the practice of speech-language pathology. CPGs are sets of recommendations based on evidence, including expert clinical opinion, that have been developed by a panel of reviewers. In this article, CPGs are defined and their…
Akinmoladun, J.A.; Ogbole, G.I.; Lawal, T.A.; Adesina, O.A.
Background: Congenital anomalies are among the leading causes of fetal and infant morbidity and mortality worldwide. Prenatal ultrasound (US) screening has become an essential part of antenatal care in the developed world. Such practice is just evolving in the developing countries such as Nigeria. The aim of this article is to present our initial experience and demonstrate the effectiveness of a prenatal US screening program in detecting congenital malformation in a developing country. Materials and Methods: This was a prospective evaluation of the prenatal US screenings conducted at a major referral hospital in Southwestern Nigeria. All pregnant women referred to the antenatal clinic for mid-trimester screening during the period of study were assessed. Results: Two hundred and eighty-seven pregnant women (5 with twin gestations) were presented for fetal anomaly scan during the study period. Twenty-nine anomalies (9.9%) were detected among the scanned population. Sixteen of the anomalies were followed to delivery/termination with a specificity of 93.5%. The commonest malformations were demonstrated in the genitourinary tract (34.5%) followed by malformations within the central nervous system (27.6%). Six (20.6%) of the anomalies were lethal. Five of the anomalies were surgically correctable. Conclusion: Institutions and hospitals across Nigeria and other low- and middle-income countries need to develop policies and programs that would incorporate a standardized routine screening prenatal US in order to improve feto-maternal well-being and reduce the high perinatal mortality and morbidity in developing nations. PMID:26759511
Velicković, Jelena V; Hajdarević, Sanela A; Palibrk, Ivan G; Janić, Natasa R; Djukanović, Marija; Miljković, Bojana; Velicković, Dejan M; Bumbasirević, Vesna
Daily routine chest radiographs (CR) are commonly performed in surgical ICU. Unnecessary CR increase costs and expose the staff and the patients to radiation risk. The goal of our study was to estimate the value of daily routine CR in the ICU and to determine the correlation between CR and physical findings in surgical ICU patients. Prospective observational study was conducted during period of two months at the ICU department at the Clinic for Digestive Surgery, Clinical Center of Serbia, Belgrade. It included 97 consecutive patients who underwent digestive surgery and stayed at the ICU for at least two days. During their ICU stay, CRs were obtained as a clinical routine or to monitor lung pathology. Patients were followed daily, and CRs (as the proportion of positive findings) were compared with physical examination and clinical presentation. A total of 717 CRs were obtained, median number per patient was 4.0 (2.0-7.0). Proportion of positive findings was significantly higher comparing to auscultation until the sixth day of ICU stay. There was no difference in CR findings from day to day after the sixth day. Therapeutic efficacy of CRs was low as only 56 (7.8%) resulted in a change of patient management. We conclude that daily routine CRs are justified in the first six days of ICU stay, and after that time they show no advantages over clinical examination.
Dadge, Jean; Casey, Dawn
Students who entered training as of September 2007 are required to have a 'sign-off mentor' in their final clinical placement to register with the Nursing and Midwifery Council. The sign-off mentor status is mandatory for confirming that, on completion of the final clinical placement, the student has met all the requirements of the pre-registration clinical assessment criteria and can register as a qualified nurse. This article describes the role of the clinical teacher in preparing and supporting mentors in one area of Wales.
Rudd, M David
This review discusses suicide warning signs in clinical practice and has three simple goals: 1) to help practitioners differentiate in a clinically meaningful fashion between warning signs and risk factors for suicide; 2) to articulate the link among warning signs for suicide, hopelessness, and intent to die; and 3) to assist practitioners in applying warning signs in day-to-day clinical practice, doing so in a concrete and effective manner.
Fonseca, Erica Lourenço; Ramos, Nilceia da Veiga; Andrade, Bruno G Nascimento; Morais, Lena L C S; Marin, Michel F Abanto; Vicente, Ana Carolina P
Klebsiella pneumoniae, Klebsiella variicola and Klebsiella quasipneumoniae are difficult to differentiate phenotypically, leading to misinterpretation of their infection prevalence. We propose a multiplex PCR for blaSHV, blaLEN and blaOKP and their flanking gene (deoR). Since this scheme focuses only on chromosomal genes, it will be feasible for Klebsiella identification in the clinical routine.
Tinto, Halidou; Noor, Ramadhani A; Wanga, Charles L; Valea, Innocent; Mbaye, Maimouna Ndour; D'Alessandro, Umberto; Ravinetto, Raffaella M
A Good Clinical Practices (GCPs) course, based on the combination of theoretical modules with a practical training in real-life conditions, was held in 2010 in Burkina Faso. It was attended by 15 trainees from nine African, Asian, and Latin American countries. There were some discrepancies between the average good results at the end of the theoretical phase and the GCP application during the first days of the practical phase, underlying the difficulties of translating theoretical knowledge into good practices. Most of the findings were not unexpected and reflected the challenges commonly faced by clinical investigators in resource-poor contexts (i.e., the high workload at peripheral health facilities, the need to conciliate routine clinical activities with clinical research, and the risk of creating a double standard among patients attending the same health facility [free care for recruited patients versus user fees for non-recruited patients with the same medical condition]). Even if limited in number and time, these observations suggest that a theoretical training alone may not be sufficient to prepare trainees for the challenges of medical research in real-life settings. Conversely, when a practical phase immediately follows a theoretical one, trainees can immediately experience what the research methodology implicates in terms of work organization and relationship with recruited and non-recruited patients. This initial experience shows the complexity of translating GCP into practice and suggests the need to rethink the current conception of GCP training.
Cairns, Alyssa; Bogan, Richard
(PSG) short onset REM peroid (SOREMP) for the diagnosis of narcolepsy may be altered by a history of shift/night work and/ or other factors that may allow for a rebound of REM sleep (e.g., undergoing a positive airway pressure titration), supporting published guidelines that other sleep disorders and insufficient and/or poorly timed sleep should be ruled out and/or adequately controlled for prior to conducting sleep testing. Further research is needed to understand racial differences in PSG SOREMP and narcolepsy. This study was limited in that data on cataplexy (with exception to that in final diagnosis) and habitual sleep duration were not available. Citation: Cairns A, Bogan R. Prevalence and clinical correlates of a short onset REM period (SOREMP) during routine PSG. SLEEP 2015;38(10):1575–1581. PMID:26039966
Green, Lawrence W.; Glanz, Karen; Ayanian, John Z.; Mittman, Brian S.; Chollette, Veronica; Rubenstein, Lisa V.
The promise of widespread implementation of efficacious interventions across the cancer continuum into routine practice and policy has yet to be realized. Multilevel influences, such as communities and families surrounding patients or health-care policies and organizations surrounding provider teams, may determine whether effective interventions are successfully implemented. Greater recognition of the importance of these influences in advancing (or hindering) the impact of single-level interventions has motivated the design and testing of multilevel interventions designed to address them. However, implementing research evidence from single- or multilevel interventions into sustainable routine practice and policy presents substantive challenges. Furthermore, relatively few multilevel interventions have been conducted along the cancer care continuum, and fewer still have been implemented, disseminated, or sustained in practice. The purpose of this chapter is, therefore, to illustrate and examine the concepts underlying the implementation and spread of multilevel interventions into routine practice and policy. We accomplish this goal by using a series of cancer and noncancer examples that have been successfully implemented and, in some cases, spread widely. Key concepts across these examples include the importance of phased implementation, recognizing the need for pilot testing, explicit engagement of key stakeholders within and between each intervention level; visible and consistent leadership and organizational support, including financial and human resources; better understanding of the policy context, fiscal climate, and incentives underlying implementation; explication of handoffs from researchers to accountable individuals within and across levels; ample integration of multilevel theories guiding implementation and evaluation; and strategies for long-term monitoring and sustainability. PMID:22623601
Nalbanski, A; Nikolov, A
Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. The rationale for routine episiotomy is based on two foundation arguments: that episiotomy reduces perineal trauma and that it prevents subsequent pelvic relaxation. A careful review finds little evidence to support these arguments. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. Efforts should be directed to determine whether episiotomy is beneficial. It is now very important to improve new birthing techniques that maintain the integrity of the perineum and do not involve surgical procedures. More trials are necessary to clarify which are the real indications to use episiotomy. Meanwhile, without the proper scientific evidence, the most correct attitude seems to be a careful use of episiotomy, with decisions on a case-by-case basis.
Buhmann, Carsten; Vettorazzi, Eik; Oehlwein, Christian; Rikkers, Fred; Poetter-Nerger, Monika; Gulberti, Alessandro; Gerloff, Christian; Moll, Christian K.; Hamel, Wolfgang
Objective. To determine the influence of deep brain stimulation (DBS) on daily routine driving behavior in Parkinson's disease (PD) patients. Methods. A cross-sectional questionnaire survey was done in 121 DBS-PD patients. The influences of patient characteristics and DBS on current driving and driving at time of surgery and the predictive value of the preoperative levodopa-test on postoperative driving were evaluated. Results. 50% of 110 driving-license holders currently drove. 63.0% rated themselves as safe drivers, 39.4% reported improvement, and 10.9% noted deterioration in driving after DBS surgery. Inactive drivers had quit driving mainly due to disease burden (90.9%). Active drivers were younger, more often males, and less impaired according to H&Y and MMSE, had surgery more recently, and reported more often overall benefit from DBS. H&Y “on” and UPDRS III “off” scores at time of surgery were lower in pre- and postoperative active than in inactive drivers. Tremor and akinesia were less frequent reasons to quit driving after than before DBS surgery. Postoperatively, 22.7% (10/44) of patients restarted and 10.6% (7/66) of patients discontinued driving, independently of H&Y stage. The preoperative levodopa-test was not predictive for the postoperative driving outcome. Conclusion. 50% of PD patients with DBS drive. DBS surgery changes daily routine driving behavior. PMID:26640738
Ronco, Claudio; Legrand, Matthieu; Goldstein, Stuart L.; Hur, Mina; Tran, Nam; Howell, Eric C.; Cantaluppi, Vincenzo; Cruz, Dinna N.; Damman, Kevin; Bagshaw, Sean M.; Di Somma, Salvatore; Lewington, Andrew
Acute kidney injury (AKI) remains a challenge in terms of diagnosis and classification, its morbidity and mortality remaining high in the face of improving clinical protocols. Current clinical criteria use serum creatinine (sCr) and urine output to classify patients. Ongoing research has identified novel biomarkers that may improve the speed and accuracy of patient evaluation and prognostication, yet the route from basic science to clinical practice remains poorly paved. International evidence supporting the use of plasma neutrophil gelatinase-associated lipocalin (NGAL) as a valuable biomarker of AKI and chronic kidney disease (CKD) for a number of clinical scenarios was presented at the 31st International Vicenza Course on Critical Care Nephrology, and these data are detailed in this review. NGAL was shown to be highly useful alongside sCr, urinary output, and other biomarkers in assessing kidney injury; in patient stratification and continuous renal replacement therapy (CRRT) selection in paediatric AKI; in assessing kidney injury in conjunction with sCr in sepsis; in guiding resuscitation protocols in conjunction with brain natriuretic peptide in burn patients; as an early biomarker of delayed graft function and calcineurin inhibitor nephrotoxicity in kidney transplantation from extended criteria donors; as a biomarker of cardiovascular disease and heart failure, and in guiding CRRT selection in the intensive care unit and emergency department. While some applications require further clarification by way of larger randomised controlled trials, NGAL nevertheless demonstrates promise as an independent biological marker with the potential to improve earlier diagnosis and better assessment of risk groups in AKI and CKD. This is a critical element in formulating quick and accurate decisions for individual patients, both in acute scenarios and in long-term care, in order to improve patient prognostics and outcomes. PMID:25012891
Rubenstein, H.; Levitt, C.
All residents of McGill University's Department of Family Medicine were surveyed by mail about their family practice clinic experience. Residents were generally satisfied with their training site and their supervision, but noted problems with volume and diversity of patients, learning certain procedures, and knowledge of community resources. They did not want more family medicine clinic time. PMID:8219838
Wright, J; Smith, M L; Jackson, D R
This paper describes the early development of clinical governance in an acute NHS Trust. Three Trust-wide workshops and 17 individual departmental workshops were held between 1998-1999. The discussions in these workshops were used to define the key founding principles of clinical governance and the operational structure. The philosophy behind clinical governance, to improve quality of services, was recognised as being part of mainstream trust business, not an optional add-on. The authors found that teamwork and multidisciplinary collaboration are essential components of future quality improvement. Effective leadership skills need to be supported and developed, with responsibilities shared between a core group within each department rather than one individual. Contributions should be recognised and rewarded. Collaboration with primary care and involvement of patients are prerequisites. Specific objectives should be agreed by each department and used to monitor progress. More effective use of existing resources (staff, time, IT and training) can be made.
Braswell, H R; Williamson, J W
The application of a protocol for the initial assessment of medical care outcomes of geriatric depression management in four multispecialty group practice clinics is described. The clinical findings of this study are limited, but the protocol for the assessment of depression outcomes was found to be feasible, practical and acceptable in all four clinics. The success of the study has positive implications both for improving management of depressed clinic patients and for adapting this quality assurance approach to other health conditions and care settings. PMID:507262
Egan, Tony; Jaye, Chrystal
The social organization of clinical learning is under-theorized in the sociological literature on the social organization of health care. Professional scopes of practice and jurisdictions are formally defined by professional principles and standards and reflected in legislation; however, these are mediated through the day-to-day clinical activities of social groupings of clinical teams. The activities of health service providers typically occur within communities of clinical practice. These are also major sites for clinical curriculum delivery, where clinical students learn not only clinical skills but also how to be health professionals. In this article, we apply Wenger's model of social learning within organizations to curriculum delivery within a health service setting. Here, social participation is the basis of learning. We suggest that it offers a powerful framework for recognizing and explaining paradox and incongruence in clinical teaching and learning, and also for recognizing opportunities, and devising means, to add value to students' learning experiences.
Álvarez-Vargas, Mayita Lizbeth; Galvez-Olortegui, José Kelvin; Galvez-Olortegui, Tomas Vladimir; Sosa-Rosado, José Manuel; Camacho-Saavedra, Luis Arturo
The aim of this study is the methodological evaluation of Clinical Practice Guidelines (CPG) in hypertension. This is the first in a series of review articles, analysis, assessment in methodology and content of clinical practice guidelines in Cardiology. Of all clinical practice guidelines, three were selected and the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used to assess each guide. The guidelines obtained the lowest score in the domain of applicability (mean 43.8%); while the highest score was for clarity of presentation (mean 81.5%). The lowest percentage was found in the applicability domain (European guideline) and the highest of all scores was found in two domains: scope and purpose, and clarity of presentation (Canadian guideline). Assessing the quality of the clinical practice guidelines analyzed, the Canadian is one with the best scores obtained by applying the AGREE II instrument, and it is advised to be used without modifications.
Genetics should now be part of everyday clinical epilepsy practice. Good data exist to provide empiric risks based on epilepsy syndrome diagnosis. Investigation of the molecular basis of some epilepsies is now a practical clinical task and is of clear value to the patient and family. In some cases, specific therapeutic decisions can now be made based on genetic findings, and this scenario of precision therapy is likely to increase in the coming years. PMID:26316866
Etkind, Paul; Arias, Donna; Bagley, Bobbie; Nelson, Mary S
A tremendous amount of resources is being poured into public health agencies for the purpose of planning to prevent, respond to, and/or recover from all manner of emergencies. As planning and practice drills have progressed, many of the shortcomings of our current public health system are being recognized. Many gray areas, particularly legal and ethical, are coming into focus. There are many questions about whether the standards of medical care and public health practice will necessarily remain constant during emergencies. This article examines whether the same might be true of the ethical standards of public health practice. Will they or should they be the same regardless of whether we are working in "usual" times or "unusual" times?
Mainstream psychotherapy has made huge strides in treating symptoms and disorders, but it has largely overlooked happiness as a therapeutic goal despite frequently hearing from clients, "Doctor, I want to be happy." This issue of Journal of Clinical Psychology: In Session describes a number of positive interventions for specific clinical problems, such as depression, anxiety, schizophrenia, loss, grief, and relationship distress. Although the name may suggest it, positive interventions do not imply that rest of psychotherapies are negative. Neither are negatives denied nor minimized. Distinct from self-help recipes proffering instant changes, positive psychology interventions refer to systematic approaches to overcome challenges by using clients' strengths and assets. A hybrid psychotherapy-coaching model and strength-based assessment can ask a client "What is right with you?" All articles are supplemented with rich case illustrations.
Botulinum toxin, the most potent biological toxin, has become a powerful therapeutic tool for a growing number of clinical applications. This review draws attention to new findings about the mechanism of action of botulinum toxin and briefly reviews some of its most frequent uses, focusing on evidence based data. Double blind, placebo controlled studies, as well as open label clinical trials, provide evidence that, when appropriate targets and doses are selected, botulinum toxin temporarily ameliorates disorders associated with excessive muscle contraction or autonomic dysfunction. When injected not more often than every three months, the risk of blocking antibodies is slight. Long term experience with this agent suggests that it is an effective and safe treatment not only for approved indications but also for an increasing number of off-label indications. PMID:15201348
Papademetriou, Marianna; Popov, Violeta
Cost-effective therapies to address the growing epidemic of obesity are a leading priority in modern medicine. Intragastric balloons (IGBs) are one such option, with increased effectiveness compared with pharmacotherapy and lifestyle and a lower rate of adverse events than bariatric surgery. IGBs are endoscopically placed or swallowed space-occupying devices in the stomach. Three IGB systems were approved in 2015 to 2016 by the Food and Drug Administration for use in the United States, with more devices nearing approval. This paper reviews the adverse events and efficacy of IGBs, and practice setup, management of common complications, and dietary advice for patients.
Walensky, Rochelle P.; Wood, Robin; Fofana, Mariam O.; Martinson, Neil A.; Losina, Elena; April, Michael D.; Bassett, Ingrid V.; Morris, Bethany L.; Freedberg, Kenneth A.; Paltiel, A. David
Background Although 900,000 HIV-infected South Africans receive antiretroviral therapy (ART), the majority of South Africans with HIV remain undiagnosed. Methods We use a published simulation model of HIV case detection and treatment to examine three HIV screening scenarios, in addition to current practice: 1) one-time; 2) every five years; and 3) annually. South African model input data include: 16.9% HIV prevalence, 1.3% annual incidence, 49% test acceptance rate, HIV testing costs of $6.49/patient, and a 47% linkage-to-care rate (including two sequential ART regimens) for identified cases. Outcomes include life expectancy, direct medical costs, and incremental cost-effectiveness. Results HIV screening one-time, every five years, and annually increase HIV-infected quality-adjusted life expectancy (mean age 33 years) from 180.6 months (current practice) to 184.9, 187.6 and 197.2 months. The incremental cost-effectiveness of one-time screening is dominated by screening every five years. Screening every five years and annually each have incremental cost-effectiveness ratios of $1,570/quality-adjusted life year (QALY) and $1,720/QALY. Screening annually is very cost-effective even in settings with the lowest incidence/prevalence, with test acceptance and linkage rates both as low as 20%, or when accounting for a stigma impact at least four-fold that of the base case. Conclusions In South Africa, annual voluntary HIV screening offers substantial clinical benefit and is very cost-effective, even with highly constrained access to care and treatment. PMID:21068674
Celler, Anna; Grimes, Joshua; Shcherbinin, Sergey; Piwowarska-Bilska, Hanna; Birkenfeld, Bozena
Patient-specific dose calculations are not routinely performed for targeted radionuclide therapy procedures, partly because they are time consuming and challenging to perform. However, it is becoming widely recognized that a personalized dosimetry approach can help plan treatment and improve understanding of the dose-response relationship. In this chapter, we review the procedures and essential elements of an accurate internal dose calculation and propose a simplified approach that is aimed to be practical for use in a busy nuclear medicine department.
Radford, J. A.; Eardley, A.; Woodman, C.; Crowther, D.
OBJECTIVE: To examine the effectiveness of routine clinic review in detecting relapse after treatment for Hodgkin's disease. DESIGN: Review of hospital records. SETTING: Regional centre for cancer treatment and research. SUBJECTS: 210 patients with Hodgkin's disease recruited to a chemotherapy trial protocol between 1984 and the end of 1990 who had achieved a complete or partial remission after treatment. MAIN OUTCOME MEASURES: The number of clinic visits made by patients over the period of observation, the number of relapses occurring during that time, and the route by which relapse was detected. RESULTS: The 210 patients generated 2512 outpatient reviews, and 37 relapses were detected. Thirty relapses (81%) were diagnosed in patients who described symptoms, which in 15 cases had resulted in an earlier appointment being arranged. In only four cases (11%; 95% confidence interval 4% to 25%) was relapse detected as a result of routine physical examination on investigation of a patient who did not have symptoms. CONCLUSIONS: Relapse of Hodgkin's disease after treatment is usually detected as a result of the investigation of symptoms rather than by routine screening of asymptomatic patients. It is therefore proposed that the frequency of routine follow up visits should be reduced and greater emphasis placed on patient education. This should underline the importance of symptoms and encourage patients to arrange an earlier appointment if these develop. PMID:9040326
Dietz, Christine A.
Discusses the need to train clinical practitioners in social work to address ongoing issues of oppression. Describes a second-year Master's in Social Work clinical practice sequence taught from feminist, poststructuralist, postmodern, and social constructionist perspectives, where students learn to assess the impacts of oppression, discover…
Tomaszek, Sandra; Wigle, Dennis A.; Keshavjee, Shaf; Fischer, Stefan
Thymomas are the most common tumors of the mediastinum. The introduction of multimodality treatment strategies, as well as novel approaches to the diagnosis of these tumors, has led to changes in the clinical management of thymomas. Here we review the literature for current clinical practice in the diagnosis, management, and treatment of thymomas. PMID:19463649
Collett, DeShana Ann
Health disparities in minorities and those of low socioeconomic status persist despite efforts to eliminate potential causes. Differences in the delivery of services can result in different healthcare outcomes and therefore, a health disparity. Some of this difference in care may attribute to discrimination resulting from clinical biases and…
Douxfils, Jonathan; Chatelain, Bernard; Chatelain, Christian; Dogné, Jean-Michel; Mullier, François
Assessment of plasma concentration/effect of edoxaban may be useful in some situations. Also, clinicians need to know how routine coagulation assays are influenced. It was our aim to determine coagulation tests useful for the assessment of edoxaban's pharmacodynamics and provide recommendations for the interpretation of haemostasis diagnostic tests. Edoxaban was spiked at concentrations ranging from 0 to 1,000 ng/ml in platelet-poor plasma which covers the on-therapy range (from ± 25 ng/ml at Ctrough to ± 170 ng/ml at Cmax). aPTT, PT, dRVVT, chromogenic anti-Xa assays, TGA and a large panel of haemostasis diagnostic tests were performed using several reagents. A concentration-dependent prolongation of aPTT, PT and dRVVT was observed. The effect was dependent on the reagents. FXa chromogenic assays showed high sensitivity and a linear correlation depending on the methodology. TGA may be useful to assess the pharmacodynamics of edoxaban but its turnaround time and the lack of standardisation are limitations. Edoxaban impairs the assessment of lupus anticoagulant, protein S (clotting method), APC-R, antithrombin (FXa-based assay) and measurement of clotting factor activity. Immunological assays and assays acting below the FXa are not influenced by edoxaban. In conclusion, some PT reagents could be used to estimate edoxaban activity. Chromogenic anti-Xa assays are required to assess the plasma concentration. TGA may be useful but requires standardisation. In case of thrombophilia or in the exploration of a haemorrhagic event, immunological assays should be recommended, when applicable. Standardisation of the time between the last intake and the sampling is mandatory to provide a proper assessment of the result.
Morin, Richard L.; Berquist, Thomas H.; Rueger, Wolfgang
We have begun a project to implement an Electronic (Filmless) Radiology Practice (ERP) at Mayo Clinic Jacksonville. This project is integrated with the implementation of a project (Automated Clinical Practice--ACP) to eliminate circulation and archival of the current paper Medical Record. The ERP will result in elimination of screen/film radiography and the transmittal of film throughout the institution by the end of 1996. In conjunction with the ACP, paper and film will not circulate within the clinic by the end of this year.
Lewin, Warren H; Schaefer, Kristen G
Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.
Hankard, R; Colomb, V; Piloquet, H; Bocquet, A; Bresson, J-L; Briend, A; Chouraqui, J-P; Darmaun, D; Dupont, C; Frelut, M-L; Girardet, J-P; Goulet, O; Rieu, D; Simeoni, U; Turck, D; Vidailhet, M
Protein energy malnutrition (PEM) occurs when energy and protein intake do not meet requirements. It has a functional and structural impact and increases both morbidity and mortality of a given disease. The Nutrition Committee of the French Pediatric Society recommends weighing and measuring any child when hospitalized or seen in consultation. The body mass index (BMI) must be calculated and analyzed according to references any time growth kinetics cannot be analyzed. Any child with a BMI below the third centile or -2 standard deviations for age and sex needs to be examined looking for clinical signs of malnutrition and signs orienting toward an etiology and requires having his BMI and height dynamics plotted on a chart. PEM warrants drawing up a nutritional strategy along with the overall care plan. A target weight needs to be determined as well as the quantitative and qualitative nutritional care including its implementation. This plan must be evaluated afterwards in order to adapt the nutritional therapy.
Nielsen, Sara Kerstine Kaya; Vangkilde, Signe; Wolitzky-Taylor, Kate B; Daniel, Sarah Ingrid Franksdatter; Hageman, Ida
Introduction Cognitive–behavioural therapy (CBT) is effective for treating anxiety disorders and is offered in most mental health services around the world. However, a relatively large number of patients with anxiety disorders do not benefit from CBT, experience relapses or drop out. Reliable predictors of treatment effects are lacking. The aim of this study is to investigate the predictive value of emotion regulation and attentional control for CBT outcome in a routine setting. Methods and analysis In this prospective and practice-based study, 112 patients with anxiety disorders referred for manual-based group CBT at two psychiatric outpatient clinics will be recruited. Emotion regulation, severity of anxiety and attentional control will be assessed with self-report measures and with an experimental computer-based attentional control task at baseline, post-treatment and at a 6-month follow-up. Emotion regulation will be measured with Difficulties in Emotion Regulation Questionnaire, severity of anxiety will be assessed with Beck Anxiety Inventory and attentional control will be measured with the self-report questionnaire, Attention Control Scale, and with an experimental computer-based attentional control task based on theory of visual attention. Data will be analysed using multilevel mixed-effects modelling. Ethics and dissemination The study is approved by the Danish National Ethical Board, the Department of Psychology Ethical Board, University of Copenhagen and by the Danish Data Protection Agency. Study findings will be disseminated through peer-reviewed journal publications and conference presentations. The Danish Committee System on Health Research Ethics has been notified about the project. Trial registration number NCT02638363. PMID:27016248
No consensus exists as to who should be tested for thrombophilia, mainly due to the lack of good quality clinical outcome data in relationship to presence or absence of a given thrombophilia. Testing may be considered if (a) finding a thrombophilia predicts recurrent thrombosis and, thus, influences length of anticoagulation treatment decisions; (b) identifying a thrombophilia has implications on management of asymptomatic family members who are carriers of the detected thrombophilia; (c) a patient wishes to better understand why a thrombotic event occurred. Testing may be helpful in patients with venous thromboembolism at intermediate risk of recurrence in whom the finding of a strong thrombophilia can be one of the arguments for long-term anticoagulation--the "risk-of-recurrence-triangle" may be a useful aid in this decision process. Patients whose venous thromboembolism was provoked by a major transient risk factor should not be tested for thrombophilia. Thrombophilia tests should only be ordered by health care professionals who can provide the "4P": (a) appropriately select which patient to test, (b) provide pre-test counseling, (c) properly interpret the test results, and (d) provide education and advice to the patient. If testing is embarked on in patients with venous thromboembolism, it is advisable to be done at the time of decision making whether to stop or continue anticoagulation, i.e. typically after 3 months of anticoagulant therapy. Thrombophilia testing is best not done at the time of an acute thrombotic event and while a patient is on an anticoagulant.
Pirani, Sylvia; Reizes, Tom
Social marketing can be an effective tool for achieving public health goals. Social marketing uses concepts from commercial marketing to plan and implement programs designed to bring about behavior change that will benefit individuals and society. Although social marketing principles have been used to address public health problems, efforts have been dominated by message-based, promotion-only strategies, and effective implementation has been hampered by both lack of understanding of and use of all of the components of a social marketing approach and lack of training. The Turning Point initiative's Social Marketing National Excellence Collaborative (SMNEC) was established to promote social marketing principles and practices to improve public health across the nation. After 4 years, the Collaborative's work has resulted in improved understanding of social marketing among participating members and the development of new tools to strengthen the social marketing skills among public health practitioners. The Collaborative has also made advances in incorporating and institutionalizing the practice of social marketing within public health in participating states.
This article reviews routine quality-control (QC) procedures for current nuclear medicine instrumentation, including the survey meter, dose calibrator, well counter, intraoperative probe, organ ("thyroid") uptake probe, gamma-camera, SPECT and SPECT/CT scanner, and PET and PET/CT scanner. It should be particularly useful for residents, fellows, and other trainees in nuclear medicine, nuclear cardiology, and radiology. The procedures described and their respective frequencies are presented only as general guidelines.
This article reviews routine quality-control (QC) procedures for current nuclear medicine instrumentation, including the survey meter, dose calibrator, well counter, intraoperative probe, organ (“thyroid”) uptake probe, γ-camera, SPECT and SPECT/CT scanner, and PET and PET/CT scanner. It should be particularly useful for residents, fellows, and other trainees in nuclear medicine, nuclear cardiology, and radiology. The procedures described and their respective frequencies are presented only as general guidelines. PMID:18587088
Zacher Dixon, Lydia
Mexican midwives have long taken part in a broader Latin American trend to promote "humanized birth" as an alternative to medicalized interventions in hospital obstetrics. As midwives begin to regain authority in reproductive health and work within hospital units, they come to see the issue not as one of mere medicalization but of violence and violation. Based on ethnographic fieldwork with midwives from across Mexico during a time of widespread social violence, my research examines an emergent critique of hospital birth as a site of what is being called violencia obstétrica (obstetric violence). In this critique, women are discussed as victims of explicit abuse by hospital staff and by the broader health care infrastructures. By reframing obstetric practices as violent-as opposed to medicalized-these midwives seek to situate their concerns about women's health care in Mexico within broader regional discussions about violence, gender, and inequality.
Cassagne, Carole; Ranque, Stéphane; Normand, Anne-Cécile; Fourquet, Patrick; Thiebault, Sandrine; Planard, Chantal; Hendrickx, Marijke; Piarroux, Renaud
Background MALDI-TOF MS recently emerged as a valuable identification tool for bacteria and yeasts and revolutionized the daily clinical laboratory routine. But it has not been established for routine mould identification. This study aimed to validate a standardized procedure for MALDI-TOF MS-based mould identification in clinical laboratory. Materials and Methods First, pre-extraction and extraction procedures were optimized. With this standardized procedure, a 143 mould strains reference spectra library was built. Then, the mould isolates cultured from sequential clinical samples were prospectively subjected to this MALDI-TOF MS based-identification assay. MALDI-TOF MS-based identification was considered correct if it was concordant with the phenotypic identification; otherwise, the gold standard was DNA sequence comparison-based identification. Results The optimized procedure comprised a culture on sabouraud-gentamicin-chloramphenicol agar followed by a chemical extraction of the fungal colonies with formic acid and acetonitril. The identification was done using a reference database built with references from at least four culture replicates. For five months, 197 clinical isolates were analyzed; 20 were excluded because they were not identified at the species level. MALDI-TOF MS-based approach correctly identified 87% (154/177) of the isolates analyzed in a routine clinical laboratory activity. It failed in 12% (21/177), whose species were not represented in the reference library. MALDI-TOF MS-based identification was correct in 154 out of the remaining 156 isolates. One Beauveria bassiana was not identified and one Rhizopus oryzae was misidentified as Mucor circinelloides. Conclusions This work's seminal finding is that a standardized procedure can also be used for MALDI-TOF MS-based identification of a wide array of clinically relevant mould species. It thus makes it possible to identify moulds in the routine clinical laboratory setting and opens new avenues
Nikles, Jane; Mitchell, Geoffrey K; Clavarino, Alexandra; Yelland, Michael J; Del Mar, Christopher B
N-of-1 trials are empirical formal tests using a within-patient randomised, double-blind, cross-over comparison of drug and placebo (or another drug), which we adapted to study individual patients' responses as a clinical tool to guide clinical management. We administered semi-structured interviews to gauge stakeholder perspectives on the possibility of using routine n-of-1 trials for this purpose. Stakeholders included government and non-government health care sector, and patient, clinician and consumer, organisations. Stakeholders supported more widespread implementation of n-of-1 trials, in a targeted fashion, with some caveats. Barriers to their widespread implementation included constraints on doctors' time, doctors' acceptance, drug company acceptance, patient willingness, and cost. Strategies for overcoming barriers included conditional Pharmaceutical Benefits Scheme listing if cost-effective. There was little consensus on which model of n-of-1 trial implementation would be most effective. We discuss different approaches to addressing the several concerns raised to enable widespread introduction of n-of-1 trials into routine clinical practice as a decision tool.
Timmons, Stephen; Baxendale, Bryn; Buttery, Andrew; Miles, Giulia; Roe, Bridget; Browes, Simon
Objectives To understand whether aviation-derived human factors training is acceptable and useful to healthcare professionals. To understand whether and how healthcare professionals have been able to implement human factors approaches to patient safety in their own area of clinical practice. Methods Qualitative, longitudinal study using semi-structured interviews and focus groups, of a multiprofessional group of UK NHS staff (from the emergency department and operating theatres) who have received aviation-derived human factors training. Results The human factors training was evaluated positively, and thought to be both acceptable and relevant to practice. However, the staff found it harder to implement what they had learned in their own clinical areas, and this was principally attributed to features of the informal organisational cultures. Conclusions In order to successfully apply human factors approaches in hospital, careful consideration needs to be given to the local context and informal culture of clinical practice. PMID:24631959
Chan, Tracey E
Recent research and ethical analysis have forced a clinical and ethical reappraisal of the utility of placebos in medical practice. The main concern of ethics and law is that using placebos in health care involves deception, which is antithetical to patient autonomy and trust in the physician-patient relationship. This article reviews the various, more nuanced scientific conceptions of the placebo effect, and evaluates the ethical and legal objections to deploying placebos in clinical practice. It argues that the placebo effect may be legitimately accommodated on the basis that it does not engage the requirement for material or quasi-fiduciary disclosures of information, and may also be justified by therapeutic privilege. In addition, this reconceptualisation of the placebo effect offers a new justification for therapeutic privilege in these contexts. Notwithstanding this, using the placebo effect in clinical practice raises regulatory issues that will require special regulatory supervision.
Hospital checklists are gaining momentum, particularly since the World Health Organization's Safe Surgery Saves Lives Program published results of its study in 2009, indicating that a safety checklist significantly improved surgical outcomes in hospitals across the world. The South Carolina Hospital Association, in partnership with Dr Atul Gawande, has launched a program to implement the World Health Organization Surgical Safety Checklist in every operating room in the state over the next few years. Governments, in such places as France and the Canadian province of Ontario, are also stepping in to make surgical checklists mandatory in their hospitals. Drawing on research, recent initiatives, and the company's experience in high-acuity units, this article explores the implications and challenges of implementing checklists in today's hospitals. If a checklist is to succeed as a mechanism for transforming evidence-based care and safety protocols into best and actual practice, it needs to be used consistently and durably; to achieve this, hospitals need to foster a supportive environment as well as acquire a system to monitor, measure, and manage a culture that effectively embraces checklists.
Langone, Luis; Vanetta, Marcos; Vazquez, Marcelo; Rotger, Viviana; Olivera, Juan Manuel
In the curricula of the Biomedical Engineering career of the Facultad de Ciencias Exactas y Tecnología of the Universidad Nacional de Tucumán, Argenitna, there are the Assisted Professional Practices. Within this framework, the students have the possibility of performing practices in the clinic Sanatorio 9 de Julio. One of the objectives of these practices is to apply the concepts, methods and procedures studied along the career in the field work under real work conditions. From the point of view of the host institution, the objective is to improve the performance of the different services and areas applying the tools of Biomedical Engineering. The present work shows an example of such practices where an equipment preliminary analysis was made, its use and maintenance corresponding to the surgical unit of the clinic.
Background To report results obtained by combining risk sharing tools with post-adoption surveillance mechanisms in order to control quality of care and implement a value-based reimbursement scheme for Neuro-reflexotherapy (NRT), a non-pharmacological treatment proven effective for neck pain (NP), thoracic pain (TP) and low back pain (LBP). Methods Pre-post prospective cohort study in routine clinical practice, carried out in primary care centers in the Spanish National Health Service in the Balearic Islands (Ib-Salut). Eight-hundred and seventy-one subacute and chronic NP, TP and LBP patients treated in Ib-Salut, who underwent NRT during 2011. A shared risk contract (SRC) was developed, where payments for NRT were linked to results on patients’ clinical evolution, reduction in medication and proportion of patients undergoing spinal surgery. Main outcome measures were local pain (NP, TP or LBP), referred pain, LBP-related disability and NP-related disability, measured using previously validated instruments at referral and 3 months later, use of medication assessed at referral and discharge, and rates of spinal surgery prescription after undergoing NRT. Results Median improvements at discharge corresponded to 57.1% of baseline value for local pain, 75.0% for referred pain, 53.8% for LBP-related disability and 45.0% for NP-related disability. Patients taking medication at discharge represented 29.0% of those taking it at referral. The proportion of patients in whom spinal surgery was prescribed after undergoing NRT was 0%. These results were consistent with those from previous randomised controlled trials (RCTs) and studies in routine practice, and complied with the standards set in the SRC. Conclusions It is feasible and effective to enhance post adoption surveillance methods with risk sharing tools to improve quality control and support value-based reimbursement decisions for NRT. The feasibility of generalising this approach to other settings and to other non
AL-ATTAS*, ASMAA; ASSIDI*, MOURAD; AL-MAGHRABI, JAUDAH; DALLOL, ASHRAF; SCHULTEN, HANS-JUERGEN; ABU-ELMAGD, MUHAMMAD; CHAUDHARY, ADEEL; ABUZENADAH, ADEL; BUDOWLE, BRUCE; BUHMEIDA, ABDELBASET; AL-QAHTANI, MOHAMMED
Background/Aim: To date, the conventional formalin-fixed, paraffin-embedded (FFPE) technique is the gold-standard for preserving histomorphology. Once FFPE tissues are stained, slides are routinely archived along with their blocks at biobanks/hospitals. However, the reuse of fixed and stained biospecimens as DNA source is not a common routine practice worldwide and, thus, indicates the need of studies to investigate the feasibility of extracting DNA from already immunohistochemistry (IHC) FFPE-stained slides and its possible reuse in subsequent downstream molecular analyses. Materials and Methods: FFPE IHC slides from colorectal cancer (CRC) patients were prepared and stored in the CEGMR Biobank. The workflow consists of digitalization of IHC stained slide’s image, removing the slide cover-slip, crude dissection and DNA extraction. Following DNA quality assessment, mutation analysis of CTNNB1 and methylation profile of CDH1 were performed. Results: High-quality DNA was obtained allowing 60% concordance between CDH1 methylation and membranous E-cadherin expression pattern. Clean CTNNB1 DNA chromatograms with evenly-spaced peaks were observed. Conclusion: This study is a proof of concept to recycle and reuse DNA from IHC stained slides with suitable concentration and integrity for further downstream molecular applications. These findings will enhance the pathologists’ knowledge, attitudes and practices (KAP) towards the use of these biospecimens and support the implementation of this approach in clinical pathology practice. Therefore, the scientific community will benefit from the largest comprehensive database of human fully annotated FFPE biospecimens already available at their disposal in order to demystify the complexity and the heterogeneity of many challenging diseases and foster the transition towards precision medicine. *These Authors contributed equally to this manuscript. PMID:27566658
Singh, Malkit; Sharma, Rahul; Gupta, Pramod K; Rana, Jatinder K; Sharma, Meera; Taneja, Neelam
Aim: The aim of this study was to evaluate and compare practically achieved disinfection efficacy of some locally available disinfectants on surfaces and infectious microbiological hospital waste. Materials and Methods: Seven disinfectants were tested at concentrations recommended by manufacturers on rough and smooth surfaces that were contaminated experimentally by locally circulating isolates of methicillin-resistant Staphylococcus aureus, multidrug-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter aerogenes, Pseudomonas aeruginosa strains, standard isolate of Salmonella typhi and Candida albicans. Reduction in microbial counts before and after surface disinfection was expressed as log reduction. A very heavy microbial waste load was simulated by immersing culture plates with heavy microbial growth in disinfectants. Daily, a sample of disinfectant was taken and subjected to in-use test. Results: The highest average log reduction of test microbes on the rough surface was given by DesNet (5.05) and Bacillocid special (5.02). A comparable average log reduction of test microbes on a smooth steel surface was noted (5.68, 5.67, 5.50) for Lysol, Bacillocid sp. and DesNet, respectively. In the discard jars, Bacillocid special worked satisfactorily for 4 days, DesNet for 3 days and Hi-giene Germitol for 1 day. The remainder of the disinfectants failed in the in-use test on Day 1. Phenolics, although widely used in our settings, may not be as good surface disinfectants as newer formulations like DesNet and Bacillocid special. Conclusions: Newer quaternary ammonium compounds and aldehyde formulations were found to be the best disinfectants for disinfection of heavy contamination. PMID:23188950
Tai, E Shyong; Chia, Boon Lock; Bastian, Amber Carla; Chua, Terrance; Ho, Sally Chih Wei; Koh, Teck Siew; Low, Lip Ping; Tey, Jeannie S; Poh, Kian Keong; Tan, Chee Eng; Ting, Peter; Tham, Tat Yean; Toh, Sue-Anne; van Dam, Rob M
The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.
Saraga, Michael; Fuks, Abraham; Boudreau, J Donald
George Engel's (1913-1999) biopsychosocial model, one of the most significant proposals for the renewal of medicine in the latter half of the 20th century, has been understood primarily as a multi-factorial approach to the etiology of disease and as a call to re-humanize clinical practice. This common reading of Engel's model misses the central aspect of his proposal, that the biopsychosocial model is an epistemology for clinical work. By stating the simple fact that the clinician is not dealing directly with a body, but first, and inevitably, with a person, Engel challenged the epistemology implicit in the classical clinical method-a method predicated on the possibility of direct access to the body. Framed in epistemological terms, the issue at stake is not the need to complement medical science with humane virtues, but rather to acknowledge that the object of clinical practice is not the body but the patient.
Mohan, Rosh Radhika; Doraswamy, Dwarakanath Chinni; Hussain, Ahad M.; Gundannavar, Gayatri; Subbaiah, Shobha Krishna; Jayaprakash, Deepika
Background and Objectives: Aim of this randomly controlled clinical study was to evaluate the role of antibiotics to prevent postoperative complications after routine periodontal surgery and also to determine whether their administration improved the surgical outcome. Materials and Methods: Forty-five systemically healthy patients with moderate to severe chronic periodontitis requiring flap surgery were enrolled in the study. They were randomly allocated to Amoxicillin, Doxycycline, and control groups. Surgical procedures were carried out with complete asepsis as per the protocol. Postoperative assessment of patient variables like swelling, pain, temperature, infection, ulceration, necrosis, and trismus was performed at intervals of 24 h, 48 h, 1 week, and 3 months. Changes in clinical parameters such as gingival index, plaque index, probing pocket depth, and clinical attachment level were also recorded. Results: There was no incidence of postoperative infection in any of the patients. Patient variables were comparable in all the three groups. Though there was significant improvement in the periodontal parameters in all the groups, no statistically significant result was observed for any group over the others. Conclusion: Results of this study showed that when periodontal surgical procedures were performed following strict asepsis, the incidence of clinical infection was not significant among all the three groups, and also that antibiotic administration did not influence the outcome of surgery. Therefore, prophylactic antibiotics for patients who are otherwise healthy administered following routine periodontal surgery to prevent postoperative infection are unnecessary and have no demonstrable additional benefits. PMID:24872630
Hallgren Elfgren, Ing-Marie; Grodzinsky, Ewa; Törnvall, Eva
Aim The purpose of this project is to describe the use of the Swedish National Diabetes Register (NDR) in clinical practice in a Swedish county and to specifically monitor the diabetes care routines at two separate primary health-care centres (PHCC) with a special focus on older patients.
Lincoln, Tania M.; Ziegler, Michael; Mehl, Stephanie; Kesting, Marie-Luise; Lullmann, Eva; Westermann, Stefan; Rief, Winfried
Objective: Randomized controlled trials have attested the efficacy of cognitive behavioral therapy (CBT) in reducing psychotic symptoms. Now, studies are needed to investigate its effectiveness in routine clinical practice settings. Method: Eighty patients with schizophrenia spectrum disorders who were seeking outpatient treatment were randomized…
Parfenov, Vladimir A.; Golyk, Volodymyr A.; Matsnev, Eduard I.; Morozova, Svetlana V.; Melnikov, Oleg A.; Antonenko, Ludmila M.; Sigaleva, Elena E.; Situkho, Maksym I.; Asaulenko, Olena I.; Popovych, Vasyl I.; Zamergrad, Maxim V.
Background Vestibular vertigo is associated with substantially reduced quality of life. Betahistine is effective in improving vertigo-associated symptoms, with longer treatment periods leading to greater improvements; however, it is not known whether these effects persist after treatment cessation. Methods VIRTUOSO was a prospective, multinational, non-comparative, post-marketing observational programme investigating the effectiveness of betahistine (48 mg/day) and the course of vertigo after the discontinuation of treatment. Patients with vestibular vertigo who were prescribed 48 mg/day betahistine were enrolled in Russia and Ukraine. Treatment duration was up to 2 months, and patients were followed up for 2 months after discontinuation of betahistine. Efficacy endpoints included clinical response (assessed by change in vertigo severity), monthly attack frequency, and physician and patient grading of overall clinical response and improvement of vertigo-associated symptoms. Results Overall, 309 patients were enrolled and 305 completed the study. Clinical response was rated as good, very good or excellent in 74.1% of patients at end of treatment, with vertigo severity significantly decreased from baseline (p < 0.001). Monthly vertigo attack frequency decreased significantly during the 2 months of treatment (p < 0.001 from baseline) and further decreased during the 2-month follow-up (p < 0.001 from end of treatment). Overall, clinical response was graded as good or excellent by 94.4% of physicians and 95.4% of patients. Clinical improvement was considered either good or excellent by 82.6–90.5% of physicians and patients for nausea, vomiting and faintness. Only one adverse event was reported, with no serious adverse events. Conclusion Our findings suggest that betahistine (48 mg/day) therapy is effective in treating vertigo in routine clinical settings. The observed effects persisted for 2 months after treatment cessation, suggesting that betahistine may facilitate
Cha, Christine B; DiVasto, Katherine A
Mental illness is a prevalent and extraordinarily complex phenomenon. Psychologists have developed distinct approaches toward understanding and treating mental illness, rooted in divergent epistemology. This introduction to the Special Issue on Clinical Psychological Science and Practice provides a brief overview of the scientist-practitioner gap, and explores one step (of many) toward bridging this divide. Seven compelling case illustrations featured in this Special Issue apply empirical findings to case formulation, treatment selection, and assessment across complex and varied clinical presentations. This issue thereby demonstrates the feasibility of integrating research and clinical expertise in mental healthcare.
Kamhi, Alan G.
Purpose: In this article, I question how practitioners can balance the certainty and confidence that they can help their patients with the uncertainty that makes them continually question their beliefs and assumptions. Method: I compare the mechanisms of science and models of clinical practice that may help practitioners achieve the right balance…
Landin, Cecelia W
Evidence based practice (EBP) can be incorporated into the curriculum of Medical Laboratory Science (MLS) Programs. Current components of curriculum can include EBP in pre-analytic, analytic, and post-analytic topics. Discussion of EBP topics in the classroom using practices assessed through the Laboratory Medicine Best Practices Initiative (LMBP) of the U.S. Centers for Disease Control and Prevention will give students a clear understanding of EBP and how it is used in the clinical laboratory for improved health care quality. Student involvement in Quality Improvement projects to improve laboratory performance and patient outcomes can be developed through capstone projects. Examples of clinical projects and application of EBP into the MLS curriculum are discussed.
Peralta-Pedrero, María Luisa; Valdivia-Ibarra, Francisco Javier; Hernández-Manzano, Mario; Medina-Beltrán, Gustavo Rodrigo; Cordero-Guillén, Miguel Angel; Baca-Zúñiga, José; Cruz-Avelar, Agles; Aguilar-Salas, Ismael; Avalos-Mejía, Annia Marisol
The process of prescribing a medication is complex and includes: deciding whether it is indicated, choosing the best option, determining the dose and the appropriate management scheme to the physiological condition of the patient, and monitoring effectiveness and toxicity. We have to inform patients about the expected side effects and indications for requesting a consultation. Specific clinical questions were designed based on the acronym PICOST. The search was made in the specific websites of clinical practice guidelines, was limited to the population of older adults, in English or Spanish. We used 10 related clinical practice guidelines, eight systematic reviews and five meta-analyses. Finally, we made a search of original articles or clinical reviews for specific topics. The development and validation of clinical practice guidelines for "rational drug prescriptions in the elderly" is intended to promote an improvement in the quality of prescription through the prevention and detection of inappropriate prescribing in the elderly and, as a result of this, a decrease in the adverse events by drugs, deterioration of health of patients and expenditure of resources.
Boudoulas, Konstantinos Dean; Leier, Carl V; Geleris, Paraschos; Boudoulas, Harisios
Accumulation of medical knowledge related to diagnosis and management over the last 5-6 decades has altered the course of diseases, improved clinical outcomes and increased survival. Thus, it has become difficult for the practicing physician to evaluate the long-term effects of a particular therapy on survival of an individual patient. Further, the approach by each physician to an individual patient with the same disease is not always uniform. In an attempt to assist physicians in applying newly acquired knowledge to patients, clinical practice guidelines were introduced by various scientific societies. Guidelines assist in facilitating the translation of new research discoveries into clinical practice; however, despite the improvements over the years, there are still several issues related to guidelines that often appear ‘lost in translation'. Guidelines are based on the results of randomized clinical trials, other nonrandomized studies, and expert opinion (i.e. the opinion of most members of the guideline committees). The merits and limitations of randomized clinical trials, guideline committees, and presentation of guidelines will be discussed. In addition, proposals to improve guidelines will be presented.
Cox, A J; West, N P; Horn, P L; Lehtinen, M J; Koerbin, G; Pyne, D B; Lahtinen, S J; Fricker, P A; Cripps, A W
Use of probiotic-containing foods and probiotic supplements is increasing; however, few studies document safety and tolerability in conjunction with defined clinical end points. This paper reports the effects of 150 days of supplementation with either a single- (Bifidobacterium animalis subsp. lactis Bl-04) or a double-strain (Lactobacillus acidophilus NCFM and Bifidobacterium animalis subsp. lactis Bi-07) probiotic on routine haematology and clinical chemistry measures in healthy active adults. Pre- to post-intervention changes in laboratory measures were determined and compared between supplement and placebo groups. Overall there were few differences in routine haematology and clinical chemistry measures between supplement and placebo groups post-intervention. Exceptions included plasma calcium (P=0.03) and urea (P=0.015); however, observed changes were small and within assay-specific laboratory reference ranges. These data provide evidence supporting the use of these probiotic supplements over a period of 5 months in healthy active adults without obvious safety or tolerability issues.
Halldorsdottir (1990) investigated students’ perspective of a caring student- teacher encounter. Students described a caring teacher as being professionally...Nursing. Gaut, D. (1986). Evaluating caring nursing competencies in nursing practice. Topics in Clinical Nursing. 8(2), 77-83. Halldorsdottir , S. (1990
Background Robotic surgery offers many potential benefits for patients. While an increasing number of healthcare providers are purchasing surgical robots, there are reports that the technology is failing to be introduced into routine practice. Additionally, in robotic surgery, the surgeon is physically separated from the patient and the rest of the team, with the potential to negatively impact teamwork in the operating theatre. The aim of this study is to ascertain: how and under what circumstances robotic surgery is effectively introduced into routine practice; and how and under what circumstances robotic surgery impacts teamwork, communication and decision making, and subsequent patient outcomes. Methods and design We will undertake a process evaluation alongside a randomised controlled trial comparing laparoscopic and robotic surgery for the curative treatment of rectal cancer. Realist evaluation provides an overall framework for the study. The study will be in three phases. In Phase I, grey literature will be reviewed to identify stakeholders’ theories concerning how robotic surgery becomes embedded into surgical practice and its impacts. These theories will be refined and added to through interviews conducted across English hospitals that are using robotic surgery for rectal cancer resection with staff at different levels of the organisation, along with a review of documentation associated with the introduction of robotic surgery. In Phase II, a multi-site case study will be conducted across four English hospitals to test and refine the candidate theories. Data will be collected using multiple methods: the structured observation tool OTAS (Observational Teamwork Assessment for Surgery); video recordings of operations; ethnographic observation; and interviews. In Phase III, interviews will be conducted at the four case sites with staff representing a range of surgical disciplines, to assess the extent to which the results of Phase II are generalisable and to
Kaldjian, Lauris Christopher
Clinical decision making is a challenging task that requires practical wisdom-the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that 'clinical judgement' will merely express 'the clinician's judgement.'
Baggaley, Rachel; Johnson, Cheryl; Garcia Calleja, Jesus Maria; Sabin, Keith; Obermeyer, Carla; Taegtmeyer, Miriam; Zaba, Basia; El-Hayek, Carol; Singh, Jerome Amir
Surveillance for human immunodeficiency virus (HIV) in low- and middle-income countries started in the 1980s. However, the questions of whether the results of HIV tests should be given to participants, and if so how, has still not been resolved. In the absence of effective treatment, it was considered acceptable to withhold results from HIV-positive participants. However, when antiretroviral treatment is available, some argue for beneficence - that it is the researcher's duty to return the test results to all those who provide samples for surveillance. The corollary is that only participants who wish to receive their test results would be eligible to participate in surveys. Others argue for autonomy - that to obtain a more representative result for the general population, surveys should not exclude participants who do not wish to receive their test results. This round table discussion takes a closer look at those two arguments. We believe that the global community should work towards routine feedback of HIV surveillance while ensuring that participants receive and understand their test results.
Johnson, Cheryl; Garcia Calleja, Jesus Maria; Sabin, Keith; Obermeyer, Carla; Taegtmeyer, Miriam; Zaba, Basia; El-Hayek, Carol; Singh, Jerome Amir
Abstract Surveillance for human immunodeficiency virus (HIV) in low- and middle-income countries started in the 1980s. However, the questions of whether the results of HIV tests should be given to participants, and if so how, has still not been resolved. In the absence of effective treatment, it was considered acceptable to withhold results from HIV-positive participants. However, when antiretroviral treatment is available, some argue for beneficence – that it is the researcher’s duty to return the test results to all those who provide samples for surveillance. The corollary is that only participants who wish to receive their test results would be eligible to participate in surveys. Others argue for autonomy – that to obtain a more representative result for the general population, surveys should not exclude participants who do not wish to receive their test results. This round table discussion takes a closer look at those two arguments. We believe that the global community should work towards routine feedback of HIV surveillance while ensuring that participants receive and understand their test results. PMID:26229207
Ezzelle, J.; Rodriguez-Chavez, I. R.; Darden, J. M.; Stirewalt, M.; Kunwar, N.; Hitchcock, R.; Walter, T.; D’Souza, M. P.
A set of Good Clinical Laboratory Practice (GCLP) standards that embraces both the research and clinical aspects of GLP were developed utilizing a variety of collected regulatory and guidance material. We describe eleven core elements that constitute the GCLP standards with the objective of filling a gap for laboratory guidance, based on IND sponsor requirements, for conducting laboratory testing using specimens from human clinical trials. These GCLP standards provide guidance on implementing GLP requirements that are critical for laboratory operations, such as performance of protocol-mandated safety assays, peripheral blood mononuclear cell processing and immunological or endpoint assays from biological interventions on IND-registered clinical trials. The expectation is that compliance with the GCLP standards, monitored annually by external audits, will allow research and development laboratories to maintain data integrity and to provide immunogenicity, safety, and product efficacy data that is repeatable, reliable, auditable and that can be easily reconstructed in a research setting. PMID:18037599
Meyers, Brett; Vlachos, Pavlos; Charonko, John; Giarra, Matthew; Goergen, Craig
Echo Particle Image Velocimetry (echoPIV) is a recent development in flow visualization that provides improved spatial resolution with high temporal resolution in cardiac flow measurement. Despite increased interest a limited number of published echoPIV studies are clinical, demonstrating that the method is not broadly accepted within the medical community. This is due to the fact that use of contrast agents are typically reserved for subjects whose initial evaluation produced very low quality recordings. Thus high background noise and low contrast levels characterize most scans, which hinders echoPIV from producing accurate measurements. To achieve clinical acceptance it is necessary to develop processing strategies that improve accuracy and robustness. We hypothesize that using a short-time moving window ensemble (MWE) correlation can improve echoPIV flow measurements on low image quality clinical scans. To explore the potential of the short-time MWE correlation, evaluation of artificial ultrasound images was performed. Subsequently, a clinical cohort of patients with diastolic dysfunction was evaluated. Qualitative and quantitative comparisons between echoPIV measurements and Color M-mode scans were carried out to assess the improvements delivered by the proposed methodology.
Kvist, Therese; Malmberg, Fredrik; Boovist, Anna-Karin; Larheden, Hanna; Dahllöf, Göran
Mandatory reporting to the social services is required by dental professionals when suspicion of child abuse or neglect occurs. The objective of this study was to analyze the recommendations previously made by the Ombudsman for Children in Sweden. The aim was to study the association between having guidelines and the inclination to report to the social services and also the association between management of multiple missed appointmens and reports to the social service. A web-based questionnaire was sent to the clinical department heads (CDH) of all PDS in Sweden, distributed and authorized by The Ombudsman for Children in Sweden. The response frequency was 95% and all county councils of Sweden were represented. The results showed regional differences regarding management of suspected child abuse, neglect and dental neglect. Clinical department heads that had reported to the social services more often had guidelines on child abuse and neglect (p < 0.000). Management of repeated missed appointments varied between clinics. Those who never had made a report to the social services more often stated that the reason for missed appointments was parental negligence (p = 0.004) and less often thought it was an actual maltreatment (p = 0.003), and they more often rescheduled when a child repeatedly missed an appointment (p = 0.013). Sixty-four percent of the clinical department heads requested additional support in this matter. In conclusion, public dental service clinics in Sweden are significantly more likely to report to the social services if guidelines regarding child abuse and neglect are available.
Clinical practice guidelines are key tools for the translation of scientific evidence into everyday patient care. Therefore guidelines can act as cornerstones of evidence based knowledge management in healthcare, if they are trustworthy, and its recommendations are not biased by authors' conflict of interests. Good medical guidelines should be disseminated by means of virtual (digital/electronic) health libraries - together with implementation tools in context, such as guideline based algorithms, check lists, patient information, a.s.f. The article presents evidence based medical knowledge management using the German experiences as an example. It discusses future steps establishing evidence based health care by means of combining patient data, evidence from medical science and patient care routine, together with feedback systems for healthcare providers.
Witmer, William K; Lebovitz, Peter J
Photography has been accepted for decades as a standard means for documenting dermatologic conditions and as an adjunct to their treatment, in both medical practice and research. The emergence of low-cost easy-to-use digital imaging systems has made good-quality photography more accessible to practitioners, while providing improved functionality in the clinical environment. Primary concerns are controlling lighting and positioning to provide a clear record of the patients skin condition and maintaining consistency over time to assure meaningful comparison of clinical end points.
Petitpierre, Stéphanie; Aubert, Vincent; Leimgruber, Annette; Spertini, François; Bart, Pierre-Alexandre
Autoantibodies are frequently determined in unclear clinical situations and in the context of an inflammatory syndrome. The aim of this article is not to review all autoantibodies in details, but to discuss those used in clinical practice by describing their methods of detection and interpretation. Thus we will focus on antinuclear antibodies (ANA), which are typically associated with connective tissue diseases, as well as anti-neutrophil cytoplasmic antibodies (ANCA), which are useful in the diagnosis of ANCA-associated vasculitides. Due to its high sensitivity indirect immunofluorescence is used as a screening test; when positive, ELISA is performed to search for antibodies more specifically associated with certain auto-immune diseases.
Fenton, Grania; Morley, Stephen
This article reports the development of natural history and active treatment benchmarks for psychological treatments of chronic pain. The benchmarks were derived from randomized controlled trials (RCTs) reported in a published meta-analysis. In two preliminary studies we surveyed small samples of active clinicians working in U.K. pain management programs. Study 1 assessed the fit between routine clinical treatment and the selected RCTs. In study 2 Delphi methodology was used to determine a set of outcome domains to be used in the development of benchmarks. In study 3 we extracted data from a set of RCTs where both pre- and post-treatment data were reported. Measures were allocated to 1 of 5 outcome domains (cognitive coping and appraisal, pain experience, pain behavior, emotional functioning, and physical functioning). Pre-treatment to post-treatment effect sizes (Cohen's d) were computed and, where necessary, aggregated within trial so that each trial contributed a single estimate to outcome domain. Effect size (ES) benchmarks were computed for all trials and those trials with an explicit cognitive behavior therapy protocol. In no case did the ES estimates for the untreated control deviate from 0. The average ES across outcome domains for the treatment arms was approximately 0.35. These benchmarks may be used to assess the effectiveness of routine clinical treatments for chronic pain. The application of these data and the limitations of the study are discussed.
Barnes, J; Cotton, P; Robinson, S; Jacobsen, M
AstraZeneca ran a bespoke study to generate age-matched clinical pathology and histopathology data from a cohort of Beagle dogs aged between 25 and 37 months to support the use of these older animals in routine preclinical toxicology studies. As the upper age range of Beagle dogs routinely used in toxicology studies does not normally exceed 24 months, there is an absence of appropriate age-matched historical control data. The generation of such data was crucial to understand whether age-related differences in spontaneous findings might confound the interpretation of toxicology study data. While the majority of the histopathology findings in all the older dogs occurred at a similar prevalence as those expected in young adult dogs (<24 months), a number of differences were observed in the thymus (involution), bone marrow (increased adiposity), testes (degenerative changes), and lung (fibrosis, pigment and alveolar hyperplasia) that could be misinterpreted as a test article effect. Minor differences in some clinical pathology values (hemoglobin, alkaline phosphatase, absolute reticulocytes) were of a small magnitude and considered unlikely to affect the interpretation of study data.
Turner, Hannah; Marshall, Emily; Stopa, Lusia; Waller, Glenn
Whilst there is a growing evidence to support the impact of cognitive-behavioural therapy (CBT) in the treatment of adults with eating disorders, much of this evidence comes from tightly controlled efficacy trials. This study aimed to add to the evidence regarding the effectiveness of CBT when delivered in a routine clinical setting. The participants were 203 adults presenting with a range of eating disorder diagnoses, who were offered CBT in an out-patient community eating disorders service in the UK. Patients completed measures of eating disorder pathology at the start of treatment, following the sixth session, and at the end of treatment. Symptoms of anxiety, depression, and psychosocial functioning were measured pre- and post-treatment. Approximately 55% of patients completed treatment, and there were no factors that predicted attrition. There were significant improvements in eating disorder psychopathology, anxiety, depression and general functioning, with particular changes in eating attitudes in the early part of therapy. Effect sizes were medium to large for both completer and intention to treat analyses. These findings confirm that evidence-based forms of CBT can be delivered with strong outcomes in routine clinical settings. Clinicians should be encouraged to deliver evidence-based treatments when working in these settings.
Kesner, Adam L; Schleyer, Paul J; Büther, Florian; Walter, Martin A; Schäfers, Klaus P; Koo, Phillip J
Positron emission tomography (PET) is increasingly used for the detection, characterization, and follow-up of tumors located in the thorax. However, patient respiratory motion presents a unique limitation that hinders the application of high-resolution PET technology for this type of imaging. Efforts to transcend this limitation have been underway for more than a decade, yet PET remains for practical considerations a modality vulnerable to motion-induced image degradation. Respiratory motion control is not employed in routine clinical operations. In this article, we take an opportunity to highlight some of the recent advancements in data-driven motion control strategies and how they may form an underpinning for what we are presenting as a fully automated data-driven motion control framework. This framework represents an alternative direction for future endeavors in motion control and can conceptually connect individual focused studies with a strategy for addressing big picture challenges and goals.
Goracci, Arianna; Casamassima, Francesco; Iovieno, Nadia; di Volo, Silvia; Benbow, Jim; Bolognesi, Simone; Fagiolini, Andrea
This case report describes the clinical course of a young woman suffering from binge eating disorder (BED) associated with obesity. It illustrates the efficacy of different medications in the treatment of BED and related conditions and is followed by the comments and clinical observations of 2 practicing psychiatrists. The issues described in this paper have important clinical implications and are topical, given that BED is now recognized as a specific disorder in the new Diagnostic and Statistical Manual of Mental Disorders, fifth edition classification system, but neither the US Food and Drug Administration nor any other regulatory agency has yet approved a drug for treatment of this disease, despite its very prevalent and disabling nature. Growing evidence from the fields of psychopathology and neurobiology, including preclinical and clinical studies, converges to support the idea that "overeating" has much in common with other behavioral addictions, and substance abuse treatment agents may show promise for the treatment of BED.
Espy, M. J.; Uhl, J. R.; Sloan, L. M.; Buckwalter, S. P.; Jones, M. F.; Vetter, E. A.; Yao, J. D. C.; Wengenack, N. L.; Rosenblatt, J. E.; Cockerill, F. R.; Smith, T. F.
Real-time PCR has revolutionized the way clinical microbiology laboratories diagnose many human microbial infections. This testing method combines PCR chemistry with fluorescent probe detection of amplified product in the same reaction vessel. In general, both PCR and amplified product detection are completed in an hour or less, which is considerably faster than conventional PCR detection methods. Real-time PCR assays provide sensitivity and specificity equivalent to that of conventional PCR combined with Southern blot analysis, and since amplification and detection steps are performed in the same closed vessel, the risk of releasing amplified nucleic acids into the environment is negligible. The combination of excellent sensitivity and specificity, low contamination risk, and speed has made real-time PCR technology an appealing alternative to culture- or immunoassay-based testing methods for diagnosing many infectious diseases. This review focuses on the application of real-time PCR in the clinical microbiology laboratory. PMID:16418529
Buj, Raquel; Mallona, Izaskun; Díez-Villanueva, Anna; Barrera, Víctor; Mauricio, Dídac; Puig-Domingo, Manel; Reverter, Jordi L.; Matias-Guiu, Xavier; Azuara, Daniel; Ramírez, Jose L.; Alonso, Sergio; Rosell, Rafael; Capellà, Gabriel; Perucho, Manuel; Robledo, Mercedes; Peinado, Miguel A.; Jordà, Mireia
Hypomethylation of DNA is a hallmark of cancer and its analysis as tumor biomarker has been proposed, but its determination in clinical settings is hampered by lack of standardized methodologies. Here, we present QUAlu (Quantification of Unmethylated Alu), a new technique to estimate the Percentage of UnMethylated Alu (PUMA) as a surrogate for global hypomethylation. QUAlu consists in the measurement by qPCR of Alu repeats after digestion of genomic DNA with isoschizomers with differential sensitivity to DNA methylation. QUAlu performance has been evaluated for reproducibility, trueness and specificity, and validated by deep sequencing. As a proof of use, QUAlu has been applied to a broad variety of pathological examination specimens covering five cancer types. Major findings of the preliminary application of QUAlu to clinical samples include: (1) all normal tissues displayed similar PUMA; (2) tumors showed variable PUMA with the highest levels in lung and colon and the lowest in thyroid cancer; (3) stools from colon cancer patients presented higher PUMA than those from control individuals; (4) lung squamous cell carcinomas showed higher PUMA than lung adenocarcinomas, and an increasing hypomethylation trend associated with smoking habits. In conclusion, QUAlu is a simple and robust method to determine Alu hypomethylation in human biospecimens and may be easily implemented in research and clinical settings. PMID:26859682
Van Esch, Ann; Huyskens, Dominique P.; Behrens, Claus F.; Samsoee, Eva; Sjoelin, Maria; Bjelkengren, Ulf; Sjoestroem, David; Clermont, Christian; Hambach, Lionel; Sergent, Francois
Purpose: With the increased commercial availability of intensity modulated arc therapy (IMAT) comes the need for comprehensive QA programs, covering the different aspects of this newly available technology. This manuscript proposes such a program for the RapidArc (RA) (Varian Medical Systems, Palo Alto) IMAT solution. Methods: The program was developed and tested out for a Millennium120 MLC on iX Clinacs and a HighDefinition MLC on a Novalis TX, using a variety of measurement equipment including Gafchromic film, 2D ion chamber arrays (Seven29 and StarCheck, PTW, Freiburg, Germany) with inclinometer and Octavius phantom, the Delta4 systam (ScandiDos, Uppsala, Sweden) and the portal imager (EPID). First, a number of complementary machine QA tests were developed to monitor the correct interplay between the accelerating/decelerating gantry, the variable dose rate and the MLC position, straining the delivery to the maximum allowed limits. Second, a systematic approach to the validation of the dose calculation for RA was adopted, starting with static gantry and RA specific static MLC shapes and gradually moving to dynamic gantry, dynamic MLC shapes. RA plans were then optimized on a series of artificial structures created within the homogeneous Octavius phantom and within a heterogeneous lung phantom. These served the double purpose of testing the behavior of the optimization algorithm (PRO) as well as the precision of the forward dose calculation. Finally, patient QA on a series of clinical cases was performed with different methods. In addition to the well established in-phantom QA, we evaluated the portal dosimetry solution within the Varian approach. Results: For routine machine QA, the ''Snooker Cue'' test on the EPID proved to be the most sensitive to overall problem detection. It is also the most practical one. The ''Twinkle'' and ''Sunrise'' tests were useful to obtain well differentiated information on the individual treatment delivery components. The AAA8
Stewart, William C; Adams, Michelle P; Stewart, Jeanette A; Nelson, Lindsay A
The purpose was to evaluate faith-based studies within the medical literature to determine whether there are ways to help physicians understand how religion affects patients’ lives and diseases. We reviewed articles that assessed the influence of religious practices on medicine as a primary or secondary variable in clinical practice. This review evaluated 49 articles and found that religious faith is important to many patients, particularly those with serious disease, and patients depend on it as a positive coping mechanism. The findings of this review can suggest that patients frequently practice religion and interact with God about their disease state. This spiritual interaction may benefit the patient by providing comfort, increasing knowledge about their disease, greater treatment adherence, and quality of life. The results of prayer on specific disease states appear inconsistent with cardiovascular disease but stronger in other disease states.
Copie-Bergman, Christiane; Wotherspoon, Andrew C; Capella, Carlo; Motta, Teresio; Pedrinis, Ennio; Pileri, Stefano A; Bertoni, Francesco; Conconi, Annarita; Zucca, Emanuele; Ponzoni, Maurilio; Ferreri, Andrés J M
The International Extranodal Lymphoma Study Group (IELSG) promoted this study to determine the inter-observer agreement in the application of the Groupe d' Etude des Lymphomes de l' Adulte (GELA) histological scoring system for evaluating residual disease in post-treatment gastric biopsies of patients with gastric Mucosa-Associated Lymphoid Tissue (MALT) lymphoma (GML). Twenty-one patients with Helicobacter pylori -associated GML and treated with anti-H. pylori therapies were considered. A total of 154 biopsy sets from follow-up endoscopic procedures after H. pylori eradication were examined independently by seven pathologists from four European countries, following histological criteria suggested by the GELA scoring system. The overall concordance rate was 83% with a kappa value of 0·64, indicating a significant agreement among the seven observers. Most non-concordant responses clustered across the border of complete remission (CR) and probable minimal residual disease (pMRD), a distinction that does not imply critical clinical impact. Accordingly, when the analysis considered CR/pMRD as a single entity, the responses showed an overall concordance rate of 89% with kappa value of 0·83, thus indicating a high degree of inter-observer agreement. This study provides additional validation of the GELA histological grading system. This scheme can therefore be recommended in routine practice and deserves to be used in prospective clinical trials.
Aims of radiation oncology are cure from malignant diseases and - at the same time preservation of anatomy (e.g. female breast, uterus, prostate) and organ functions (e.g. brain, eye, voice, sphincter ani). At present, methods and results of clinical radiotherapy (RT) are based on experiences with natural history and radiobiology of malignant tumors in properly defined situations as well as on technical developments since World War II in geometrical and biological treatment planning in teletherapy and brachytherapy. Radiobiological research revealed tolerance limits of healthy tissues to be respected, effective total treatment doses of high cure probability depending on histology and tumor volume, and - more recently - altered fractionation schemes to be adapted to specific growth fractions and intrinsic radiosensitivities of clonogenic tumor cells. In addition, Biological Response Modifiers (BRM), such as cis-platinum, oxygen and hyperthermia may steepen cell survival curves of hypoxic tumor cells, others - such as tetrachiordekaoxid (TCDO) - may enhance repair of normal tissues. Computer assisted techniques in geometrical RT-planning based on individual healthy and pathologic anatomy (CT, MRT) provide high precision RT for well defined brain lesions by using dedicated linear accelerators (Stereotaxy). CT-based individual tissue compensators help with homogenization of distorted dose distributions in magna field irradiation for malignant lymphomas and with total body irradiation (TBI) before allogeneic bone marrow transplantation, e.g. for leukemia. RT with fast neutrons, Boron Neutron Capture Therapy (BNCT), RT with protons and heavy ions need to be tested in randomized trials before implementation into clinical routine.
Hayton, A; Beveridge, T; Marks, P; Wallace, A
Objective: To assess the influence and significance of the use of iterative reconstruction (IR) algorithms on patient dose in CT in Australia. Methods: We examined survey data submitted to the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) National Diagnostic Reference Level Service (NDRLS) during 2013 and 2014. We compared median survey dose metrics with categorization by scan region and use of IR. Results: The use of IR results in a reduction in volume CT dose index of between 17% and 44% and a reduction in dose–length product of between 14% and 34% depending on the specific scan region. The reduction was highly significant (p < 0.001, Wilcoxon rank-sum test) for all six scan regions included in the NDRLS. Overall, 69% (806/1167) of surveys included in the analysis used IR. Conclusion: The use of IR in CT is achieving dose savings of 20–30% in routine practice in Australia. IR appears to be widely used by participants in the ARPANSA NDRLS with approximately 70% of surveys submitted employing this technique. Advances in knowledge: This study examines the impact of the use of IR on patient dose in CT on a national scale. PMID:26133224
Thompson, Rose; Drew, Cheney J G; Thomas, Rhys H
There has been an academic "gold rush" with researchers mining the deep seams of whole-exome and whole-genome sequencing since 2008. Although undoubtedly a major advance initially for identifying new disease-associated genes for rare monogenetic disorders--more recently, common and complex conditions have been successfully studied using these techniques. With great power comes great responsibility, however, and we must not forget that next generation sequencing produces unique ethical conundrums and validation challenges. We review the progression of published papers using whole-exome sequencing from a clinical and technical viewpoint before then reflecting on the key arguments that need to be fully understood before these tools can become a routine part of clinical practice and we ask what may be the role for the biomedical scientists?
Coleman, M R; Davis, M H; Rodd, J M; Robson, T; Ali, A; Owen, A M; Pickard, J D
Clinical audits have highlighted the many challenges and dilemmas faced by clinicians assessing persons with disorders of consciousness (vegetative state and minimally conscious state). The diagnostic decision-making process is highly subjective, dependent upon the skills of the examiner and invariably dictated by the patients' ability to move or speak. Whilst a considerable amount has been learnt since Jennett and Plum coined the term 'vegetative state', the assessment process remains largely unchanged; conducted at the bedside, using behavioural assessment tools, which are susceptible to environmental and physiological factors. This has created a situation where the rate of misdiagnosis is unacceptably high (up to 43%). In order to address these problems, various functional brain imaging paradigms, which do not rely upon the patient's ability to move or speak, have been proposed as a source of additional information to inform the diagnostic decision making process. Although accumulated evidence from brain imaging, particularly functional magnetic resonance imaging (fMRI), has been encouraging, the empirical evidence is still based on relatively small numbers of patients. It remains unclear whether brain imaging is capable of informing the diagnosis beyond the behavioural assessment and whether brain imaging has any prognostic utility. In this study, we describe the functional brain imaging findings from a group of 41 patients with disorders of consciousness, who undertook a hierarchical speech processing task. We found, contrary to the clinical impression of a specialist team using behavioural assessment tools, that two patients referred to the study with a diagnosis of vegetative state did in fact demonstrate neural correlates of speech comprehension when assessed using functional brain imaging. These fMRI findings were found to have no association with the patient's behavioural presentation at the time of investigation and thus provided additional diagnostic
Informed consent is the core aspect of the patient-physician relationship. Since its beginnings, clinical bioethics was opposed to the authoritarian paternalism characteristic of medicine since the 19th century. The informed consent was developed to provide patients with sufficient information to allow autonomous decisions when faced with medical diagnostic and therapeutic alternatives. In spite of bioethics effort to perfect informed consent, the discipline has been unable to avoid informed consent from becoming an impersonal and administrative procedure. Even though the major goal of this procedure is to provide sufficient information to allow patients an objective weighting of benefits and risks of medical practice, the uncertainties of medicine make full disclosure unattainable. Collecting more information finally leads to indecision and ultimate trust in medical advice. The clinical encounter is fundamentally a fiduciary relationship, and bioethics ought to accept that its main objective is to strengthen the trust bond that is essential to the clinical encounter. This goal may become incompatible with the quest for unlimited autonomy. Patients often will only require information as long as they distrust that medical institutions and their professionals are considering their interests and needs. The main proposal of this article is to temper bioethics insistence on autonomy, and accept that patients essentially seek to be protected and cared for. Informed consent ought to relent its efforts at full autonomy to the benefit of trustworthiness in medicine, and trust in clinical practice.
Andreadis, Emmanuel A; Angelopoulos, Epameinondas T; Agaliotis, Gerasimos D; Tsakanikas, Athanasios P; Mousoulis, George P
Automated office blood pressure (AOBP) measurement with the patient resting alone in a quiet examining room can eliminate the white-coat effect associated with conventional readings taken by manual sphygmomanometer. The key to reducing the white-coat response appears to be multiple blood pressure (BP) readings taken in a non-observer office setting, thus eliminating any interaction that could provoke an office-induced increase in BP. Furthermore, AOBP readings have shown a higher correlation with the mean awake ambulatory BP compared with BP readings recorded in routine clinical practice. Although there is a paucity of studies connecting AOBP with organ damage, AOBP values were recently found to be equally associated with left ventricular mass index as those of ambulatory BP. This concludes that in contrast to routine manual office BP, AOBP readings compare favourably with 24-hour ambulatory BP measurements in the appraisal of cardiac remodelling and, as such, could be complementary to ambulatory readings in a way similar to home BP measurements.
Kirk, Timothy W
Understanding, shared meaning, and mutual trust lie at the heart of the therapeutic nurse-patient relationship. This article introduces the concept of clinical intimacy by applying the interpersonal process model of intimacy to the nurse-patient relationship. The distinction between complementary and reciprocal behaviours, and between intimate interactions and intimate relationships, addresses background concerns about the appropriateness of intimacy in nursing relationships. The mutual construction of meaning in the interactive process between nurses and patients is seen to lie at the heart of clinical intimacy as a hermeneutic enterprise. Intimacy is distinguished from empathy based on intentionality and the status and location of meaning. Reasons for continued investigation into clinical intimacy as an explanatory model for nursing as a hermeneutic practice are presented.
Zyambo, Cosmas M; Willig, James H; Cropsey, Karen L; Carson, April P; Wilson, Craig; Tamhane, Ashutosh R; Westfall, Andrew O; Burkholder, Greer A
Background Treatment-related reductions in morbidity and mortality among human immunodeficiency virus (HIV)-positive patients have been attenuated by cigarette smoking, which increases risk of cardiovascular, respiratory, and neoplastic diseases. This study investigated factors associated with smoking status among HIV-positive patients. Methods This cross-sectional study included 2,464 HIV-positive patients attending the HIV Clinic at the University of Alabama at Birmingham between April 2008 and December 2013. Smoking status (current, former, never), psychosocial factors, and clinical characteristics were assessed. Multinomial logistic regression was used to obtain unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association of the various factors with smoking status. Results Among HIV-positive patients (mean age 45 years, 75% male, 55% African-American), the majority reported a history of smoking (39% current and 22% former smokers). In adjusted models, patient characteristics associated with increased odds of current smoking were male gender (OR for heterosexual men, 1.8 [95% CI: 1.3–2.6]; for men who have sex with men, 1.5 [1.1–1.9]), history of respiratory diseases (1.5 [1.2–1.9]), unsuppressed HIV viral load (>50 copies/mL) (1.5 [1.1–1.9]), depression (1.6 [1.3–2.0]), anxiety (1.6 [1.2–2.1]), and prior and current substance abuse (4.7 [3.6–6.1] and 8.3 [5.3–13.3] respectively). Male gender, anxiety, and substance abuse were also associated with being a former smoker. Conclusions Smoking was common among HIV-positive patients, with several psychosocial factors associated with current and former smoking. This suggests smoking cessation programs in HIV clinic settings may achieve greater impact by integrating interventions that also address illicit substance abuse and mental health. PMID:26767146
Netterlid, Eva; Månsson, Marie Edwinson; Håkansson, Anders
One way to maintain confidence in vaccination programmes is to improve monitoring of immunisation safety. We studied active parental reporting of adverse events after a booster dose of diphtheria-tetanus toxoid (DT). 7193 children received the vaccine. Questionnaires were submitted by 84.2% of the parents, who reported reactions for 9.2% of the children. Four percent of events were classified as moderate/severe by interviews. Relative risk of redness and swelling reported was 0.24 (95% CI, 0.13-0.42) compared to a clinical trial, while it was 71.0 (44-114) compared to passive surveillance. Active surveillance by parental reports is a useful complement to passive surveillance of childhood immunisations to generate hypotheses for evaluation in controlled studies.
Keyser, Andreas; Hilker, Michael K; Diez, Claudius; Philipp, Alois; Foltan, Maik; Schmid, Christof
In a number of studies, centrifugal blood pumps--in comparison with roller pumps--have been shown to attenuate trauma to blood components. Nevertheless, the impact of these results on the postoperative course needs to be discussed controversially. In a prospective randomized study, 240 consecutive adult patients underwent elective myocardial revascularization with cardiopulmonary bypass employing five different pumps (Roller, Avecor, Sarns, Rotaflow, Bio-Medicus). We analyzed clinical course, blood loss, damage of blood components, and impairment of the hemostatic system. The study population was homogenous with respect to age, gender, myocardial function, and operative data. No differences were found with respect to time of ventilation, duration of intensive care stay, hospitalization, and laboratory data. The choice of arterial pump during standard extracorporeal bypass for elective coronary artery bypass grafting is no matter of concern.
Donahue, Manus J.; Dethrage, Lindsey; Faraco, Carlos C.; Jordan, Lori C.; Clemmons, Paul; Singer, Robert; Mocco, J; Shyr, Yu; Desai, Aditi; O’Duffy, Anne; Riebau, Derek; Hermann, Lisa; Connors, John; Kirshner, Howard; Strother, Megan K.
Background and Purpose A promising method for identifying hemodynamic impairment that may serve as a biomarker for stroke risk in patients with intracranial (IC) stenosis is cerebrovascular reactivity (CVR) mapping using non-invasive MRI. Here, abilities to measure CVR safely in the clinic using hypercarbic hyperoxic (carbogen) gas challenges, which increase oxygen delivery to tissue, are investigated. Methods In sequence with structural and angiographic imaging, blood-oxygenation-level-dependent (BOLD) carbogen-induced CVR scans were performed in patients with symptomatic IC stenosis (n=92) and control (n=10) volunteers, with a subgroup of patients (n=57) undergoing cerebral blood flow-weighted (CBFw) pseudo-continuous arterial spin labeling (pCASL) CVR. Subjects were stratified for four sub-studies: to evaluate relationships between (i) carbogen and hyercarbic normoxic (HN) CVR in healthy tissue (n=10), (ii) carbogen CBF CVR and BOLD CVR in IC stenosis patients (n=57), (iii) carbogen CVR and clinical measures of disease in patients with asymmetric IC atherosclerotic (n=31) and moyamoya (n=29) disease, and (iv) the CVR scan and immediate and longer-term complications (n=92). Results Non-invasive BOLD carbogen-induced CVR values correlate with (i) lobar HN gas stimuli in healthy tissue (R=0.92; P<0.001), (ii) carbogen-induced CBF CVR in IC stenosis patients (R=0.30–0.33; P<0.012), and (iii) angiographic measures of disease severity both in atherosclerotic and moyamoya patients after appropriate processing. No immediate stroke-related complications were reported in response to carbogen administration; longer-term neurological events fell within the range for expected events in this patient population. Conclusions Carbogen-induced CVR elicited no added adverse events and provided a surrogate marker of cerebrovascular reserve consistent with IC vasculopathy. PMID:24938845
Mengelle, C; Mansuy, J-M; Sandres-Sauné, K; Barthe, C; Boineau, J; Izopet, J
The aim of the study was to evaluate the MagNA Pure 96™ nucleic acid extraction system using clinical respiratory specimens for identifying viruses by qualitative real-time PCR assays. Three extraction methods were tested, that is, the MagNA Pure LC™, the COBAS Ampliprep™, and the MagNA Pure 96™ with 10-fold dilutions of an influenza A(H1N1)pdm09 sample. Two hundred thirty-nine respiratory specimens, 35 throat swabs, 164 nasopharyngeal specimens, and 40 broncho-alveolar fluids, were extracted with the MagNA Pure 96™ and the COBAS Ampliprep™ instruments. Forty COBAS Ampliprep™ positive samples were also tested. Real-time PCRs were used to identify influenza A and influenza A(H1N1)pdm09, rhinovirus, enterovirus, adenovirus, varicella zoster virus, cytomegalovirus, and herpes simplex virus. Similar results were obtained on RNA extracted from dilutions of influenza A(H1N1)pdm09 with the three systems: the MagNA Pure LC™, the COBAS Ampliprep™, and the MagNA Pure 96™. Data from clinical respiratory specimens extracted with the MagNA Pure 96™ and COBAS Ampliprep™ instruments were in 98.5% in agreement (P < 0.0001) for influenza A and influenza A(H1N1)pdm09. Data for rhinovirus were in 97.3% agreement (P < 0.0001) and in 96.8% agreement for enterovirus. They were in 100% agreement for adenovirus. Data for cytomegalovirus and HSV1-2 were in 95.2% agreement (P < 0.0001). The MagNA Pure 96™ instrument is easy-to-use, reliable, and has a high throughput for extracting total nucleic acid from respiratory specimens. These extracts are suitable for molecular diagnosis with any type of real-time PCR assay.
Practice is often described as applied science, but real life is far too complex and interactive to be handled by analytical scientific methods. The limitations of usefulness of scientific method in clinical practice result from many factors. The complexity of the large number of ill-defined variables at many levels of the problem. Scientific method focuses on one variable at a time across a hundred identical animals to extract a single, generalizable 'proof' or piece of 'truth'. Clinical practice deals with a hundred variables at one time within one animal from among a clientele of non-identical animals in order to optimize a mix of outcomes intended to satisfy that particular animal's current needs and desires. Interdependence among the variables. Most factors in the illness, the disease, the patient and the setting are interdependent, and cannot be sufficiently isolated to allow their separate study. Practice as a human transaction involving at least two people is too complex to be analysed one factor at a time when the interaction stimulates unpredictable responses. Ambiguous data. Words have many usages. People not only assign different interpretations to the same words, they assign different 'meanings', especially according to the threat or hope they may imply. The perceptual data gleaned from physical examination may be difficult to specify exactly or to confirm objectively. The accuracy and precision of investigational data and their reporting can be low, and are frequently unknown. Differing goals between science and practice. Science strives for exact points of propositional knowledge, verifiable by logical argument using objective data and repetition of the experiment.(ABSTRACT TRUNCATED AT 250 WORDS)
Pitts, N B; Drummond, J; Guggenberger, R; Ferrillo, P; Johnston, S
This article outlines the subjects presented and discussed at the December 2012 IADR Dental Materials Innovation Workshop held at King's College London. Incorporating new materials and techniques into clinical practice was considered from 4 perspectives: (1) Accelerating the "research to regulatory approval" process was presented with current developments in the United States, with the National Institutes of Health/Food and Drug Administration process as a working example; (2) intellectual property and regulatory requirements were discussed across the well-established US and EU frameworks, as well as the more recently developed procedures across Brazil, Russia, India, and China; (3) the challenges and opportunities of incorporating innovations into dental education were considered with reference to the future needs of both students and faculty; and (4) the key but difficult and unpredictable step of translating such innovations into routine dental practice was then explored. Constructive and far-ranging discussion among the broadly based Workshop participants (from dental research, education, practice, and industry, as well as environmental organizations and the World Health Organization) mapped out key issues for the future. The focus was on facilitating the more timely adoption of improvements in both materials and techniques to improve patient health and health systems, while minimizing environmental impact.
Anderson, Sandra D.
Indirect challenges act to provoke bronchoconstriction by causing the release of endogenous mediators and are used to identify airway hyper-responsiveness. This paper reviews the historical development of challenges, with exercise, eucapnic voluntary hyperpnoea (EVH) of dry air, wet hypertonic saline, and with dry powder mannitol, that preceded their use in clinical practice. The first challenge developed for clinical use was exercise. Physicians were keen for a standardized test to identify exercise-induced asthma (EIA) and to assess the effect of drugs such as disodium cromoglycate. EVH with dry air became a surrogate for exercise to increase ventilation to very high levels. A simple test was developed with EVH and used to identify EIA in defence force recruits and later in elite athletes. The research findings with different conditions of inspired air led to the conclusion that loss of water by evaporation from the airway surface was the stimulus to EIA. The proposal that water loss caused a transient increase in osmolarity led to the development of the hypertonic saline challenge. The wet aerosol challenge with 4.5% saline, provided a known osmotic stimulus, to which most asthmatics were sensitive. To simplify the osmotic challenge, a dry powder of mannitol was specially prepared and encapsulated. The test pack with different doses and an inhaler provided a common operating procedure that could be used at the point of care. All these challenge tests have a high specificity to identify currently active asthma. All have been used to assess the benefit of treatment with inhaled corticosteroids. Over the 50 years, the methods for testing became safer, less complex, and less expensive and all used forced expiratory volume in 1 sec to measure the response. Thus, they became practical to use routinely and were recommended in guidelines for use in clinical practice. PMID:26908255
Parker, Sharon M; Litt, John; van Driel, Mieke; Russell, Grant; Mazza, Danielle; Jayasinghe, Upali W; Del Mar, Chris; Lloyd, Jane; Smith, Jane; Zwar, Nicholas; Taylor, Richard; Powell Davies, Gawaine
Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease. Setting 32 urban general practices in 4 Australian states. Randomisation Stratified randomisation of practices. Participants 122 general practitioners (GPs) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness. Intervention The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information. Outcome measures Primary: 1. Change in proportion of patients aged 40–69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45–69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor. Secondary change in self-reported frequency and confidence of GPs and PNs in assessment. Results Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPs and PNs in the intervention group improved in the assessment of some risk factors. Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit. Trial registration number
Hansen, Karen Kirhofer; Prince, Jeffrey S.; Nixon, G. William
Objective: To evaluate the utility of oblique chest views in the diagnosis of rib fractures when used as a routine part of the skeletal survey performed for possible physical abuse. Methods: Oblique chest views have been part of the routine skeletal survey protocol at Primary Children's Medical Center since October 2002. Dictated radiology reports…
Carrera, V; Llopis, I; Sastre, J; Sogorb, M A; Vilanova, E
This work was performed to adapt the manual laboratory method of measuring serum paraoxonase activity using a routine automatized method in the clinical laboratory and to study the distribution of paraoxonase activity in a large population from Alcoy, a region of Spain. The serum samples for the study were obtained from extractions of blood from 2891 individuals, distributed by sex and age groups, in a routine check in a primary care facility of Alcoy. Paraoxonase activity was assayed by measuring the release of p-nitrophenol according to a previously published method adapted to an automatized analyzer. The mean paraoxonase activity recorder was 70.2 +/- 16.5 IU/L. Paraoxonase activity in children (both males and females) was significantly lower (p < 0.0005) than in older individuals. Paraoxonase activity detected in males and females older than 56 was slightly lower than that detected in younger individuals, although in this case the difference was not statistically significant. The paraoxonase activity shows higher mean values in females than in males (p < 0.0005). Human paraoxonase activity shows a unimodal distribution pattern in the studied population, which is in contrast with other studies showing bimodal distribution.
Ammenwerth, E; Kutscha, U; Kutscha, A; Mahler, C; Eichstädter, R; Haux, R
Documentation of the nursing process is an important, but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems, such as low quality and high writing efforts, are reported. However, it is still unclear if computer-based documentation systems can reduce these problems. At the Heidelberg University Medical Center, computer-based nursing process documentation projects began in 1998. A computer-based nursing documentation system has now been successfully introduced on four wards of three different departments, supporting all six phases of the nursing process. The introduction of the new documentation system was accompanied by systematic evaluations of prerequisites and consequences. In this paper, we present preliminary results of this evaluation, focusing on prerequisites of computer-based nursing process documentation. We will discuss in detail the creation and use of predefined nursing care plans as one important prerequisite for computer-based nursing documentation. We will also focus on acceptance issues and on organizational and technical issues.
Tomlinson, Lindsay; Boone, Laura I; Ramaiah, Lila; Penraat, Kelley A; von Beust, Barbara R; Ameri, Mehrdad; Poitout-Belissent, Florence M; Weingand, Kurt; Workman, Heather C; Aulbach, Adam D; Meyer, Dennis J; Brown, Diane E; MacNeill, Amy L; Bolliger, Anne Provencher; Bounous, Denise I
The purpose of this paper by the Regulatory Affairs Committee (RAC) of the American Society for Veterinary Clinical Pathology (ASVCP) is to review the current regulatory guidances (eg, guidelines) and published recommendations for best practices in veterinary toxicologic clinical pathology, particularly in the pharmaceutical and biotechnology industries, and to utilize the combined experience of ASVCP RAC to provide updated recommendations. Discussion points include (1) instrumentation, validation, and sample collection, (2) routine laboratory variables, (3) cytologic laboratory variables, (4) data interpretation and reporting (including peer review, reference intervals and statistics), and (5) roles and responsibilities of clinical pathologists and laboratory personnel. Revision and improvement of current practices should be in alignment with evolving regulatory guidance documents, new technology, and expanding understanding and utility of clinical pathology. These recommendations provide a contemporary guide for the refinement of veterinary toxicologic clinical pathology best practices.
The expectation of obstetrics is a perfect outcome. Obstetrics malpractice can cause morbidity and mortality that may engender litigation. Globally, increasing trend to litigation in obstetrics practice has resulted in high indemnity cost to the obstetrician with consequent frustration and overall danger to the future of obstetrics practice. The objective was to review litigations and the Obstetrician in Clinical Practice, highlighting medical ethics, federation of gynecology and obstetrics (FIGO’s) ethical responsibility guideline on women's sexual and reproductive health and right; examine the relationship between medical ethics and medical laws; X-ray medical negligence and litigable obstetrics malpractices; and make recommendation towards the improvement of obstetrics practices to avert misconduct that would lead to litigation. Review involves a literature search on the internet in relevant journals, textbooks, and monographs. Knowledge and application of medical ethics are important to the obstetricians to avert medical negligence that will lead to litigation. A medical negligence can occur in any of the three triads of medicare viz: Diagnosis, advice/counseling, and treatment. Lawsuits in obstetrics generally center on errors of omission or commission especially in relation to the failure to perform caesarean section or to perform the operation early enough. Fear of litigation, high indemnity cost, and long working hours are among the main reasons given by obstetricians for ceasing obstetrics practice. Increasing global trend in litigation with high indemnity cost to the obstetrician is likely to jeopardize the future of obstetrics care especially in countries without medical insurance coverage for health practitioners. Litigation in obstetrics can be prevented through the Obstetrician's mindfulness of its possibility; acquainting themselves of the medical laws and guidelines related to their practice; ensuring adequate communication with, and consent of
Wang, Yibing; Skilton, Rachel J.; Cutcliffe, Lesley T.; Andrews, Emma; Clarke, Ian N.; Marsh, Pete
Background Genital chlamydia infection is the most commonly diagnosed sexually transmitted infection in the UK. C. trachomatis genital infections are usually caused by strains which fall into two pathovars: lymphogranuloma venereum (LGV) and the genitourinary genotypes D–K. Although these genotypes can be discriminated by outer membrane protein gene (ompA) sequencing or multi-locus sequence typing (MLST), neither protocol affords the high-resolution genotyping required for local epidemiology and accurate contact-tracing. Principal Findings We evaluated variable number tandem repeat (VNTR) and ompA sequencing (now called multi-locus VNTR analysis and ompA or “MLVA-ompA”) to study local epidemiology in Southampton over a period of six months. One hundred and fifty seven endocervical swabs that tested positive for C. trachomatis from both the Southampton genitourinary medicine (GUM) clinic and local GP surgeries were tested by COBAS Taqman 48 (Roche) PCR for the presence of C. trachomatis. Samples tested as positive by the commercial NAATs test were genotyped, where possible, by a MLVA-ompA sequencing technique. Attempts were made to isolate C. trachomatis from all 157 samples in cell culture, and 68 (43%) were successfully recovered by repeatable passage in culture. Of the 157 samples, 93 (i.e. 59%) were fully genotyped by MLVA-ompA. Only one mixed infection (E & D) in a single sample was confirmed. There were two distinct D genotypes for the ompA gene. Most frequent ompA genotypes were D, E and F, comprising 20%, 41% and 16% of the type-able samples respectively. Within all genotypes we detected numerous MLVA sub-types. Conclusions Amongst the common genotypes, there are a significant number of defined MLVA sub-types, which may reflect particular background demographics including age group, geography, high-risk sexual behavior, and sexual networks. PMID:21347295
Wright, Adam; Phansalkar, Shobha; Bloomrosen, Meryl; Jenders, Robert A.; Bobb, Anne M.; Halamka, John D.; Kuperman, Gilad; Payne, Thomas H.; Teasdale, S.; Vaida, A. J.; Bates, D. W.
Background Evidence demonstrates that clinical decision support (CDS) is a powerful tool for improving healthcare quality and ensuring patient safety. However, implementing and maintaining effective decision support interventions presents multiple technical and organizational challenges. Purpose To identify best practices for CDS, using the domain of preventive care reminders as an example. Methods We assembled a panel of experts in CDS and held a series of facilitated online and inperson discussions. We analyzed the results of these discussions using a grounded theory method to elicit themes and best practices. Results Eight best practice themes were identified as important: deliver CDS in the most appropriate ways, develop effective governance structures, consider use of incentives, be aware of workflow, keep content current, monitor and evaluate impact, maintain high quality data, and consider sharing content. Keys themes within each of these areas were also described. Conclusion Successful implementation of CDS requires consideration of both technical and socio-technical factors. The themes identified in this study provide guidance on crucial factors that need consideration when CDS is implemented across healthcare settings. These best practice themes may be useful for developers, implementers, and users of decision support. PMID:21991299
Plaza, Vicente; Bellido-Casado, Jesús; Alonso-Coello, Pablo; Rodrigo, Gustavo
The Clinical Practice Guidelines on asthma have contributed towards unifying concepts and reaching a consensus on performances between different professional groups. However, they have failed in the overall improvement in the management of asthma, the final objective that they are meant to achieve. Today, almost 20 years after they appeared, the majority of asthmatic patients are still inadequately controlled, partly due to lack of follow up by doctors and the rest of health care staff who have to look after them. This lack of follow up of these recommendations is probably associated with a lack of well structured planning in their circulation and implementation. Also, although the recommendations of these guidelines agree in what is essential, they differ in other aspects, which in turn could be determining factors in clinical practice. The purpose of this article has been to establish the main differences in the recommendations that the principal clinical practice guidelines on the disease propose on the diagnosis, classification and treatment of asthma. To do this we have compared, The British Guideline on the Management of Asthma 2007, The Global Strategy for Asthma Management and Prevention/Global Initiative for Asthma 2006 (GINA), the National Prevention program for Education on Asthma (Programa Nacional de Prevención para la Educación del Asma) (NAEPP), the Spanish Guide for the Management of Asthma (Guía Española para el Manejo del Asma 2003) (GEMA) and the ALAT y SEPAR guides, Latin-America and Spain. Recommendations for the Prevention and Treatment of Asthma Exacerbation (América Latina y España. Recomendaciones para la Prevención y el Tratamiento de la Exacerbación Asmática 2008) (ALERTA).
Grover, Sandeep; Avasthi, Ajit
Technical maturation of liquid chromatography tandem mass spectrometry (LC-MS/MS) brought this technology into most tertiary care clinical laboratories worldwide. It extended the technological armamentarium of clinical laboratories significantly, both in analytical and economical terms. Especially in therapeutic drug monitoring, endocrinology, and toxicology, it became an indispensable routine tool. Although well-designed LC-MS/MS assays generally outperform immunoassays because of increased accuracy, sensitivity, precision, and analytical multiplexing capability, they are not free from analytical problems. Besides limitations in selectivity due to the occurrence of "isobaric" interferences, unpredictable ion yield attenuations, known as "ion suppression effect," have to be considered. In addition, most LC-MS/MS methods used in clinical laboratories are still laboratory-developed tests ("in-house assays") operating on very heterogeneous instrument configurations. Consequently, assay heterogeneity and lack of traceability to reference procedures or materials may lead to an increased imprecision in proficiency testing as well as inaccurate result reporting if basic rules of assay validation and "post marketing" surveillance are violated.
Seidman, Michael D; Gurgel, Richard K; Lin, Sandra Y; Schwartz, Seth R; Baroody, Fuad M; Bonner, James R; Dawson, Douglas E; Dykewicz, Mark S; Hackell, Jesse M; Han, Joseph K; Ishman, Stacey L; Krouse, Helene J; Malekzadeh, Sonya; Mims, James Whit W; Omole, Folashade S; Reddy, William D; Wallace, Dana V; Walsh, Sandra A; Warren, Barbara E; Wilson, Meghan N; Nnacheta, Lorraine C
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.
This article lists the integral elements of the Sherlock Holmes method, which is based on the intelligent collection of information through detailed observation, careful listening and thorough examination. The information thus obtained is analyzed to develop the main and alternative hypotheses, which are shaped during the deductive process until the key leading to the solution is revealed. The Holmes investigative method applied to clinical practice highlights the advisability of having physicians reason through and seek out the causes of the disease with the data obtained from acute observation, a detailed review of the medical history and careful physical examination.
Jamison, Robert N.; Edwards, Robert R.
There is much evidence to suggest that psychological and social issues are predictive of pain severity, emotional distress, work disability, and response to medical treatments among persons with chronic pain. Psychologists can play an important role in the identification of psychological and social dysfunction and in matching personal characteristics to effective interventions as part of a multidisciplinary approach to pain management, leading to a greater likelihood of treatment success. The assessment of different domains using semi-structured clinical interviews and standardized self-report measures permits identification of somatosensory, emotional, cognitive, behavioral and social issues in order to facilitate treatment planning. We briefly describe measures to assess constructs related to pain and intervention strategies for the behavioral treatment of chronic pain and discuss related psychiatric and substance abuse issues. Finally, we offer a future look at the role of integrating pain management in clinical practice in the psychological assessment and treatment for persons with chronic pain. PMID:22383018
Zubeir, I E M El; Kanbar, T; Alber, J; Lämmler, C; Akineden, O; Weiss, R; Zschöck, M
Methicillin/oxacillin resistance of 10 S. intermedius strains was investigated by conventional and molecular methods. The strains tested had been isolated in Germany during routine veterinary microbiological examinations of specimens from a small animal clinic between May and September 2005. Epidemiological relationships of the strains were studied by macrorestriction analysis of their chromosomal DNA using pulsed field gel electrophoresis (PFGE). Species identity of the 10 S. intermedius strains was confirmed by conventional methods and by PCR mediated amplification of S. intermedius specific segments of thermonuclease encoding gene nuc. As controls, four methicillin/oxacillin resistant S. intermedius (MRSI) strains obtained from specimens sent by four veterinarians and three selected methicillin/oxacillin sensitive S. intermedius (MSSI), also obtained from the small animal clinic, were tested. The 10 strains, representing approximately 6% of all S. intermedius isolated from the clinic throughout the time period mentioned above, and the four MRSI obtained from veterinarians, were methicillin/oxacillin and penicillin resistant using disk diffusion tests and could be cultivated on oxacillin resistant screening agar base (ORSAB). Both resistances could be confirmed by multiplex PCR detecting the resistance genes mecA and blaZ. The three MSSI were methicillin/oxacillin sensitive in all tests. Epidemiological investigation by macrorestriction analysis of the chromosomal DNA of the strains by pulsed field gel electrophoresis revealed that all 10 MRSI strains obtained from the clinic and the four MRSI strains obtained from veterinarians, in contrast to the three MSSI strains, represent identical or closely related bacterial clones possibly indicating a cross-infection of the animals in the clinic and the distribution of a single MRSI clone in the pet population.
Bugaj, T J; Nikendei, C
Today, skills laboratories or "skills labs", i.e. specific practical skill training facilities, are a firmly established part of medical education offering the possibility of training clinical procedures in a safe and fault-forging environment prior to real life application at bedside or in the operating room. Skills lab training follows a structured teaching concept, takes place under supervision and in consideration of methodological-didactic concepts, ideally creating an atmosphere that allows the repeated, anxiety- and risk-free practice of targeted skills. In this selective literature review, the first section is devoted to (I) the development and dissemination of the skills lab concept. There follows (II) an outline of the underlying idea and (III) an analysis of key efficacy factors. Thereafter, (IV) the training method's effectiveness and transference are illuminated, before (V) the use of student tutors, in the sense of peer-assisted-learning, in skills labs is discussed separately. Finally, (VI) the efficiency of the skills lab concept is analyzed, followed by an outlook on future developments and trends in the field of skills lab training.
Bugaj, T. J.; Nikendei, C.
Today, skills laboratories or “skills labs”, i.e. specific practical skill training facilities, are a firmly established part of medical education offering the possibility of training clinical procedures in a safe and fault-forging environment prior to real life application at bedside or in the operating room. Skills lab training follows a structured teaching concept, takes place under supervision and in consideration of methodological-didactic concepts, ideally creating an atmosphere that allows the repeated, anxiety- and risk-free practice of targeted skills. In this selective literature review, the first section is devoted to (I) the development and dissemination of the skills lab concept. There follows (II) an outline of the underlying idea and (III) an analysis of key efficacy factors. Thereafter, (IV) the training method’s effectiveness and transference are illuminated, before (V) the use of student tutors, in the sense of peer-assisted-learning, in skills labs is discussed separately. Finally, (VI) the efficiency of the skills lab concept is analyzed, followed by an outlook on future developments and trends in the field of skills lab training. PMID:27579363
... 42 Public Health 1 2010-10-01 2010-10-01 false Clinical or other practical demonstration. 21.44... COMMISSIONED OFFICERS Appointment § 21.44 Clinical or other practical demonstration. In the discretion of the... the Regular Corps may be required to perform successfully a clinical or other practical...
... 42 Public Health 1 2011-10-01 2011-10-01 false Clinical or other practical demonstration. 21.44... COMMISSIONED OFFICERS Appointment § 21.44 Clinical or other practical demonstration. In the discretion of the... the Regular Corps may be required to perform successfully a clinical or other practical...
Bown, Stephen G.
Many individuals in the field are frustrated by the slow progress getting PDT established in mainstream clinical practice. The five key reasons are: 1. Lack of adequate evidence of safety and efficacy and optimization of dosimetry. These are fundamental. The number of randomized controlled studies is still small. For some cancer applications, it is difficult to get patients to agree to be randomised, so different approaches must be taken. Anecdotal results are not acceptable to sceptics and regulators. 2. The regulatory processes. The rules get more complex every day, but there is no choice, they must be met. The full bureaucratic strength of the pharmaceutical industry is needed to address these issues. 3. Conservatism of the medical profession. Established physicians are reluctant to change practice, especially if it means referring patients to different specialists. 4. Lack of education. It is amazing how few physicians have even heard of PDT and many that have, are sceptical. The profile of PDT to both the medical profession and the general public needs to be raised dramatically. Patient demand works wonders! 5. Money. Major investment is required to run clinical trials. Pharmaceutical companies may see PDT as a threat (eg reduced market for chemotherapy agents). Licensed photosensitisers are expensive. Why not reduce the price initially, to get the technique established and stimulate demand? PDT has the potential for enormous cost savings for health service providers. With appropriate motivation and resources these problems can be addressed. Possible routes forward will be suggested.
With the advent of the human genome project, we have never known so much about the uniqueness of individuals. Personalized medicine is poised to use this genetic and genomic information along with the impact of environment and clinical presentation to provide healthcare from an individual perspective. This offers the opportunity to improve our ability to diagnose and predict disease, provide earlier intervention, identify new treatment regimens, and address the safety and efficacy of drug use. The impact of personalized medicine to our current model of healthcare delivery is tremendous, and although strides have been made, there are still challenges and barriers to overcome before personalized medicine can be fully implemented. Advanced practice nurses may not be fully aware of the personalized medicine initiative or may not be well versed on genetic and genomic content, which is a key concept of personalized medicine. The role of advanced practice nurses is an integral part of the healthcare system, and as such, they are poised to be key providers and contributors to personalized medicine. The personalized medicine initiative is discussed along with examples of genetic and genomic information that lend to our understanding, diagnosis, and treatment of disease, as well as the role and responsibilities of advanced practice nurses. Resources for personalized medicine and genetic and genomic content are provided.
Loncarić-Katušin, Mirjana; Milošević, Milan; Žilić, Antonio; Mišković, Petar; Majerić-Kogler, Višnja; Žunić, Josip
The aim of the study was to show the role of tools in the evaluation of chronic pain (CP) in general practitioner (GP) everyday clinical practice. The study was done by analyzing electronic database of the first visits of 1090 CP patients referred to the Pain Clinic of the Karlovac General Hospital, Karlovac, Croatia, by their GPs. All patient records were analyzed according to the cause of CP, strongest pain a week before the examination, quality of sleep, and the Patients' Global Impression of Change scale. All statistical analyses were done using the IBM SPSS Statistics version 22.214.171.124 (www.spss.com). CP predominantly occurs in older age group. Patients with musculoskeletal pain accounted for the highest percentage (n = 316; 29%), followed by those with neuropathic pain (n = 253; 23.20%) and those with low back pain (n = 225; 20.60%). The mean pain intensity rating scale score was 8.3 ± 1.8 a week before the examination and the mean quality of sleep score was 6.8 ± 1.9. Moderate and severe sleep quality disorder was significantly present in patients over 65 years of age (p = 0.007), patients with musculoskeletal and neuropathic pain, back pain, and those having rated Patients' Global Impression of Change scale as worsening (p = 0.001). The severity of pain and poor quality of sleep are the leading causes of deterioration of the Patients' Global Impression of Change scale in patients suffering from musculoskeletal and neuropathic pain. In order to treat CP comprehensively, it is important for GPs to evaluate the outcomes of clinical treatment using tools for CP assessment.
Bhargava, Deepa; Al-Lawatia, Zainab; Al-Abri, Rashid; Bhargava, Kamlesh
Objectives: A perception exists that clinicians in Oman are reluctant to adopt evidence-based practice (EBP). This pilot study was undertaken to study the feasibility of using EBP pathways at the point of care in otorhinolaryngology head and neck surgery. The ultimate aim was to facilitate EBP with the probability of developing a new system for implementing research findings/translational research at the clinical point of care. Methods: A cross-sectional prospective questionnaire pilot survey of clinicians at Sultan Qaboos University Hospital (SQUH), Oman, a tertiary care medical centre, was undertaken. Respondents included 135 physicians and surgeons with between 3 months and 25 years of clinical experience and included personnel ranging from interns to senior consultants, in areas ranging from primary care to specialist care. Results: Of those polled, 90% (95% confidence interval (CI) 85–95%) either strongly agreed or agreed that evidence-based practice protocols (EBPP) could help in decision making. A total of 87.4% of participants (95% CI 81.8–93%) either strongly agreed or agreed that EBPPs can improve clinical outcomes; 91.8% of participants (95% CI 87.2–96.4%) would use and apply EBPP in day-to-day care if they were available at the point of care and embedded in the hospital information system. Conclusions: The perception that clinicians at SQUH are reluctant to adopt EBP is incorrect. The introduction of EBP pathways is very feasible at the primary care level. Institutional support for embedding EBP in hospital information systems is needed as well as further outcome research to assess the improvement in quality of care. PMID:22548137
Uchida, Kanji; Nakata, Koh; Carey, Brenna; Chalk, Claudia; Suzuki, Takuji; Sakagami, Takuro; Koch, Diana E; Stevens, Carrie; Inoue, Yoshikazu; Yamada, Yoshitsugu; Trapnell, Bruce C
Autoantibodies against granulocyte/macrophage colony-stimulating factor (GMAbs) cause autoimmune pulmonary alveolar proteinosis (PAP) and measurement of the GMAb level in serum is now commonly used to identify this disease, albeit, in a clinical research setting. The present study was undertaken to optimize and standardize serum GMAb concentration testing using a GMAb enzyme-linked immunosorbent assay (GMAb ELISA) to prepare for its introduction into routine clinical use. The GMAb ELISA was evaluated using serum specimens from autoimmune PAP patients, healthy people, and GMAb-spiked serum from healthy people. After optimizing assay components and procedures, its accuracy, precision, reliability, sensitivity, specificity, and ruggedness were evaluated. The coefficient of variation in repeated measurements was acceptable (<15%) for well-to-well, plate-to-plate, day-to-day, and inter-operator variation, and was not affected by repeated freeze-thaw cycles of serum specimens or the reference standards, or by storage of serum samples at -80°C. The lower limit of quantification (LLOQ) of the PAP patient-derived polyclonal GMAb reference standard (PCRS) was 0.78ng/ml. Receiver operating characteristic curve analysis identified a serum GMAb level of 5μg/ml (based on PCRS) as the optimal cut off value for distinguishing autoimmune PAP serum from normal serum. A pharmaceutical-grade, monoclonal GMAb reference standard (MCRS) was developed as the basis of a new unit of measure for GMAb concentration: one International Unit (IU) of GMAb is equivalent to 1μg/ml of MCRS. The median [interquartile range] serum GMAb level was markedly higher in autoimmune PAP patients than in healthy people (21.54 [12.83-36.38] versus 0.08 [0.05-0.14] IU; n=56, 38; respectively; P<0.0001). Results demonstrate that serum GMAb measurement using the GMAb ELISA was accurate, precise, reliable, had an acceptable LLOQ, and could be accurately expressed in standardized units. These findings support the
Herrett, Emily; Gallagher, Arlene M; Bhaskaran, Krishnan; Forbes, Harriet; Mathur, Rohini; van Staa, Tjeerd; Smeeth, Liam
The Clinical Practice Research Datalink (CPRD) is an ongoing primary care database of anonymised medical records from general practitioners, with coverage of over 11.3 million patients from 674 practices in the UK. With 4.4 million active (alive, currently registered) patients meeting quality criteria, approximately 6.9% of the UK population are included and patients are broadly representative of the UK general population in terms of age, sex and ethnicity. General practitioners are the gatekeepers of primary care and specialist referrals in the UK. The CPRD primary care database is therefore a rich source of health data for research, including data on demographics, symptoms, tests, diagnoses, therapies, health-related behaviours and referrals to secondary care. For over half of patients, linkage with datasets from secondary care, disease-specific cohorts and mortality records enhance the range of data available for research. The CPRD is very widely used internationally for epidemiological research and has been used to produce over 1000 research studies, published in peer-reviewed journals across a broad range of health outcomes. However, researchers must be aware of the complexity of routinely collected electronic health records, including ways to manage variable completeness, misclassification and development of disease definitions for research. PMID:26050254
We are far from having seen the ideal method of screening for colorectal cancer (CRC) and the downsides of screening have not been fully addressed. Funding of adequately sized screening trials with a 10-15-year perspective for endpoints CRC mortality and incidence is difficult to get. Also, with such time horizons, there will always be an ongoing study to be awaited before feeling obliged to invest in the next. New, promising screening methods may, however, emerge far more often than every 10th year, and the knowledge gap may easily widen unless research is made a key responsibility for any ongoing cancer screening program. Previous lost battles on screening research may be won if accepting that scientific evidence may be obtained within the framework of screening programs - provided that they are designed as platforms for Comparative Effectiveness Research (CER). Accepting that CER-based screening programs should be preferred to non-CER programs and seriously compete for their funding sources, then CER screening programs may not be considered so much as contenders for ordinary clinical research funds. Also, CER within a screening framework may benefit patients in routine clinics as shown by screening research in Nordic countries. The Nordic countries have been early contributors to research on CRC screening, but slow in implementing screening programs.
Shokoples, Sandra; Mukhi, Shamir N.; Scott, Allison N.
In clinical laboratories, diagnosis of imported malaria is commonly performed by microscopy. However, the volume of specimens is generally low and maintaining proficiency in reading blood smears, particularly at the species level, is challenging in this setting. To address this problem, the Provincial Laboratory for Public Health (ProvLab) in Alberta, Canada, implemented real-time PCR for routine confirmation of all smear-positive samples in the province. Here we report our experience over a 4-year period (2008 to 2012) with this new diagnostic algorithm. While detection of Plasmodium falciparum by microscopy alone was accurate, real-time PCR served as an important adjunct to microscopy for the identification of non-falciparum species. In 18% of cases, the result was reported as non-falciparum or the species could not be identified by microscopy alone, and in all cases, the species was resolved by real-time PCR. In another 4% of cases, the species was misidentified by microscopy. To enhance surveillance for malaria, we integrated our demographic, clinical, and laboratory data into a new system developed by the Canadian Network for Public Health Intelligence, called the Malaria System for Online Surveillance (SOS). Using this application, we characterized our patient populations and travel history to identify risk factors associated with malaria infection abroad. PMID:23554200
Dendrou, Calliope A; McVean, Gil; Fugger, Lars
Neuroinflammation is emerging as a central process in many neurological conditions, either as a causative factor or as a secondary response to nervous system insult. Understanding the causes and consequences of neuroinflammation could, therefore, provide insight that is needed to improve therapeutic interventions across many diseases. However, the complexity of the pathways involved necessitates the use of high-throughput approaches to extensively interrogate the process, and appropriate strategies to translate the data generated into clinical benefit. Use of 'big data' aims to generate, integrate and analyse large, heterogeneous datasets to provide in-depth insights into complex processes, and has the potential to unravel the complexities of neuroinflammation. Limitations in data analysis approaches currently prevent the full potential of big data being reached, but some aspects of big data are already yielding results. The implementation of 'omics' analyses in particular is becoming routine practice in biomedical research, and neuroimaging is producing large sets of complex data. In this Review, we evaluate the impact of the drive to collect and analyse big data on our understanding of neuroinflammation in disease. We describe the breadth of big data that are leading to an evolution in our understanding of this field, exemplify how these data are beginning to be of use in a clinical setting, and consider possible future directions.
Bajwa, Sj; Kulshrestha, A
The introduction of newer more selective α(-2) adrenergic agonist, dexmedetomidine has made a revolution in the field of anesthesia owing to its varied application. The aim of the current review is to highlight the various clinical and pharmacological aspects of dexmedetomidine in daily routine practice of anesthesiology and intensive care besides its potential role in other clinical specialties. This review of dexmedetomidine was carried out after searching the medical literature in Pubmed, Science direct, Scopus, Google scholar and various text books and journal articles using keywords anesthesia, dexmedetomidine, neurosurgery, pediatric surgery, regional dexmedetomidine, anesthesia, regional, neurosurgery, and pediatric surgery. Dexmedetomidine has made its application from a novel sedating agent in the intensive care unit to its use as an adjuvant in various regional anesthetic techniques because of its "cooperative sedation" without any respiratory depression. It has a favorable pharmacokinetic profile suitable to be used in the perioperative period to reduce the requirements of opioids and anesthetic drugs. There are few side-effects of dexmedetomidine, which should always be kept in mind before choosing the patients for its use. The various side-effects associated with dexmedetomidine include, but are not limited to hypotension, bradycardia, worsening of heart block, dry mouth, and nausea. However, large scale randomized controlled trials are still needed to establish various effects of dexmedetomidine and to clearly define its safety profile.
Moses, G C; Lightle, G O; Tuckerman, J F; Henderson, A R
The authors evaluated the Cobas FARA centrifugal analyzer with respect to pipetting precision and accuracy, instrument temperature, spectrophotometric response, and analytic performance for the assay of five serum enzymes and glucose. Spectrophotometric response, temperature response, pipetting precision, and accuracy were satisfactory. However, sufficient time must be allowed for cuvet contents to reach a stable temperature before measurements are made. Total day-to-day imprecision (within plus between run) was less than 5% (coefficient of variation) for aspartate and alanine aminotransferases (AST; Enzyme Commission classification number [EC] EC 126.96.36.199; and ALT; EC 188.8.131.52); alkaline phosphatase (AP; EC 184.108.40.206); gamma-glutamyltransferase (GGT; EC 220.127.116.11); lactate dehydrogenase (LD; EC 18.104.22.168); creatine kinase (CK; EC 22.214.171.124); and glucose assays. Results compare well with those obtained with other current clinical chemistry analyzers; correlation coefficients were greater than 0.993. Sample-to-sample carryover was negligible, and method linearity was satisfactory for all tests.
Valbuena-López, Silvia; Hinojar, Rocío; Puntmann, Valentina O
Cardiovascular magnetic resonance plays an increasingly important role in routine cardiology clinical practice. It is a versatile imaging modality that allows highly accurate, broad and in-depth assessment of cardiac function and structure and provides information on pertinent clinical questions in diseases such as ischemic heart disease, nonischemic cardiomyopathies, and heart failure, as well as allowing unique indications, such as the assessment and quantification of myocardial iron overload or infiltration. Increasing evidence for the role of cardiovascular magnetic resonance, together with the spread of knowledge and skill outside expert centers, has afforded greater access for patients and wider clinical experience. This review provides a snapshot of cardiovascular magnetic resonance in modern clinical practice by linking image acquisition and postprocessing with effective delivery of the clinical meaning.
Newe, Axel; Becker, Linda; Schenk, Andrea
Background & Objectives The Portable Document Format (PDF) is the de-facto standard for the exchange of electronic documents. It is platform-independent, suitable for the exchange of medical data, and allows for the embedding of three-dimensional (3D) surface mesh models. In this article, we present the first clinical routine application of interactive 3D surface mesh models which have been integrated into PDF files for the presentation and the exchange of Computer Assisted Surgery Planning (CASP) results in liver surgery. We aimed to prove the feasibility of applying 3D PDF in medical reporting and investigated the user experience with this new technology. Methods We developed an interactive 3D PDF report document format and implemented a software tool to create these reports automatically. After more than 1000 liver CASP cases that have been reported in clinical routine using our 3D PDF report, an international user survey was carried out online to evaluate the user experience. Results Our solution enables the user to interactively explore the anatomical configuration and to have different analyses and various resection proposals displayed within a 3D PDF document covering only a single page that acts more like a software application than like a typical PDF file (“PDF App”). The new 3D PDF report offers many advantages over the previous solutions. According to the results of the online survey, the users have assessed the pragmatic quality (functionality, usability, perspicuity, efficiency) as well as the hedonic quality (attractiveness, novelty) very positively. Conclusion The usage of 3D PDF for reporting and sharing CASP results is feasible and well accepted by the target audience. Using interactive PDF with embedded 3D models is an enabler for presenting and exchanging complex medical information in an easy and platform-independent way. Medical staff as well as patients can benefit from the possibilities provided by 3D PDF. Our results open the door for a
Tunkel, David E; Bauer, Carol A; Sun, Gordon H; Rosenfeld, Richard M; Chandrasekhar, Sujana S; Cunningham, Eugene R; Archer, Sanford M; Blakley, Brian W; Carter, John M; Granieri, Evelyn C; Henry, James A; Hollingsworth, Deena; Khan, Fawad A; Mitchell, Scott; Monfared, Ashkan; Newman, Craig W; Omole, Folashade S; Phillips, C Douglas; Robinson, Shannon K; Taw, Malcolm B; Tyler, Richard S; Waguespack, Richard; Whamond, Elizabeth J
The American Academy of Otolaryngology--Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tinnitus. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 13 recommendations developed address the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the impact of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.
Martin, Graham P; Weaver, Simon; Currie, Graeme; Finn, Rachael; McDonald, Ruth
The need for organizational innovation as a means of improving health-care quality and containing costs is widely recognized, but while a growing body of research has improved knowledge of implementation, very little has considered the challenges involved in sustaining change - especially organizational change led 'bottom-up' by frontline clinicians. This study addresses this lacuna, taking a longitudinal, qualitative case-study approach to understanding the paths to sustainability of four organizational innovations. It highlights the importance of the interaction between organizational context, nature of the innovation and strategies deployed in achieving sustainability. It discusses how positional influence of service leads, complexity of innovation, networks of support, embedding in existing systems, and proactive responses to changing circumstances can interact to sustain change. In the absence of cast-iron evidence of effectiveness, wider notions of value may be successfully invoked to sustain innovation. Sustainability requires continuing effort through time, rather than representing a final state to be achieved. Our study offers new insights into the process of sustainability of organizational change, and elucidates the complement of strategies needed to make bottom-up change last in challenging contexts replete with competing priorities.
Rogers, Geraint B; Shaw, Dominick; Marsh, Robyn L; Carroll, Mary P; Serisier, David J; Bruce, Kenneth D
Over the last decade, technological advances have revolutionised efforts to understand the role played by microbes in airways disease. With the application of ever more sophisticated techniques, the literature has become increasingly inaccessible to the non-specialist reader, potentially hampering the translation of these gains into improvements in patient care. In this article, we set out the key principles underpinning microbiota research in respiratory contexts and provide practical guidance on how best such studies can be designed, executed and interpreted. We examine how an understanding of the respiratory microbiota both challenges fundamental assumptions and provides novel clinical insights into lung disease, and we set out a number of important targets for ongoing research. PMID:26304986
Cooper, Rory A.
Background Wheelchair prescription is complex with thousands of choices and options. Theoretically, a higher quality or innovative wheelchair that is appropriately matched to the user and their unique needs will increase participation. It is well accepted that there is an alarmingly high incidence of carpal tunnel syndrome, and rotator cuff injuries among manual wheelchair users. Development Since the initial conceptualization, the SMARTWheel was intended to better understand the physiological and physical effects of wheelchair propulsion on the body. Initially, little was known about wheelchair propulsion and the SMARTWheel transformed the nascent field of wheelchair propulsion biomechanics. Impact Although still an important area of clinical research, the SMARTWheel has been critical to the study of the relationship between the type of wheelchair, set-up, activity, technique, anatomy, and physiology and repetitive strain injury. There has been growing evidence that the wheelchair-user interaction explains a substantial portion of the risk of developing a degenerative injury and on community participation. A noteworthy contribution of this work was the release of the clinical practice guideline, entitled, Preservation of Upper Limb Function Following Spinal Cord Injury in 2005. Discussion The SMARTWheel has been used by other scientists in areas that were not originally envisioned to be applications. It has been used to support the design of tools for developing a trail mapping rating and description system. It has also supported the design of accessible pedestrian walkways standards, accessible playground surfaces, and to evaluate carpets for wheelchair accessibility. It is likely that there are more new areas of exploration to emerge. This article describes the evolution of the SMARTWheel as new technologies became available and its applications in the field of wheelchair biomechanics and clinical service delivery. PMID:19658010
Cooper, Rory A
Wheelchair prescription is complex with thousands of choices and options. Theoretically, a higher quality or innovative wheelchair that is appropriately matched to the user and their unique needs will increase participation. It is well accepted that there is an alarmingly high incidence of carpal tunnel syndrome, and rotator cuff injuries among manual wheelchair users. Since the initial conceptualization, the SMART(Wheel) was intended to better understand the physiological and physical effects of wheelchair propulsion on the body. Initially, little was known about wheelchair propulsion and the SMART(Wheel) transformed the nascent field of wheelchair propulsion biomechanics. Although still an important area of clinical research, the SMART(Wheel) has been critical to the study of the relationship between the type of wheelchair, set-up, activity, technique, anatomy, and physiology and repetitive strain injury. There has been growing evidence that the wheelchair-user interaction explains a substantial portion of the risk of developing a degenerative injury and on community participation. A noteworthy contribution of this work was the release of the clinical practice guideline, entitled, Preservation of Upper Limb Function Following Spinal Cord Injury in 2005. The SMART(Wheel) has been used by other scientists in areas that were not originally envisioned to be applications. It has been used to support the design of tools for developing a trail mapping rating and description system. It has also supported the design of accessible pedestrian walkways standards, accessible playground surfaces, and to evaluate carpets for wheelchair accessibility. It is likely that there are more new areas of exploration to emerge. This article describes the evolution of the SMART(Wheel) as new technologies became available and its applications in the field of wheelchair biomechanics and clinical service delivery.
Rogers, Katherine D; Young, Alys; Lovell, Karina; Evans, Chris
This article discusses translation issues arising during the production of a British Sign Language (BSL) version of the psychological outcome measure "Clinical Outcomes in Routine Evaluation-Outcome Measure" (CORE-OM). The process included forward translation, meeting with a team of translators, producing a second draft of the BSL version and back translating into English. Further modifications were made to the BSL version before piloting it with d/Deaf populations. Details of the translation process are addressed, including (a) the implications of translating between modalities (written text to visual language); (b) clarity of frequency anchors: analog versus digital encoding; (c) pronouns and the direction of signing; and (iv) the influence of the on-screen format. The discussion of item-specific issues encountered when producing a BSL version of the CORE-OM includes the expression of precise emotional states in a language that uses visual modifiers, problems associated with iconic signs, and the influence of Deaf world knowledge when interpreting specific statements. Finally, it addresses the extent to which lessons learned through this translation process are generalizable to other signed languages and spoken language translations of standardized instruments. Despite the challenges, a BSL version of the CORE-OM has been produced and found to be reliable.
Osorio, Lyda; Uribe, Marcela; Ardila, Gloria Ines; Orejuela, Yaneth; Velasco, Margarita; Bonelo, Anilza; Parra, Beatriz
There is insufficient evidence of the usefulness of dengue diagnostic tests under routine conditions. We sought to analyse how physicians are using dengue diagnostics to inform research and development. Subjects attending 14 health institutions in an endemic area of Colombia with either a clinical diagnosis of dengue or for whom a dengue test was ordered were included in the study. Patterns of test-use are described herein. Factors associated with the ordering of dengue diagnostic tests were identified using contingency tables, nonparametric tests and logistic regression. A total of 778 subjects were diagnosed with dengue by the treating physician, of whom 386 (49.5%) were tested for dengue. Another 491 dengue tests were ordered in subjects whose primary diagnosis was not dengue. Severe dengue classification [odds ratio (OR) 2.2; 95% confidence interval (CI) 1.1-4.5], emergency consultation (OR 1.9; 95% CI 1.4-2.5) and month of the year (OR 3.1; 95% CI 1.7-5.5) were independently associated with ordering of dengue tests. Dengue tests were used both to rule in and rule out diagnosis. The latter use is not justified by the sensitivity of current rapid dengue diagnostic tests. Ordering of dengue tests appear to depend on a combination of factors, including physician and institutional preferences, as well as other patient and epidemiological factors. PMID:25993399
Armer, Jane M; Allcock, Rebecca L
Background Detection of alcohol consumption in clients undergoing treatment for alcohol dependence can be difficult. The ethanol metabolites ethyl glucuronide and ethyl sulphate are detectable for longer in urine than either breath ethanol or urine ethanol. Our aim was to develop a liquid chromatography-tandem mass spectrometry method for urine ethyl glucuronide and ethyl sulphate for use in a routine clinical laboratory and define clinical cut-offs in a large population who had not consumed alcohol for at least two weeks. Methods Urine samples were diluted in 0.05% formic acid in HPLC grade water and then directly injected onto a Waters Acquity ultra high performance liquid chromatography coupled to a Waters TQ Detector. Eighty participants were recruited who had not consumed alcohol for at least two weeks to define cut-offs for urine ethyl glucuronide and ethyl sulphate. Samples and alcohol diaries were also collected from 12 alcohol-dependent clients attending a treatment programme. Results The assay was validated with a lower limit of quantitation of 0.20 mg/L for ethyl glucuronide and 0.04 mg/L for ethyl sulphate. Accuracy, precision, linearity and recovery were acceptable. Cut-offs were established for ethyl glucuronide, ethyl sulphate and ethyl sulphate/creatinine ratio (≤0.26 mg/L, ≤0.22 mg/L and ≤0.033 mg/mmol, respectively) in a non-drinking population. The validated cut-offs correctly identified clients in alcohol treatment who were continuing to drink alcohol. Conclusions A simple liquid chromatography-tandem mass spectrometry method for urine ethyl glucuronide and ethyl sulphate has been validated and cut-offs defined using 80 participants who had not consumed alcohol for at least two weeks. This is the largest study to date to define cut-offs for ethyl glucuronide, ethyl sulphate and ethyl sulphate/creatinine ratio.
Zhang, Yu-Dong; Wu, Chen-Jiang; Zhang, Jing; Wang, Xiao-Ning; Liu, Xi-Sheng; Shi, Hai-Bin
Dynamic contrast enhanced (DCE) MR renography has been identified as an interesting tool to determine single-kidney GFR. However, a fundamental issue for the applicability of MR-based estimate of single-kidney GFR is selecting a balance between spatial and temporal resolution of DCE-MRI data. The purpose is to assess the feasibility of GFR estimate from high-resolution (HR) dynamic contrast-enhanced (DCE) MRI in a routine clinical modal. Standard MR renography (2.4s/phase, total 4min; 4-ml Gd) and five-phase, HR-based imaging protocol (0, 30, 70, 120, and 240s; 0.05mmol/kg Gd) were prospectively performed in twelve volunteers who were scheduled for routine renal MRI. Data were plotted with Patlak, two-compartment modified Tofts model (2CTM), and two-compartment filtration model (2CFM) for GFR estimate. During all the measurements, only the signal intensities in the aorta and whole kidney parenchyma were considered. Standard 2CFM and 2CTM produced lower residuals over the fitted interval than HR-based measures (p<0.05); and HR-bases 2CFM and 2CTM did not reflect significant correlation to standard values. Standard Patlak plots with 0-240s data points produced significantly lower GFR and higher residuals than that plots with 0-120s data points (p<0.05). HR-based Patlak plots with 0, 30, 70, and 120s data points significantly correlated with reference values (Pearson ρ=0.97, p<0.01), and produced a 33.2% underestimation of reference value, which was better than that plots with 0, 30, 70, 120, and 240s data points (ρ=0.92, p<0.01; 58.6% underestimation of reference value). It concludes that it is feasible to estimate GFR with HR-based DCE-MRI and appreciate kinetic model. Patlak plots from 0, 30, 70, and 120s data points is better than plots from 0, 30, 70, 120, and 240s data points.
Beaton, John; Dienhart, Anna; Schmidt, Jonathan; Turner, Jean
This clinical practice pattern survey had two unique aspects. It was a national survey of American Association for Marriage and Family Therapy (AAMFT) members in Canada that included all AAMFT membership categories, including student, affiliate, associate, clinical, and supervisor. It compared practice pattern data for clinical members from Canada…
Penot, Pauline; Héma, Arsène; Bado, Guillaume; Kaboré, Firmin; Soré, Ibrahim; Sombié, Diamasso; Traoré, Jean-Richard; Guiard-Schmid, Jean-Baptiste; Fontanet, Arnaud; Slama, Laurence; Sawadogo, Adrien Bruno; Laurent, Christian
Introduction Gender differences in antiretroviral therapy (ART) outcomes are critical in sub-Saharan Africa. We assessed the association between gender and virologic failure among adult patients treated in a public routine clinic (one of the largest in West Africa) in Burkina Faso. Methods We performed a case-control study between July and October 2012 among patients who had received ART at the Bobo Dioulasso Day Care Unit. Patients were eligible if they were 15 years or older, positive for HIV-1 or HIV-1+2, and on first-line ART for at least six months. Cases were all patients with two consecutive HIV loads >1000 copies/mL (Biocentric Generic or Abbott Real Time assays), or one HIV load >1000 copies/mL associated with immunologic or clinical failure criteria. Controls were all patients who only had HIV loads <300 copies/mL. The association between gender and virologic failure was assessed using a multivariate logistic regression, adjusted on age, level of education, baseline CD4+ T cell count, first and current antiretroviral regimens and time on ART. Results Of 2303 patients (74.2% women; median age: 40 years; median time on ART: 34 months), 172 had virologic failure and 2131 had virologic success. Among the former, 130 (75.6%) had confirmed virologic failure, 38 (22.1%) had viro-immunologic failure, and four (2.3%) had viro-clinical failure. The proportion of men was significantly higher among the cases than among the controls (37.2% vs. 24.9%; p<0.001). Compared to controls, cases were also younger, more immunodeficient at ART initiation, less likely to receive a protease inhibitor-based antiretroviral regimen and had spent a longer period of time on ART. After adjustment, male gender remained strongly associated with virologic failure (odds ratio 2.52, 95% CI: 1.77–3.60; p<0.001). Conclusions Men on ART appeared more vulnerable to virologic failure than women. Additional studies are needed to confirm the poorer prognosis of men in this setting and to
Baugh, Reginald F; Basura, Gregory J; Ishii, Lisa E; Schwartz, Seth R; Drumheller, Caitlin Murray; Burkholder, Rebecca; Deckard, Nathan A; Dawson, Cindy; Driscoll, Colin; Gillespie, M Boyd; Gurgel, Richard K; Halperin, John; Khalid, Ayesha N; Kumar, Kaparaboyna Ashok; Micco, Alan; Munsell, Debra; Rosenbaum, Steven; Vaughan, William
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Bell's Palsy. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 11 recommendations developed encourage accurate and efficient diagnosis and treatment and, when applicable, facilitate patient follow-up to address the management of long-term sequelae or evaluation of new or worsening symptoms not indicative of Bell's palsy. There are myriad treatment options for Bell's palsy; some controversy exists regarding the effectiveness of several of these options, and there are consequent variations in care. In addition, there are numerous diagnostic tests available that are used in the evaluation of patients with Bell's palsy. Many of these tests are of questionable benefit in Bell's palsy. Furthermore, while patients with Bell's palsy enter the health care system with facial paresis/paralysis as a primary complaint, not all patients with facial paresis/paralysis have Bell's palsy. It is a concern that patients with alternative underlying etiologies may be misdiagnosed or have an unnecessary delay in diagnosis. All of these quality concerns provide an important opportunity for improvement in the diagnosis and management of patients with Bell's palsy.
Loukas, Marios; Hanna, Michael; Alsaiegh, Nada; Shoja, Mohammadali M; Tubbs, R Shane
Egypt is famously known for its Nile and pyramids, yet not many people know that Egypt made possible the origin of the anatomical sciences. Several ancient papyri guide us through the Egyptians' exploration of the human body and how they applied anatomical knowledge to clinical medicine to the best of their knowledge. It is through records, such as the Edwin Smith, Ebers, and Kahun papyri and other literature detailing the work of the Egyptian embalmers, physicians, and Greek anatomists, that we are able to take a glimpse into the evolution of the anatomical sciences from 3000 B.C. to 250 B.C. It is through the Egyptian embalmer that we were able to learn of some of the first interactions with human organs and their detailed observation. The Egyptian physician's knowledge, being transcribed into the Ebers and Edwin Smith papyri, enabled future physicians to seek reference to common ailments for diagnosing and treating a variety of conditions ranging from head injuries to procedures, such as trans-sphenoidal surgery. In Alexandria, Herophilus, and Erasistratus made substantial contributions to the anatomical sciences by beginning the practice of human dissection. For instance, Herophilus described the anatomy of the heart valves along with Erasistratus who demonstrated how blood was prevented from flowing retrograde under normal conditions. Hence, from various records, we are able to unravel how Egypt paved the road for study of the anatomical sciences.
Froment, P; Marchandin, H; Vande Perre, P; Lamy, B
The process of plate streaking has been automated to improve the culture readings, isolation quality, and workflow of microbiology laboratories. However, instruments have not been well evaluated under routine conditions. We aimed to evaluate the performance of the fully automated InoqulA instrument (BD Kiestra B.V., The Netherlands) in the automated seeding of liquid specimens and samples collected using swabs with transport medium. We compared manual and automated methods according to the (i) within-run reproducibility using Escherichia coli-calibrated suspensions, (ii) intersample contamination using a series of alternating sterile broths and broths with >10(5) CFU/ml of either E. coli or Proteus mirabilis, (iii) isolation quality with standardized mixed bacterial suspensions of diverse complexity and a 4-category standardized scale (very poor, poor, fair to good, or excellent), and (iv) agreement of the results obtained from 244 clinical specimens. By involving 15 technicians in the latter part of the comparative study, we estimated the variability in the culture quality at the level of the laboratory team. The instrument produced satisfactory reproducibility with no sample cross-contamination, and it performed better than the manual method, with more colony types recovered and isolated (up to 11% and 17%, respectively). Finally, we showed that the instrument did not shorten the seeding time over short periods of work compared to that for the manual method. Altogether, the instrument improved the quality and standardization of the isolation, thereby contributing to a better overall workflow, shortened the time to results, and provided more accurate results for polymicrobial specimens.
van Dam, B A F M; Oosterkamp, B C M; den Boer, J C L; Bruers, J J M
Support is an important factor in the implementation of clinical practice guidelines. Data from 5 studies from 1998 through 2013 offer insight into the support for clinical practice guidelines among dentists, orthodontists, dental hygienists and denturists in the Netherlands. In these, attitudes, opinions, knowledge and behaviour were seen as indicators of support. Dentists have an increasingly positive attitude towards clinical practice guidelines. The majority is aware of and uses at least 1 of the guidelines available to them and are in favour of the development of clinical practice guidelines. Orthodontists and dental hygienists have available few such guidelines, but the majority of both groups favour their development. Among denturists, who also have little experience with clinical practice guidelines, there are fewer supporters for their development. All in all, among caregivers in oral healthcare in the Netherlands, support for the use and development of clinical practice guidelines is growing.
Sheridan, Stacey L; Crespo, Eric
Background Guidelines now recommend routine assessment of global coronary heart disease (CHD) risk scores. We performed a systematic review to assess whether global CHD risk scores result in clinical benefits or harms. Methods We searched MEDLINE (1966 through June 13, 2007) for articles relevant to our review. Using predefined inclusion and exclusion criteria, we included studies of any design that provided physicians with global risk scores or allowed them to calculate scores themselves, and then measured clinical benefits and/or harms. Two reviewers reviewed potentially relevant studies for inclusion and resolved disagreement by consensus. Data from each article was then abstracted into an evidence table by one reviewer and the quality of evidence was assessed independently by two reviewers. Results 11 studies met criteria for inclusion in our review. Six studies addressed clinical benefits and 5 addressed clinical harms. Six studies were rated as "fair" quality and the others were deemed "methodologically limited". Two fair quality studies showed that physician knowledge of global CHD risk is associated with increased prescription of cardiovascular drugs in high risk (but not all) patients. Two additional fair quality studies showed no effect on their primary outcomes, but one was underpowered and the other focused on prescribing of lifestyle changes, rather than drugs whose prescribing might be expected to be targeted by risk level. One of these aforementioned studies showed improved blood pressure in high-risk patients, but no improvement in the proportion of patients at high risk, perhaps due to the high proportion of participants with baseline risks significantly exceeding the risk threshold. Two fair quality studies found no evidence of harm from patient knowledge of global risk scores when they were accompanied by counseling, and optional or scheduled follow-up. Other studies were too methodologically limited to draw conclusions. Conclusion Our review
Greenberg, Joshua A.; Hsu, Jonathan; Bawazeer, Mohammad; Marshall, John; Friedrich, Jan O.; Nathens, Avery; Coburn, Natalie; May, Gary R.; Pearsall, Emily; McLeod, Robin S.
There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone–induced pancreatitis. Une hausse de l’incidence de pancréatite aiguë a été constatée à l’échelle mondiale. Malgré l’amélioration de l’accès aux soins et aux techniques d’imagerie et d’intervention, la pancréatite aiguë est toujours associée à une morbidité et une mortalité importantes. Bien qu’il existe des guides de pratique clinique pour la prise en charge de la pancréatite aiguë, des études récentes sur la vérification de la prise en charge clinique de cette affection révèlent des lacunes importantes dans la conformité aux recommandations fondées sur des données probantes. Ces résultats mettent en relief l’importance de formuler des recommandations compréhensibles et applicables pour le diagnostic et la prise en charge de la pancréatite aiguë. La présente ligne directrice vise à fournir des recommandations fondées sur des données probantes pour la prise en charge de la pancréatite aiguë, qu’elle soit bénigne ou grave, ainsi que de ses complications et de celles de la pancréatite causée par un calcul biliaire. PMID:27007094
Background Neuropathic pain (NeP) is a common symptom of a group of a variety of conditions, including diabetic neuropathy, trigeminal neuralgia, or postherpetic neuralgia. Prevalence of NeP has been estimated to range between 5-7.5%, and produces up to 25% of pain clinics consultations. Due to its severity, chronic evolution, and associated co-morbidities, NeP has an important individual and social impact. The objective was to analyze the effect of pregabalin (PGB) on pain alleviation and longitudinal health and non-health resources utilization and derived costs in peripheral refractory NeP in routine medical practice in primary care settings (PCS) in Spain. Methods Subjects from PCS were older than 18 years, with peripheral NeP (diabetic neuropathy, post-herpetic neuralgia or trigeminal neuralgia), refractory to at least one previous analgesic, and included in a prospective, real world, and 12-week two-visit cost-of-illness study. Measurement of resources utilization included both direct healthcare and indirect expenditures. Pain severity was measured by the Short Form-McGill Pain Questionnaire (SF-MPQ). Results One-thousand-three-hundred-fifty-four PGB-naive patients [58.8% women, 59.5 (12.7) years old] were found eligible for this secondary analysis: 598 (44%) switched from previous therapy to PGB given in monotherapy (PGBm), 589 (44%) received PGB as add-on therapy (PGB add-on), and 167 (12%) patients changed previous treatments to others different than PGB (non-PGB). Reductions of pain severity were higher in both PGBm and PGB add-on groups (54% and 51%, respectively) than in non-PGB group (34%), p < 0.001. Incremental drug costs, particularly in PGB subgroups [€34.6 (80.3), €160.7 (123.9) and €154.5 (133.0), for non-PGB, PGBm and PGBadd-on, respectively (p < 0.001)], were off-set by higher significant reductions in all other components of health costs yielding to a greater total cost reductions: -€1,045.3 (1,989.6),-€1,312.9 (1,543.0), and -€1
Young, Jessica; Jaye, Chrystal; Egan, Tony; Williamson, Martyn; Askerud, Anna; Radue, Peter; Penese, Maree
Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient's well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients' medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice's repertoires are characterised by care and are driven by the moral imperative to care. They do 'whatever it takes', although there is a cost to this form of care. Well-functioning communities of clinical practice use patient's well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the 'messiness' of community-based care.
... drugs, devices, and biologics; as well as inspections of clinical investigators, IRBs, and research... HUMAN SERVICES Food and Drug Administration Food and Drug Administration Clinical Trial Requirements, Compliance, and Good Clinical Practice; Public Workshop AGENCY: Food and Drug Administration, HHS....
Berke, David M; Rozell, Cassandra A; Hogan, Thomas P; Norcross, John C; Karpiak, Christie P
Evidence-based practice (EBP) requires that practitioners routinely access, appraise, and utilize the best available research. We surveyed a representative sample of the Society of Clinical Psychology; 549 psychologists (response rate = 46%) reported their frequency of engaging in EBP when offering psychological services, rated their current knowledge of 12 online research resources, and evaluated their current knowledge of 12 research methods and designs. These psychologists reported, on average, using EBP in 73.1% of their psychological services. With the exception of PsycINFO and MEDLINE, clinical psychologists related low to moderate knowledge of online research resources. By contrast, these psychologists reported considerable knowledge of most research methods and designs, except for odds ratios and structural equation modeling. Psychologists' theoretical orientation, clinical experience, and employment setting predicted knowledge of both online resources and research designs. We discuss the educational and practice ramifications of these results.
Beyer-Westendorf, Jan; Camm, A John; Coleman, Craig I; Tamayo, Sally
Randomised controlled trials (RCTs) are considered the gold standard of clinical research as they use rigorous methodologies, detailed protocols, pre-specified statistical analyses and well-defined patient cohorts. However, RCTs do not take into account the complexity of real-world clinical decision-making. To tackle this, real-world data are being increasingly used to evaluate the long-term safety and effectiveness of a given therapy in routine clinical practice and in patients who may not be represented in RCTs, addressing key clinical questions that may remain. Real-world evidence plays a substantial role in supporting the use of non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) in clinical practice. By providing data on patient profiles and the use of anticoagulation therapies in routine clinical practice, real-world evidence expands the current awareness of NOACs, helping to ensure that clinicians are well-informed on their use to implement patient-tailored clinical decisions. There are various issues with current anticoagulation strategies, including under- or overtreatment and frequent monitoring with VKAs. Real-world studies have demonstrated that NOAC use is increasing (Dresden NOAC registry and Global Anticoagulant Registry in the FIELD-AF [GARFIELD-AF]), as well as reaffirming the safety and effectiveness of rivaroxaban previously observed in RCTs (XArelto on preveNtion of sTroke and non-central nervoUS system systemic embolism in patients with non-valvular atrial fibrillation [XANTUS] and IMS Disease Analyzer). This article will describe the latest updates in real-world evidence across a variety of methodologies, such as non-interventional studies (NIS), registries and database analyses studies. It is anticipated that these studies will provide valuable clinical insights into the management of thromboembolism, and enhance the current knowledge on anticoagulant use and outcomes for patients.
Hunter, Jerry L.; Snyder, Frank
At Toledo Hospital, family practice residents have assumed responsibility for the normal obstetrics clinic. Specialty consultations are provided by the hospital's obstetrics residency program. A medical audit of the clinic indicates that the family practice residents obtained consultations and made referrals at the appropriate times. (JMD)
Kealy, David; Ogrodniczuk, John S
Pathological narcissism is associated with significant interpersonal problems, which are unlikely to be acknowledged by narcissistic patients as clinical issues. Although a substantial clinical and theoretical literature deals with narcissism, a succinct overview of core narcissistic interpersonal problems is lacking, particularly in terms of their presentation in clinical settings. This article provides a descriptive overview of the major types of interpersonal problems associated with pathological narcissism: dominance, vindictiveness, and intrusiveness. We outline how these problems can manifest in patients' relations with others and in treatment situations. Clinical vignettes are provided to highlight the presentation of narcissistic interpersonal dysfunction in various types of clinical encounters, and to facilitate discussion of treatment implications.
Goebel, Juliane; Seifert, Ingmar; Nensa, Felix; Schemuth, Haemi P.; Maderwald, Stefan; Quick, Harald H.; Schlosser, Thomas; Jensen, Christoph; Bruder, Oliver; Nassenstein, Kai
Objectives T1 mapping allows quantitative myocardial assessment, but its value in clinical routine remains unclear. We investigated, whether the average native myocardial T1 value can be used as a diagnostic classifier between healthy and diffuse diseased myocardium. Methods Native T1 mapping was performed in 54 persons with healthy hearts and in 150 patients with diffuse myocardial pathologies (coronary artery disease (CAD): n = 76, acute myocarditis: n = 19, convalescent myocarditis: n = 26, hypertrophic cardiomyopathy (HCM): n = 12, dilated cardiomyopathy (DCM): n = 17) at 1.5 Tesla in a mid-ventricular short axis slice using a modified Look-Locker inversion recovery (MOLLI) sequence. The average native myocardial T1 value was measured using dedicated software for each patient. The mean as well as the range of the observed average T1 values were calculated for each group, and compared using t-test. The ability of T1 mapping to differentiate between healthy and diffuse diseased myocardium was assessed using receiver operating characteristic analysis (ROC). Results The mean T1 value of the group “healthy hearts” (955±34ms) differed significantly from that of the groups DCM (992±37ms, p<0.001), HCM (980±44ms, p = 0.035), and acute myocarditis (974±36ms, p = 0.044). No significant difference was observed between the groups “healthy hearts” and CAD (951±37ms, p = 0.453) or convalescent myocarditis (965±40ms, p = 0.240). The average native T1 value varied considerably within all groups (range: healthy hearts, 838-1018ms; DCM, 882-1034ms; HCM, 897-1043ms; acute myocarditis, 925-1025ms; CAD, 867-1082ms; convalescent myocarditis, 890-1071ms) and overlapped broadly between all groups. ROC analysis showed, that the average native T1 value does not allow for differentiating between healthy and diffuse diseased myocardium, except for the subgroup of DCM. Conclusions The average native T1 value in cardiac MR imaging does not allow differentiating between healthy
Chida, Natasha M.; Ghanem, Khalil G.; Auwaerter, Paul G.; Wright, Scott M.; Melia, Michael T.
Clinical excellence should be recognized, particularly in the current climate that appropriately prioritizes relationship-centered care. In order to develop a recognition model, a definition of clinical excellence must be created and agreed upon. A paradigm recently suggested by C. Christmas describes clinical excellence through the following domains: diagnostic acumen, professionalism and humanism, communication and interpersonal skills, skillful negotiation of the healthcare system, knowledge, taking a scholarly approach to clinical practice, and having passion for clinical medicine. This work references examples of infectious disease (ID) clinical excellence across Christmas' domains and, in doing so, both examines how the definition of clinical excellence applies to ID practice and highlights the importance of ID physicians. Emphasizing such aspirational standards may not only inspire trainees and practicing physicians to pursue their own fulfilling clinical ID careers, it may also encourage health systems to fully value outstanding ID physicians who labor tirelessly to provide patients with exceptional care. PMID:27419186
Carneiro, António Vaz
The role of science in clinical practice is nowadays fundamental. The constant publication of studies and clinical trials provides evidence of good quality that can be used by the clinician as a basis for medical decision-making, even in a context of uncertainty and risk. Valid and relevant information can help solve the problems of clinical knowledge in practice. The main question is then how practicing clinicians can learn about the innovations and acquire the recent information that can help them to change their practice for the better. The volume of medical literature is enormous and constantly growing, and it is difficult to manage. The increasing availability of secondary data sources for daily patient care provides practical and rapid access to all this information, enabling improvements in the quality of care. In this paper we present and discuss a set of modern and high-quality instruments to obtain useful information for clinical practice.
Ip, Barry; Cavanna, Annlouise; Corbett, Beverley
This paper examines the recent development of a computer-assisted learning program--in Practice--at the School of Health Science, in the University of Wales Swansea. The project, which began in 2001, was developed in close collaboration with The Meningitis Trust, the aim being to produce a software package to increase nursing students' knowledge…
Hands, Robin; Rong, Yuhang
The Neag School of Education at the University of Connecticut is committed to the intentionality of interweaving course work and practice in its 5-year teacher preparation program, the Integrated Bachelor's and Master's program. It offers a wide range of field experiences to teacher candidates. Teacher candidates enter the program at the beginning…
Price, Adrienne; Price, Bob
This article explores practical ways of role modelling practice with students on clinical placements. Students are frequently assigned to a senior practitioner for periods of observation, which involves shadowing the practitioner in practice. Learning opportunities are not necessarily seized because a strategy is not in place to enhance learning. The article provides guidance on how to proceed effectively with role modelling.
Background In primary care, patients with multiple chronic conditions are the rule rather than the exception. The Chronic Care Model (CCM) is an evidence-based framework for improving chronic illness care, but little is known about the extent to which it has been implemented in routine primary care. The aim of this study was to describe how multimorbid older patients assess the routine chronic care they receive in primary care practices in Germany, and to explore the extent to which factors at both the practice and patient level determine their views. Methods This cross-sectional study used baseline data from an observational cohort study involving 158 general practitioners (GP) and 3189 multimorbid patients. Standardized questionnaires were employed to collect data, and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire used to assess the quality of care received. Multilevel hierarchical modeling was used to identify any existing association between the dependent variable, PACIC, and independent variables at the patient level (socio-economic factors, weighted count of chronic conditions, instrumental activities of daily living, health-related quality of life, graded chronic pain, no. of contacts with GP, existence of a disease management program (DMP) disease, self-efficacy, and social support) and the practice level (age and sex of GP, years in current practice, size and type of practice). Results The overall mean PACIC score was 2.4 (SD 0.8), with the mean subscale scores ranging from 2.0 (SD 1.0, subscale goal setting/tailoring) to 3.5 (SD 0.7, delivery system design). At the patient level, higher PACIC scores were associated with a DMP disease, more frequent GP contacts, higher social support, and higher autonomy of past occupation. At the practice level, solo practices were associated with higher PACIC values than other types of practice. Conclusions This study shows that from the perspective of multimorbid patients receiving care in German
Muldoon, Becky T; Mai, Vinh Q; Burch, Henry B
Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.
Griffith, Richard; Tengnah, Cassam
The numbers of district nurse clinics are continuing to grow in primary care and they provide timely and more cost effective intervention for patients. The clinics provide exciting opportunities for district nurses but also carry an increased risk of exposure to liability. This article discusses some of the key areas of accountability underpinning the duty of care of district nurses working in nurse-led clinics.
Farmer, Adam D; Albu-Soda, Ahmed; Aziz, Qasim
The diverse array of end organ innervations of the vagus nerve, coupled with increased basic science evidence, has led to vagus nerve stimulation becoming a management option in a number of clinical disorders. This review discusses methods of electrically stimulating the vagus nerve and its current and potential clinical uses.
Schmidt, Jennifer A
Seborrheic dermatitis is a chronic, recurring skin disorder that has no cure.Current clinical research has implicated Malassezia yeast in the etiology. Using a clear, concise clinical picture and a thorough patient history, even the novice NP can formulate an effective treatment plan.
Ishii, Lisa E; Tollefson, Travis T; Basura, Gregory J; Rosenfeld, Richard M; Abramson, Peter J; Chaiet, Scott R; Davis, Kara S; Doghramji, Karl; Farrior, Edward H; Finestone, Sandra A; Ishman, Stacey L; Murphy, Robert X; Park, John G; Setzen, Michael; Strike, Deborah J; Walsh, Sandra A; Warner, Jeremy P; Nnacheta, Lorraine C
Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice
Lanza, Gaetano A; Camici, Paolo G; Galiuto, Leonarda; Niccoli, Giampaolo; Pizzi, Carmine; Di Monaco, Antonio; Sestito, Alfonso; Novo, Salvatore; Piscione, Federico; Tritto, Isabella; Ambrosio, Giuseppe; Bugiardini, Raffaele; Crea, Filippo; Marzilli, Mario
A growing amount of data is increasingly showing the relevance of coronary microvascular dysfunction (CMVD) in several clinical contexts. This article reviews techniques and clinical investigations of the main noninvasive and invasive methods proposed to study coronary microcirculation and to identify CMVD in the presence of normal coronary arteries, also trying to provide indications for their application in clinical practice.
Zuydam, A C; Ghazali, N; Lowe, D; Skelly, R; Rogers, S N
A broad patient-completed screening tool in routine clinical practice in head and neck oncology has merit, but clinicians should be aware that its simplicity could lead to some patients and the detail of their problems being missed. The purpose of this study was to compare the University of Washington Quality of Life (UWQoL) swallowing domain with the MD Anderson Dysphagia Inventory (MDADI) in relation to the need for interventions for swallowing around one year after treatment. The group comprised 112 consecutively referred patients to speech and language therapy between January 2007 and August 2009 after primary operation for previously untreated oral and oropharyngeal squamous cell carcinoma (SCC). A total of 78 patients completed questionnaires (median time of assessment 11.7 months, IQR 6.1-12.2). There were significant (p<0.001) and moderately strong correlations (rs=0.51-0.62) between the UWQoL swallowing domain score and MDADI subscales and total scores, and also with individual MDADI questions: taking a great deal of effort (rs=0.71); being upset (rs=0.61); and not going out (rs=0.62) were the strongest in regard to swallowing. Use of a gastrostomy tube was associated with worse UWQoL and MDADI scores. In conclusion, patients who score 100 on the UWQoL do not require swallowing to be evaluated further. Those who score 70 could benefit from the detailed MDADI to help to clarify the specific problem and the impact it has before being referred to speech and language therapy. Those who score less than 70 should be brought to the attention of speech and language therapists to confirm that appropriate support and intervention are in place.
Ogawa, Hisao; Kojima, Sunao
"Evidence-based medicine (EBM)" implies effective and high quality practice for patients based on well-grounded medical science. The success of clinical trials in Japan is essential to build original evidence specific for Japanese patients. Based on this concept, we have performed several large-scale clinical trials to provide EBM, including the Japanese Antiplatelets Myocardial Infarction Study [JAMIS; clinical improvement in acute myocardial infarction (AMI) patients with antiplatelet therapy], the Japanese beta-Blockers and Calcium Antagonists Myocardial Infarction (JBCMI; comparison of the effects of beta-blockers and calcium antagonists on cardiovascular events in post-AMI patients), a multicenter study for aggressive lipid-lowering strategy by HMG-CoA reductase inhibitors in patients with AMI (MUSASHI; effects of statin therapy on cardiovascular events in patients with AMI), and the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD trial; efficacy of low-dose aspirin therapy for primary prevention of atherosclerotic events in type 2 diabetic patients). The results of these prospective studies were directly linked with clinical practice. We have acquired the know-how of large-scale clinical trials; an important point is to have passion for "buildup evidence specific for the Japanese" and to recruit subjects for enrollment after explaining the significance of "clinical trials for the Japanese".
Matumoto, Silvia; Fortuna, Cinira Magali; Kawata, Lauren Suemi; Mishima, Silvana Martins; Pereira, Maria José Bistafa
This study aims to present the re-signification process of the meanings of nurses' clinical practice in primary care from the perspective of extended clinic and permanent education. An intervention research was carried out with the approval of an ethics committee. Nine nurses participated in reflection groups from September to December 2008 in Ribeirão Preto-SP-Brazil. The redefinition process of the meanings proposed by the institutional analysis was mapped. The results point out that the nurses perceive differences in clinical work, by acknowledging the sense of user-centered clinical practice; daily limits and tensions and the need for support from managers and the team to deal with users' problems and situations. They identify the necessity to open space in the schedule to do that. It was concluded that nurses' clinical practice is being consolidated, and that collective analysis processes permit learning and the reconstruction of practices.
Paar, Christian; Geit, Maria; Stekel, Herbert; Berg, Jörg
We developed a sequencing assay for genotypic HIV-1 tropism determination. The assay allows examination of HIV RNA from plasma and HIV DNA from peripheral blood mononuclear cells (PBMC), including PBMC samples from patients with undetectable viral loads. Assessment of 100 pairs of plasma and PBMC samples showed a high concordance of 90%. With the limitations of population-based sequencing, the assay was found to be robust and suitable for the routine clinical laboratory.
Molloy, Síle F; Henley, Patricia
This article describes the processes and procedures involved in planning, conducting and reporting monitoring activities for large Clinical Trials of Investigational Medicinal Products (CTIMPs), focusing on those conducted in resource-limited settings.
Wenz, Frederik; Sedlmayer, Felix; Herskind, Carsten; Welzel, Grit; Sperk, Elena; Neumaier, Christian; Gauter-Fleckenstein, Benjamin; Vaidya, Jayant S.; Sütterlin, Marc
Summary Accelerated partial breast irradiation (APBI) has been under clinical investigation for more than 15 years. There are several technical approaches that are clinically established, e.g. brachytherapy, intraoperative radiotherapy (IORT), or external-beam radiotherapy. The understanding of the underlying biology, optimal technical procedures, patient selection criteria, and imaging changes during follow-up has increased enormously. After completion of several phase III trials using brachytherapy or IORT, APBI is currently increasingly used either in phase IV studies, registries, or in selected patients outside of clinical studies. Consensus statements about suitable patients are available from several international and national societies like ASTRO, ESTRO, and DEGRO. One may expect that 15-25% of patients undergoing breast-conserving surgery may qualify for APBI, i.e. patients with small invasive ductal breast cancer without clinical lymph node involvement. PMID:26600760
Yip, Amelia; Leduc, Matthew; Teo, Vincent; Timmons, Matthew; Schull, Michael J
The objective was to develop and validate a method to link routinely captured electronic data for the measurement of emergency department (ED) quality indicators. Electronic ED data were linked to calculate time to antibiotics and time to electrocardiogram (ECG) for pneumonia and chest pain patients, respectively; validation was by comparison with chart data. Linked electronic data correctly identified 40/40 pneumonia and 65/65 chest pain patients. The median difference in time to antibiotics calculated from linked electronic data versus chart data was 6 minutes (standard deviation [SD] = 14.0); for time to ECG it was 0 minutes (SD = 70). The percentage of ED patients meeting target time to antibiotics was 47% with electronic data versus 44% with charts; for time to ECG, 8% met target time with electronic data versus 11% with charts. A simple computer algorithm for linking routine ED electronic data for quality-of-care measurement was validated.
Keiffer, Melanie R
Clinical practice guidelines augment clinician decision making. Researchers cite a lack of knowledge of guideline existence, complexity of guidelines, staff attitude, lack of training, time and resource constraints as reasons for nonadherence. This project sought to understand factors that promote or prevent guideline implementation at the point of care. Respondents' viewed clinical practice guidelines as valid tools necessary to standardize patient care and exhibited proficiency in synthesis and integration of guidelines into clinical decisions and treatment plans. Efficient and effective guidelines impact patient safety and quality by increasing the consistency of behavior and replacing idiosyncratic behaviors with best practices.
Nijjar, Chandanjit Kaur; Smith, Melvyn Howard; Eltringham, Ian Joseph
Concerns over the reliability of routine sensitivity testing in coagulase-negative staphylococci often lead to the use of potentially less-effective antibiotics as few laboratories have access to routine tests for the mecA resistance gene. Although previous studies have shown a reasonable correlation between oxacillin disc and automated sensitivity testing, changing epidemiology and methodology dictate periodic reappraisal of these methods. In the present study, we evaluated two real-time PCR assays against novel targets in the mecA gene as an adjunct to routine susceptibility testing using the Vitek II AST-P620 card. All samples were further examined for the presence of the mecC gene. Of 118 strains of coagulase-negative staphylococci tested, 81 were oxacillin resistant and 37 oxacillin susceptible by the Vitek II assay compared with 103 positive and 15 negative by mecA PCR. In-house PCR results correlated well with a previously published reference PCR, though little correlation was found between mecA PCR or Vitek II and PBP 2a latex agglutination. Incubation conditions may have affected the accuracy of the latter test. None of the strains tested were mecC PCR positive. The inclusion of dual-target PCRs in the testing algorithm was inexpensive and offered the safest strategy for determining beta-lactam susceptibility in coagulase-negative staphylococci in our laboratory.
Wing, Rena R.
Look AHEAD was a randomized clinical trial designed to examine the long-term health effects of weight loss in overweight and obese individuals with type 2 diabetes. The primary result was that the incidence of cardiovascular events over a median follow up of 9.6 years was not reduced in the intensive lifestyle group relative to the control group. This finding is discussed, with emphasis on its implications for design of clinical trials and clinical treatment of obese people with type 2 diabetes. PMID:24853636
Youn, Soo Jeong; Castonguay, Louis G; Xiao, Henry; Janis, Rebecca; McAleavey, Andrew A; Lockard, Allison J; Locke, Benjamin D; Hayes, Jeffrey A
The goal of this article is to present information about a standardized multidimensional measure of psychological symptoms, the Counseling Center Assessment of Psychological Symptoms (CCAPS; Locke et al., 2011; Locke, McAleavey, et al., 2012; McAleavey, Nordberg, Hayes, et al., 2012), developed to assess difficulties specific to college students' mental health. We provide (a) a brief review and summary of the psychometric and research support for the CCAPS; (b) examples of the use of the CCAPS for various purposes, including clinical, training, policy, and counseling center advocacy; and (c) implications of the integration of routine outcome monitoring and feedback for the future of training, research, and clinical practice. In particular, the article emphasizes how the assimilation of and symbiotic relationship between research and practice can address the scientist-practitioner gap.
Spence, Richard T., Ed.; DiNitto, Diana M., Ed.; Straussner, Shulamith Lala Ashenberg, Ed.
This book offers helping professionals an introduction to the neurobiological aspects of substance abuse. It presents the basic information on the subject, including the various neurobiological theories of addiction, and places them in a psychosocial context. In addition to connecting the theoretical information with practical applications, the…
Haley, Janice M
Although nursing is well grounded in the conceptualization of person as body-mind-spirit, there is little evidence that advanced practice nurses routinely address the spirit in giving patient care, especially with adolescents in the outpatient setting. The neglect of spiritual aspects of care may be related to lack of a framework, or education/incorporation into nurse practitioner preparation. This article describes one method of integrating adolescent spiritual/faith assessment into a nurse practitioner clinical course. Readings, assignments, and a grading rubric are offered.
Tagle, Rodrigo; González, Fernando; Acevedo, Mónica
Microalbuminuria is a new tool in the management of patients with diabetes mellitus or hypertension. Microalbuminuria is an easily measured biomarker in a urine sample. Urinary albumin to creatinine ratio in first morning urine sample correlates with 24 hours urinary albumin excretion, but it is easier to obtain, and can identify hypertensive or diabetic patients with high risk for cardiovascular events. Therapeutic interventions such as renin angiotensin system blockade have demonstrated their usefulness in reducing urinary albumin excretion in clinical studies. It would be advisable to incorporate urinary albumin to creatinine ratio to the routine clinical monitoring of patients with cardiovascular risk, such as those with hypertension and diabetes mellitus.
Tranquart, F; Mercier, L; Frinking, P; Gaud, E; Arditi, M
With contrast-enhanced ultrasound (CEUS) now established as a valuable imaging modality for many applications, a more specific demand has recently emerged for quantifying perfusion and using measured parameters as objective indicators for various disease states. However, CEUS perfusion quantification remains challenging and is not well integrated in daily clinical practice. The development of VueBox™ alleviates existing limitations and enables quantification in a standardized way. VueBox™ operates as an off-line software application, after dynamic contrast-enhanced ultrasound (DCE-US) is performed. It enables linearization of DICOM clips, assessment of perfusion using patented curve-fitting models, and generation of parametric images by synthesizing perfusion information at the pixel level using color coding. VueBox™ is compatible with most of the available ultrasound platforms (nonlinear contrast-enabled), has the ability to process both bolus and disruption-replenishment kinetics loops, allows analysis results and their context to be saved, and generates analysis reports automatically. Specific features have been added to VueBox™, such as fully automatic in-plane motion compensation and an easy-to-use clip editor. Processing time has been reduced as a result of parallel programming optimized for multi-core processors. A long list of perfusion parameters is available for each of the two administration modes to address all possible demands currently reported in the literature for diagnosis or treatment monitoring. In conclusion, VueBox™ is a valid and robust quantification tool to be used for standardizing perfusion quantification and to improve the reproducibility of results across centers.
Previous investigations have shown that cross-contamination in a burn unit is mainly clothes-borne. New barrier garments have been designed and tried experimentally. The aim of the present study was to investigate the effects of different clothing routines on cross-contamination. In a long-term study, the rates and routes of colonizations with Staphylococcus aureus, Streptococcus groups A, B, C, F, and G and Pseudomonas aeruginosa were examined. The exogenous colonization rates were, with S. aureus 77%, with Streptococcus species 52% and with Ps. aeruginosa 32%. The colonization rate with Ps. aeruginosa was higher in patients with larger burns. Patients dispersed Streptococcus and Ps. aeruginosa as well as S. aureus into the air of their rooms in considerable amounts, but dispersers were not more important as sources of cross-colonization than non-dispersers. In comparison of clothing routines, there was no difference in overall colonization rates. The newly designed barrier garment that was made from apparently particle-tight material did not reduce the transfer of bacteria from patient to patient. A less rigid routine than that previously used did not increase the risk of cross-contamination. A thorough change of barrier dress after close contact nursing delayed the first exogenous S. aureus colonization from day 6 to day 14 after admission. This routine might be recommended for clinical use. Otherwise, methods must be developed for adequate selection of materials intended for barrier garments. Images Plate 1 PMID:109498
Sherman, Scott E; Fotiades, John; Rubenstein, Lisa V; Gilman, Stuart C; Vivell, Susan; Chaney, Edmund; Yano, Elizabeth M; Felker, Bradford
Although health care organizations seeking to improve quality often must change the system for delivering care, there is little available evidence on how to educate staff and providers about this change. As part of a 2002-2003 Veterans Health Administration multisite project using collaborative care to improve the management of depression, the authors implemented the Translating Initiatives for Depression into Effective Solutions (TIDES) program. Five steps were followed for teaching systems-based practice: (1) determine providers' educational needs (through administrative data, expert opinion, and provider discussion), (2) develop educational materials (based on needs assessed), (3) help each of seven sites develop an educational intervention, (4) implement the intervention, and (5) monitor the intervention's effectiveness. Sites relied primarily on passive educational strategies. There was variable implementation of the different components (e.g., lecture, educational outreach). No site chose to write up its education plan, as was suggested. The authors thus suggest that the educational model was successful at identifying providers' needs and creating appropriate materials, because the program was not advertised in other ways and because almost all providers referred patients to the program. However, the educational model was only partially successful at getting sites to develop and implement an educational plan, although provider behavior did change. Overall, the program was somewhat effective at teaching systems-based practice. The authors believe the best way to enhance effectiveness is to build education into the system rather than rely on a separate system for education.
In this essay, I provide a description of the discipline of ethics using the philosophies of Aristotle and the American pragmatist John Dewey. Specifically, I argue that ethics is an active undertaking that is ambiguous and pluralistic. I then normatively prescribe the way in which clinical ethicists ought to approach their work in medicine. Rather than endeavouring to become, or behaving as if they are, experts, clinical ethicists must be humble. They must practise ethics. That is, they must admit ethics is the study and pursuit of the good life but that this study and pursuit occurs imperfectly in the face of problematic situations.
Aarts, Johanna W M; Faber, Marjan J; Cohlen, Ben J; Van Oers, Anne; Nelen, WillianNe L D M; Kremer, Jan A M
The Internet is expected to innovate healthcare, in particular patient-centredness of care. Within fertility care, information provision, communication with healthcare providers and support from peers are important components of patient-centred care. An online infertility community added to an in vitro fertilisation or IVF clinic's practice provides tools to healthcare providers to meet these. This study's online infertility community facilitates peer-to-peer support, information provision to patients and patient provider communication within one clinic. Unfortunately, these interventions often fail to become part of clinical routines. The analysis of a first introduction into usual care can provide lessons for the implementation in everyday health practice. The aim was to explore experiences of professionals and patients with the implementation of an infertility community into a clinic's care practice. We performed semi-structured interviews with both professionals and patients to collect these experiences. These interviews were analyzed using the Normalisation Process Model. Assignment of a community manager, multidisciplinary division of tasks, clear instructions to staff in advance and periodical evaluations could contribute to the integration of this online community. Interviews with patients provided insights into the possible impact on daily care. This study provides lessons to healthcare providers on the implementation of an online infertility community into their practice.
Background There is a scarcity of research published on clinical scholarship. Much of the conceptualisation has been conducted in the academy. Nurse academics espouse that the practice of nursing must be built within a framework of clinical scholarship. A key concept of clinical scholarship emerging from discussions in the literature is that it is an essential component of enabling evidence–based nursing and the development of best practice standards to provide for the needs of patients/clients. However, there is no comprehensive definition of clinical scholarship from the practicing nurses. The aim of this study was to contribute to this definitional discussion on the nature of clinical scholarship in nursing. Methods Naturalistic inquiry informed the method. Using an interpretative approach 18 practicing nurses from Australia, Canada and England were interviewed using a semi-structured format. The audio-taped interviews were transcribed and the text coded for emerging themes. The themes were sorted into categories and the components of clinical scholarship described by the participants compared to the scholarship framework of Boyer [JHEOE 7:5-18, 2010]. Results Clinical scholarship is difficult to conceptualise. Two of the essential elements of clinical scholarship are vision and passion. The other components of clinical scholarship were building and disseminating nursing knowledge, sharing knowledge, linking academic research to practice and doing practice-based research. Conclusion Academic scholarship dominated the discourse in nursing. However, in order for nursing to develop and to impact on health care, clinical scholarship needs to be explored and theorised. Nurse educators, hospital-based researchers and health organisations need to work together with academics to achieve this goal. Frameworks of scholarship conceptualised by nurse academics are reflected in the findings of this study with their emphasis on reading and doing research and translating it
Kalogeropoulos, Dimitris A; Carson, Ewart R; Collinson, Paul O
Given that clinicians presented with identical clinical information will act in different ways, there is a need to introduce into routine clinical practice methods and tools to support the scientific homogeneity and accountability of healthcare decisions and actions. The benefits expected from such action include an overall reduction in cost, improved quality of care, patient and public opinion satisfaction. Computer-based medical data processing has yielded methods and tools for managing the task away from the hospital management level and closer to the desired disease and patient management level. To this end, advanced applications of information and disease process modelling technologies have already demonstrated an ability to significantly augment clinical decision making as a by-product. The wide-spread acceptance of evidence-based medicine as the basis of cost-conscious and concurrently quality-wise accountable clinical practice suffices as evidence supporting this claim. Electronic libraries are one-step towards an online status of this key health-care delivery quality control environment. Nonetheless, to date, the underlying information and knowledge management technologies have failed to be integrated into any form of pragmatic or marketable online and real-time clinical decision making tool. One of the main obstacles that needs to be overcome is the development of systems that treat both information and knowledge as clinical objects with same modelling requirements. This paper describes the development of such a system in the form of an intelligent clinical information management system: a system which at the most fundamental level of clinical decision support facilitates both the organised acquisition of clinical information and knowledge and provides a test-bed for the development and evaluation of knowledge-based decision support functions.
A Randomized Controlled Trial Protocol to Evaluate the Effectiveness of an Integrated Care Management Approach to Improve Adherence Among HIV-Infected Patients in Routine Clinical Care: Rationale and Design
Fredericksen, Rob J; Church, Anna; Harrington, Anna; Ciechanowski, Paul; Magnani, Jennifer; Nasby, Kari; Brown, Tyler; Dhanireddy, Shireesha; Harrington, Robert D; Lober, William B; Simoni, Jane; Safren, Stevan A; Edwards, Todd C; Patrick, Donald L; Saag, Michael S; Crane, Paul K; Kitahata, Mari M
Background Adherence to antiretroviral medications is a key determinant of clinical outcomes. Many adherence intervention trials investigated the effects of time-intensive or costly interventions that are not feasible in most clinical care settings. Objective We set out to evaluate a collaborative care approach as a feasible intervention applicable to patients in clinical care including those with mental illness and/or substance use issues. Methods We developed a randomized controlled trial (RCT) investigating an integrated, clinic-based care management approach to improve clinical outcomes that could be integrated into the clinical care setting. This is based on the routine integration and systematic follow-up of a clinical assessment of patient-reported outcomes targeting adherence, depression, and substance use, and adapts previously developed and tested care management approaches. The primary health coach or care management role is provided by clinic case managers allowing the intervention to be generalized to other human immunodeficiency virus (HIV) clinics that have case managers. We used a stepped-care approach to target interventions to those at greatest need who are most likely to benefit rather than to everyone to maintain feasibility in a busy clinical care setting. Results The National Institutes of Health funded this study and had no role in study design, data collection, or decisions regarding whether or not to submit manuscripts for publication. This trial is currently underway, enrollment was completed in 2015, and follow-up time still accruing. First results are expected to be ready for publication in early 2017. Discussion This paper describes the protocol for an ongoing clinical trial including the design and the rationale for key methodological decisions. There is a need to identify best practices for implementing evidence-based collaborative care models that are effective and feasible in clinical care. Adherence efficacy trials have not led to
... HUMAN SERVICES Food and Drug Administration Food and Drug Administration Clinical Trial Requirements, Compliance, and Good Clinical Practice; Public Workshop AGENCY: Food and Drug Administration, HHS. ACTION: Notice of public workshop. The Food and Drug Administration (FDA), Baltimore District Office,...
Hepler, Charles D.
Research needs for pharmacy administration and clinical pharmacy include study of the relationship of pharmacists and society, management methods for providing health care services, pharmacist training and socialization, competence evaluation, formative and summative research on drug use control, and organizational decision making. (MSE)
Trepanier, Lauren A
This article describes clinical examples in which pharmacokinetic parameters can be used to optimize veterinary patient care. Specific applications include extrapolating drug dosages, optimizing therapy with therapeutic drug monitoring, interpreting pharmacokinetic information provided by drug labels and pharmaceutical companies, and adjusting drug dosages in patients with hepatic or renal failure.
Barone, Joseph; And Others
A postdoctoral pharmacy fellowship is described that provides training in industrial clinical pharmacy practice and related tasks associated with the development of new pharmaceuticals, through experience in industrial and hospital settings and in research projects. (MSE) PUBTYPE[141
Cavus, Erol; Neumann, Tobias; Doerges, Volker; Moeller, Thora; Scharf, Edwin; Wagner, Klaus; Bein, Berthold; Serocki, Goetz
In the present preliminary study we evaluated the C-MAC® D-Blade (Karl Storz, Tuttlingen, Germany), a new videolaryngoscopic C-MAC blade for difficult intubation, during both routine and difficult intubations. First, both the conventional direct laryngoscopy and the D-Blade were used in 15 consecutive patients with normal airways during routine induction of anesthesia. Second, the D-Blade was used as a rescue device in 20 of 300 (6.7%) consecutive patients, when conventional direct laryngoscopy failed. In the 15 patients during routine induction of anesthesia, with direct laryngoscopy, a Cormack-Lehane (C/L) grade 1 and grade 2a view was seen in 7 and 8 patients, respectively. It was possible to insert the D-Blade and to get a video view of the glottis on the first attempt in all patients; with the D-Blade, all 15 patients had a C/L 1 view. The time to successful intubation with the D-Blade was 15 (8-26) seconds (median (range)). In the 20 patients, in whom unexpected difficulty with direct laryngoscopy was observed, C/L grades 3 and 4 were present in 15 and 5 patients, respectively. With the use of the D-Blade, indirect C/L video view improved to C/L class 1 in 15 patients, and to 2a in 5 patients, respectively. The time from touching the laryngoscope to optimal laryngoscopic view was 11 (5-45) seconds and for successful intubation 17 (3-80) seconds. In all 35 patients, with the D-Blade no direct view of the glottis was possible and subsequently a semiflexible tube guide was required.
Baker, P; Needleman, I
A sizeable proportion of patients in clinical practice will have some form of periodontal disease and most of these patients can be well managed in primary care. Unfortunately, dento-legal claims regarding inappropriate periodontal care are increasing rapidly and are now one of the most common reasons for litigation in dentistry. In this paper we will look at aspects of contemporary management of periodontal disease in clinical practice and offer guidance for examination, management and referral.
Peters, Kathleen; Halcomb, Elizabeth J; McInnes, Susan
As a practice-based discipline a key component of undergraduate nurse education is clinical practice experience. The quality of clinical experiences has a significant impact on the students' ability to function competently post graduation. The relationship between higher education institutions (HEIs) and health service placement providers impacts upon the quality of clinical placements. In Australia, the growth of primary care nursing and the shortage of acute clinical places has prompted HEIs to explore the placement of students in general practice. Given the increasing attention being paid to non-traditional clinical placements, it is timely to explore how universities are establishing relationships and models of clinical placement. This paper uses qualitative research methods to explore the perspectives of 12 Australian general practice nurses who have experience in facilitating undergraduate clinical placements about the relationships between HEIs and nurses. Findings are presented in the following three themes: (1) Appropriate preparation for placement: They don't know what primary health really means, (2) Seeking greater consultation in the organisation of clinical placements: they've got to do it one way for everyone, and (3) Uncertainty and lack of support: I had no contact with the university. Clinical placements in general practice can be an innovative strategy providing non-traditional, yet high quality, teaching and learning experiences for undergraduate nursing students. To optimise the quality of these placements, however, it is essential that HEIs provide appropriate support to the practice nurses mentoring these students.
Wing, R R
Look AHEAD (Action for Health in Diabetes) was a randomized clinical trial designed to examine the long-term health effects of weight loss in overweight and obese individuals with type 2 diabetes. The primary result was that the incidence of cardiovascular events over a median follow-up of 9.6 years was not reduced in the Intensive Lifestyle Group relative to the control group. This finding is discussed, with emphasis on its implications for design of trials and clinical treatment of obese persons with type 2 diabetes.
Background Widespread application of research findings to improve patient outcomes remains inadequate, and failure to routinely translate research findings into daily clinical practice is a major barrier for the implementation of any evidence-based guideline. Strategies to increase guideline uptake in primary care pediatric practices and to facilitate adherence to recommendations are required. Objective Our objective was to operationalize the US National Heart, Lung, and Blood Institute’s Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents into a mobile clinical decision support (CDS) system for healthcare providers, and to describe the process development and outcomes. Methods To overcome the difficulty of translating clinical practice guidelines into a computable form that can be used by a CDS system, we used a multilayer framework to convert the evidence synthesis into executable knowledge. We used an iterative process of design, testing, and revision through each step in the translation of the guidelines for use in a CDS tool to support the development of 4 validated modules: an integrated risk assessment; a blood pressure calculator; a body mass index calculator; and a lipid management instrument. Results The iterative revision process identified several opportunities to improve the CDS tool. Operationalizing the integrated guideline identified numerous areas in which the guideline was vague or incorrect and required more explicit operationalization. Iterative revisions led to workable solutions to problems and understanding of the limitations of the tool. Conclusions The process and experiences described provide a model for other mobile CDS systems that translate written clinical practice guidelines into actionable, real-time clinical recommendations. PMID:28270384
Clinical practice guidelines (CPGs) play a major role in pharmacy education. Students learn to locate, retrieve, and apply CPGs in didactic coursework and practice experiences. However, they often memorize and quote recommendations without critical analysis, which tends to undermine their clinical growth. Students should become genuine drug experts, based on strong critical-thinking skills and the ability to assimilate extensive clinical and scientific knowledge. Clinical practice guidelines improve health care, and students should be familiar with them, but there are legitimate criticisms of CPGs, stemming largely from potential conflicts of interest and limitations in the quality and scope of available evidence. Despite such flaws, CPGs can be used to facilitate the clinical growth of students if the emphasis is placed on critically analyzing and evaluating CPG recommendations, as opposed to blindly accepting them. From that perspective, the role that CPGs have come to play in education may need to be reconsidered. PMID:26889060
Zhang, Y; Liu, X J
Digital medical technologies or computer aided medical procedures, refer to imaging, 3D reconstruction, virtual design, 3D printing, navigation guided surgery and robotic assisted surgery techniques. These techniques are integrated into conventional surgical procedures to create new clinical protocols that are known as "digital surgical techniques". Conventional health care is characterized by subjective experiences, while digital medical technologies bring quantifiable information, transferable data, repeatable methods and predictable outcomes into clinical practices. Being integrated into clinical practice, digital techniques facilitate surgical care by improving outcomes and reducing risks. Digital techniques are becoming increasingly popular in trauma surgery, orthopedics, neurosurgery, plastic and reconstructive surgery, imaging and anatomic sciences. Robotic assisted surgery is also evolving and being applied in general surgery, cardiovascular surgery and orthopedic surgery. Rapid development of digital medical technologies is changing healthcare and clinical practices. It is therefore important for all clinicians to purposefully adapt to these technologies and improve their clinical outcomes.
Jamison, Jennifer R
The chiropractic profession is increasingly expressing the sentiment that chiropractic clinical intervention should rest upon a scientific foundation. Before ‘scientific research’ can become meaningful in chiropractic clinical practice, it is necessary that field practitioners be conversant with research terminology. If chiropractic clinical practice is to achieve credibility as a scientific mode of health care and if the benefits of a ‘scientific’ practice model are to enhance patient care, then future chiropractic practitioners must be familiar with a currently accredited scientific frame of reference. A survey of final year chiropractic students at Phillip Institute of Technology found that respondents appreciation of the strength of diverse clinical research methodologies and their ranking of criteria for ascertaining a cause-effect association bears some similarity (RHO = 0.97 and 0.98 respectively, p < 0.05) to that of the ‘scientific’ clinical community.
Moon, Hee-Won; Kim, Hyeong Nyeon; Hur, Mina; Shim, Hee Sook; Kim, Heejung; Yun, Yeo-Min
Since every single test has some limitations for detecting toxigenic Clostridium difficile, multistep algorithms are recommended. This study aimed to compare the current, representative diagnostic algorithms for detecting toxigenic C. difficile, using VIDAS C. difficile toxin A&B (toxin ELFA), VIDAS C. difficile GDH (GDH ELFA, bioMérieux, Marcy-l'Etoile, France), and Xpert C. difficile (Cepheid, Sunnyvale, California, USA). In 271 consecutive stool samples, toxigenic culture, toxin ELFA, GDH ELFA, and Xpert C. difficile were performed. We simulated two algorithms: screening by GDH ELFA and confirmation by Xpert C. difficile (GDH + Xpert) and combined algorithm of GDH ELFA, toxin ELFA, and Xpert C. difficile (GDH + Toxin + Xpert). The performance of each assay and algorithm was assessed. The agreement of Xpert C. difficile and two algorithms (GDH + Xpert and GDH+ Toxin + Xpert) with toxigenic culture were strong (Kappa, 0.848, 0.857, and 0.868, respectively). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of algorithms (GDH + Xpert and GDH + Toxin + Xpert) were 96.7%, 95.8%, 85.0%, 98.1%, and 94.5%, 95.8%, 82.3%, 98.5%, respectively. There were no significant differences between Xpert C. difficile and two algorithms in sensitivity, specificity, PPV and NPV. The performances of both algorithms for detecting toxigenic C. difficile were comparable to that of Xpert C. difficile. Either algorithm would be useful in clinical laboratories and can be optimized in the diagnostic workflow of C. difficile depending on costs, test volume, and clinical needs.
In addition to usual medical care it is often critical to consider the patient's inner world in order to sensitively differentiate between harmful and helpful suggestive elements. The respective abilities in terms of hypnotic communication can be easily learned. Confident, empathic attention and a calm, understanding and figurative language narrowing the focus on positive emotions and positive change, which have been shown to improve the patient's chances of healing, are of particular importance. Proper clinical hypnosis goes one step further: it makes explicit use of suggestions, trance, and trance phenomena. The major clinical indications for hypnosis include psychosomatic disorders, anxiety disorders, obsessive-compulsive disorders, depression, and pain syndromes. Hypnosis can also be employed as an adjunct for surgical therapy.
Casanova, J M; Sanmartín, V; Martí, R M; Morales, J L; Soler, J; Purroy, F; Pujol, R
The acquisition of competences (the set of knowledge, skills and attitudes required to perform a job to a professional level) is considered a fundamental part of medical training. Dermatology competences should include, in addition to effective clinical interviewing and detailed descriptions of skin lesions, appropriate management (diagnosis, differentiation, and treatment) of common skin disorders and tumors. Such competences can only be acquired during hospital clerkships. As a way of certifying these competences, we propose evaluating the different components as follows: knowledge, via clinical examinations or critical incident discussions; communication and certain instrumental skills, via structured workplace observation and scoring using a set of indicators; and attitudes, via joint evaluation by staff familiar with the student.
Klein, Harvey G; Spahn, Donat R; Carson, Jeffrey L
Every year, about 75 million units of blood are collected worldwide. Red blood cell (RBC) transfusion is one of the few treatments that adequately restore tissue oxygenation when oxygen demand exceeds supply. Although the respiratory function of blood has been studied intensively, the trigger for RBC transfusion remains controversial, and doctors rely primarily on clinical experience. Laboratory assays that indicate failing tissue oxygenation would be ideal to guide the need for transfusion, but none has proved easy, reproducible, and sensitive to regional tissue hypoxia. The clinical importance of the RBCs storage lesion (ie, the time-dependent metabolic, biochemical, and molecular changes that stored blood cells undergo) is poorly understood. RBCs can be filtered, washed, frozen, or irradiated for specific indications. Donor screening and testing have dramatically reduced infectious risks in the developed world, but infection remains a major hazard in developing countries, where 13 million units of blood are not tested for HIV or hepatitis viruses. Pathogen inactivation techniques are in clinical trials for RBCs, but none is available for use. Despite serious immunological and non-immunological complications, RBC transfusion holds a therapeutic index that exceeds that of many common medications.
Hamric, Ann B.
Describes attitude sets characterized as ethics as intuition, ethics as foreign language, and ethics as irrelevant to practice among nurses and physicians and the consequences they engender. Addresses strategies to bridge the gap between ethics knowledge and clinical practice, including interdisciplinary ethics education. (JOW)
Joffe, Victoria; Pring, T.
Background: Children with phonological problems are a significant proportion of many therapists' caseloads. However, little is known about current clinical practice with these children or whether research on the effects of therapy have influenced this practice. Aims: To investigate the methods of assessment and remediation used by therapists…
This report presents a subset of data collected from the American Association for Marriage and Family Therapy (AAMFT) Practice Research Network project conducted in 2002. A sample of 47 clinical members of AAMFT who indicated they practiced in a rural community provided descriptive information on demographic characteristics, training, clinical…
Lammert, Marilyn; Dolan, Mary M.
Describes two dimensions of Gestalt therapy that can enhance clinical practice--orientation to the present and active-experimental style--and examines them in relation to some traditional principles of practice. Gestalt theory offers a method of discovery that is a combination of phenomenology and behaviorism. (JAC)
Harris, Cory S; Raz, Amir
Increasingly a focus of research as well as media reports and online forums, the use of placebos in clinical medicine extends beyond sugar pills and saline injections. Physician surveys conducted in various countries invariably report that placebos are routinely used clinically, impure placebos more frequently than the pure ones, and that physicians consider them to be of legitimate therapeutic value. Inconsistent study methodologies and physician conceptualisations of placebos may complicate the interpretation of survey data, but hardly negate the valuable insights these research findings provide. Because impure placebos are often not recognised as such by practitioners, they remain at the fringe of many placebo-related debates, hence quietly absent from discussions concerning policy and regulation. The apparent popularity of impure placebos used in clinical practice thus presents unresolved ethical concerns and should direct future discussion and research.
Purpose: In this article, the author comments on aspects of Kamhi's (2014) article, which caused the author to think more deeply about definitions of language, theories of learning, and how these two core components of intervention prepare clinical scientists as they search the literature for new knowledge. Interprofessional collaborative…
Prior, Patsy; Wilkinson, Jill; Neville, Stephen
The role of practice nurses is a specific feature of the modernisation agenda of the New Zealand health service. Increasing importance is being placed on service improvement through effective decision making and enhanced clinical performance. To contribute to the development of primary health care it is crucial that nurses have the skills to appropriately implement research based and other evidence in practice. This study involved 55 West Auckland practice nurses working in the general practice setting. The aim of the study was to describe nurses' perceptions of their use of evidence-based practice, attitudes toward evidence-based practice and perceptions of their knowledge/skills associated with evidence-based practice. An additional aim was to determine the effect of educational preparation on practice, attitudes and knowledge/skills toward evidence-based practice. A descriptive survey design was selected for this study. The results demonstrated that nurses' attitudes toward evidence-based practice, knowledge and skills relevant to the implementation of evidence-based practice and the educational preparation of the nurses were important factors influencing the effective utilisation and application of research results in practice. Educational interventions are identified as an integral aspect of implementing evidence-based practice and enhancing practice nurses' knowledge and skill relevant to the use of evidence in practice. Further research is needed to assess the contextual factors which can inhibit or promote achievement of evidence-based practice by practice nurses.
Van Haard, P M; Engel, R; Postma, T
A universal extraction procedure is described for fat-soluble vitamins in human serum. Methods are presented for routine quantitative analysis by isocratic straight phase HPLC with UV-detection of (alpha + beta)-carotene, vitamin E (alpha-tocopherol) and vitamin A (all-trans-retinol) in one single run, and of vitamin K1 (trans-phylloquinone) and 25-hydroxy vitamin D3 after sample clean-up using disposable reversed-phase cartridges. The limits of detection, precisions and selectivities of the developed assays are shown to be satisfactory after more than three years' experience. The routine clinical determination of fat-soluble vitamins can be performed in less than 5 mL of serum. Analyses of external quality control and randomly taken outpatient samples are shown to be of great value in assessing laboratory performance.
Charon, R; Banks, J T; Connelly, J E; Hawkins, A H; Hunter, K M; Jones, A H; Montello, M; Poirer, S
Introduced to U.S. medical schools in 1972, the field of literature and medicine contributes methods and texts that help physicians develop skills in the human dimensions of medical practice. Five broad goals are met by including the study of literature in medical education: 1) Literary accounts of illness can teach physicians concrete and powerful lessons about the lives of sick people; 2) great works of fiction about medicine enable physicians to recognize the power and implications of what they do; 3) through the study of narrative, the physician can better understand patients' stories of sickness and his or her own personal stake in medical practice; 4) literary study contributes to physicians' expertise in narrative ethics; and 5) literary theory offers new perspectives on the work and the genres of medicine. Particular texts and methods have been found to be well suited to the fulfillment of each of these goals. Chosen from the traditional literary canon and from among the works of contemporary and culturally diverse writers, novels, short stories, poetry, and drama can convey both the concrete particularity and the metaphorical richness of the predicaments of sick people and the challenges and rewards offered to their physicians. In more than 20 years of teaching literature to medical students and physicians, practitioners of literature and medicine have clarified its conceptual frameworks and have identified the means by which its studies strengthen the human competencies of doctoring, which are a central feature of the art of medicine.
Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research. PMID:20064195
Aronson, Jeffrey K
1 This is a manifesto for UK clinical pharmacology. 2 A clinical pharmacologist is a medically qualified practitioner who teaches, does research, frames policy, and gives information and advice about the actions and proper uses of medicines in humans and implements that knowledge in clinical practice. Those without medical qualifications who practise some aspect of clinical pharmacology could be described as, say, ‘applied pharmacologists’. 3 Clinical pharmacology is operationally defined as a translational discipline in terms of the basic tools of human pharmacology (e.g. receptor pharmacology) and applied pharmacology (e.g. pharmacokinetics) and how they are used in drug discovery and development and in solving practical therapeutic problems in individuals and populations. 4 Clinical pharmacologists are employed by universities, health-care services, private organizations (such as drug companies), and regulatory agencies. They are • mentors and teachers, teaching laboratory science, clinical science, and all aspects of practical drug therapy as underpinned by the science of pharmacology; they write and edit didactic and reference texts; • researchers, covering research described by the operational definition; • clinicians, practising general medicine, clinical toxicology, other medical specialties, and general practice; • policy makers, framing local, national, and international medicines policy, including formularies, licensing of medicines and prescribing policies. 5 The future of clinical pharmacology depends on the expansion and maintenance of a central core of practitioners (employed by universities or health-care services), training clinical pharmacologists to practise in universities, health-care services, private organizations, and regulatory agencies, and training other clinicians in the principles and practice of clinical pharmacology. PMID:20642541
Ninove, Laetitia; Nougairede, Antoine; Gazin, Celine; Thirion, Laurence; Delogu, Ilenia; Zandotti, Christine; Charrel, Remi N; De Lamballerie, Xavier
Real-time PCR techniques are now commonly used for the detection of viral genomes in various human specimens and require for validation both external and internal controls (ECs and ICs). In particular, ICs added to clinical samples are necessary to monitor the extraction, reverse transcription, and amplification steps in order to detect false-negative results resulting from PCR-inhibition or errors in the technical procedure. Here, we performed a large scale evaluation of the use of bacteriophages as ICs in routine molecular diagnosis. This allowed to propose simple standardized procedures (i) to design specific ECs for both DNA and RNA viruses and (ii) to use T4 (DNA) or MS2 (RNA) phages as ICs in routine diagnosis. Various technical formats for using phages as ICs were optimised and validated. Subsequently, T4 and MS2 ICs were evaluated in routine real-time PCR or RT-PCR virological diagnostic tests, using a series of 8,950 clinical samples (representing 36 distinct specimen types) sent to our laboratory for the detection of a variety of DNA and RNA viruses. The frequency of inefficient detection of ICs was analyzed according to the nature of the sample. Inhibitors of enzymatic reactions were detected at high frequency in specific sample types such as heparinized blood and bone marrow (>70%), broncho-alveolar liquid (41%) and stools (36%). The use of T4 and MS2 phages as ICs proved to be cost-effective, flexible and adaptable to various technical procedures of real-time PCR detection in virology. It represents a valuable strategy for enhancing the quality of routine molecular diagnosis in laboratories that use in-house designed diagnostic systems, which can conveniently be associated to the use of specific synthetic ECs. The high rate of inhibitors observed in a variety of specimen types should stimulate the elaboration of improved technical protocols for the extraction and amplification of nucleic acids.
Korbel, Lindsey; George, Mathew; Kitzmiller, Joseph
Clinicians and patients continue to convey interest in personalized medicine. The objective of personalized medicine is to improve healthcare by tailoring disease prevention, diagnosis, and treatment strategies for individuals based on their unique clinical history and genetic composition. This article offers an overview of pharmacogenomics, discusses caveats specific to pharmacogenomics in pediatric populations, provides evidence-based recommendations for pediatric clinicians, and offers insight regarding the future role of pharmacogenomics testing in pediatric medicine. Reviews of the current literature and thoughtful discussions are presented regarding the pharmacogenomics of antidepressants, codeine and oncologic, asthma, and immunomodulatory pharmacotherapies.
The article analyses the significance of the concept of "obsession" in nineteenth-century alienism. From a clinical point of view, Esquirol's description was completed by other authors (Jules Falret, Legrand du Saulle). In the area of psychopathological studies, French alienism, with Morel's emotional delirium or Janet's psychasthenia, defended the emotional theory, as opposed to the intellectual disorder proposed by German doctors. Lastly, the importance of the cultural framework is stressed in the appearance of obsessive symptoms and their interpretation. Along these lines, the article discusses the relationship of religious scruples to melancholy or the appearance of diagnostic categories subject to fin de siècle codes and mentalities.
Taylor, Stephen; Jayasuriya, Ashini; Smit, Erasmus
Genotypic resistance testing is now a standard of care in HIV management. Although there are clear, published guidelines to recommend the appropriate use of these tests, clinicians and scientists still struggle to determine the optimal use of resistance tests given the finite budgets and time constraints under which they work. In this article we discuss some 'real-life' clinical situations and aim to provide a useful insight into when and where genotypic resistance testing can be optimally applied in the management of HIV-positive adults.
Almería, S; López-Gatius, F
Neospora caninum is a protozoan parasite with a wide host range but with a preference for cattle and dogs. Since the description of N. caninum as a new genus and species in 1988, bovine neosporosis has become a disease of international concern as it is among the main causes of abortion in cattle. At present there is no effective treatment or vaccine. This review focuses on the epidemiology of the disease and on prospects for its control in cattle. Finally, based on the implications of clinical findings reported to date, a set of recommendations is provided for veterinarians and cattle farmers.
This paper discusses error type their possible consequences and the doctors who make them. There is no single, all-encompassing typology of medical errors. They are frequently multifactorial in origin and use from the mental processes of individuals; from defects in perception, thinking reasoning planning and interpretation and from failures of team-working omissions and poorly executed actions. They also arise from inadequately designed and operated healthcare systems or procedures. The paper considers error-truth relatedness, the approach of UK courts to medical errors, the learning opportunities which flow from error recognition and the need for personal and professional self awareness of clinical fallibilities. PMID:12389767
Kamhi, Alan G.
Purpose: This lead article of the Clinical Forum addresses some of the gaps that exist between clinical practice and current knowledge about instructional factors that influence learning and language development. Method: Topics reviewed and discussed include principles of learning, generalization, treatment intensity, processing interventions,…
Satta, G; Atzeni, A; McHugh, T D
Whole genome sequencing (WGS) has the potential to revolutionize the diagnosis of Mycobacterium tuberculosis infection but the lack of bioinformatic expertise among clinical microbiologists is a barrier for adoption. Software products for analysis should be simple, free of charge, able to accept data directly from the sequencer (FASTQ files) and to provide the basic functionalities all-in-one. The main aim of this narrative review is to provide a practical guide for the clinical microbiologist, with little or no practical experience of WGS analysis, with a specific focus on software products tailor-made for M. tuberculosis analysis. With sequencing performed by an external provider, it is now feasible to implement WGS analysis in the routine clinical practice of any microbiology laboratory, with the potential to detect resistance weeks before traditional phenotypic culture methods, but the clinical microbiologist should be aware of the limitations of this approach.
Bell, Sue Ellen; Hulbert, James R
Translating social justice into clinical nurse specialist (CNS) practice involves not only facilitating equitable access to healthcare resources but also changing the definition of health from individual centric to population based. Clinical nurse specialists working within hospitals or healthcare systems generally have not explored the ethical conflicts between demand and available healthcare resources. Application of social justice to CNS practice requires microallocation decisions in direct patient care and macroallocation decisions in the distribution of all societal goods that alleviate health disparities. This article reviews the meaning, history, and current basis for the application of the principle of social justice to CNS practice.
Villiger, B; Monnat, A
The complexity of the new antidoping regulations of the International Olympic Committee (IOC), the International Federations (IF) and the National Olympic Committees (NOC) rises a lot of problems in handling the prescriptions of medication in athletes in the daily practice. In addition, several countries have passed antidoping laws which makes the prescription and the delivery of doping agens illegal. This may have severe consequences for the prescribing doctors. It is therefore the goal of the article to inform the practitioning doctors about the new antidoping regulations and their impact on prescribing or delivering potential doping agens to athletes. It will focus on the new dopinglists, the different doping control systems, the problems with the pharmacological treatment of certain diseases as asthma and the necessary reports which have to be sent to the NOC's or the IF's after prescribing certain medications or methods.
Reid, Gregor; Jass, Jana; Sebulsky, M. Tom; McCormick, John K.
Probiotics are defined as live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. There is now mounting evidence that selected probiotic strains can provide health benefits to their human hosts. Numerous clinical trials show that certain strains can improve the outcome of intestinal infections by reducing the duration of diarrhea. Further investigations have shown benefits in reducing the recurrence of urogenital infections in women, while promising studies in cancer and allergies require research into the mechanisms of activity for particular strains and better-designed trials. At present, only a small percentage of physicians either know of probiotics or understand their potential applicability to patient care. Thus, probiotics are not yet part of the clinical arsenal for prevention and treatment of disease or maintenance of health. The establishment of accepted standards and guidelines, proposed by the Food and Agriculture Organization of the United Nations and the World Health Organization, represents a key step in ensuring that reliable products with suitable, informative health claims become available. Based upon the evidence to date, future advances with single- and multiple-strain therapies are on the horizon for the management of a number of debilitating and even fatal conditions. PMID:14557292
Manski, Charles F.; Tetenov, Aleksey
Medical research has evolved conventions for choosing sample size in randomized clinical trials that rest on the theory of hypothesis testing. Bayesian statisticians have argued that trials should be designed to maximize subjective expected utility in settings of clinical interest. This perspective is compelling given a credible prior distribution on treatment response, but there is rarely consensus on what the subjective prior beliefs should be. We use Wald’s frequentist statistical decision theory to study design of trials under ambiguity. We show that ε-optimal rules exist when trials have large enough sample size. An ε-optimal rule has expected welfare within ε of the welfare of the best treatment in every state of nature. Equivalently, it has maximum regret no larger than ε. We consider trials that draw predetermined numbers of subjects at random within groups stratified by covariates and treatments. We report exact results for the special case of two treatments and binary outcomes. We give simple sufficient conditions on sample sizes that ensure existence of ε-optimal treatment rules when there are multiple treatments and outcomes are bounded. These conditions are obtained by application of Hoeffding large deviations inequalities to evaluate the performance of empirical success rules. PMID:27601679
Cline, John C
Detoxification is a vital cellular task that, if lacking, can lead to early morbidity and mortality. The process of detoxification involves the mobilization, biotransformation, and elimination of toxicants of exogenous and endogenous origin. This article discusses the phase I and phase II detoxification and biotransformation pathways and promotes using food to support these highly complex processes. The author identifies the comprehensive elimination diet as a useful therapeutic tool for clinicians and patients to use to achieve detoxification. Using this diet, the patient removes the most common allergenic foods and beverages from the diet and replaces them with nonallergenic choices for a period of 4 wk, gradually adding back the eliminated foods and observing their effects. Another effective clinical tool that the author discusses is the detox-focused core food plan, which identifies the variety of foods required to supply key nutrients that can maximize the effectiveness of detoxification. Finally, the author provides a case study in which these tools were used to help a patient suffering from major, debilitating illnesses that resulted from exposure to malathion, including severe vomiting and diarrhea, headaches, night sweats, severe arthralgias and myalgias, episcleritis, and shortness of breath. The article details the interventions used and the clinical results (ie, successful resolution of most issues after 3 mo).
Tarver, William J.
Vitamin D and its metabolites have clinical significance because they play a critical function in calcium homeostasis and bone metabolism. Although not all of the pathologic mechanisms have been adequately described, vitamin D insufficiency and deficiency, as measured by low levels of 25-OH vitamin D, are associated with a variety of clinical conditions including osteoporosis, falls and fractures in the elderly, decreased immune function, bone pain, and possibly colon cancer and cardiovascular health.2 Apart from inadequate dietary intake, patients may present with low levels of vitamin D if they receive inadequate sunlight. The astronaut population is potentially vulnerable to low levels of vitamin D for several reasons. Firstly, they may train for long periods in Star City, Russia, which by virtue of its northern latitude receives less sunlight in winter months. Secondly, astronauts are deprived of sunlight while aboard the International Space Station (ISS). In addition, ISS crew members are exposed to microgravity for prolonged durations and are likely to develop low bone mineral density despite the use of countermeasures. Therefore, closely monitoring and maintaining adequate vitamin D levels is important for the astronaut corps.
Zagaynova, Elena; Gladkova, Natalia D.; Shakhov, Andrey; Terentjeva, Anna; Snopova, Ludmila B.; Kuznetzova, Irina A.; Streltzova, Olga; Shakhova, Natalia M.; Kamensky, Vladislav A.; Gelikonov, Grigory V.; Gelikonov, Valentin M.; Kuranov, Roman V.; Myakov, Alex
Clinical studies using OCT involved 2000 patients in various fields of medicine such as gastroenterology, urology, laryngology, gynecology, dermatology, stomatology, etc. Layered high-contrast images were typical for benign epithelial conditions. OCT distinguish in mucosae: epithelium, connective tissue layer, and smooth-muscle layer. Various benign processes occurring in mucosa manifest in OCT images as changes in the epithelial height, scattering properties and the course of the basement membrane. Lack of the layered structural pattern is the main criterion for dysplastic / malignant images. In clinic: OCT data may be critical for choosing a tissue site for excisional biopsy, OCT can detect tumor borders and their linear dimensions, OCT can be used to plan a resection line in operations and to control adequacy of resection, to monitor whether reparative processes are timely and adequate. OCT sensitivity of the uterine cervix, urinary bladder and larynx is 82, 98, 77%, respectively, specificity - 78, 71, 96%, diagnostic accuracy - 81, 85, 87% with significantly good agreement index of clinicians kappa - 0.65, 0.79, 0.83 (confidence intervals: 0.57-0.73; 0.71-0.88; 0.74-0.91). Error in detection of high grade dysplasia and microinvasive cancer is 21.4% in average. Additional modification of OCT (cross-polarisation OCT, OCM), development of the procedure (biotissue compression, application of chemical agents) can improve the specificity and sensitivity of traditional modality.
Rani, Alka; Sharma, Manoj Kumar; Singh, Amarjeet
To estimate the prevalence, to compare the impact of dysmenorrhea on routine life among adolescent girls, to compare the practices and perceptions regarding Dysmenorrhea and to ascertain the reason for difference if any, a cross-sectional study was conducted in urban, rural and slum areas of Chandigarh, India. 300 girls in age group of 11-18 years, who had attained menarche were included in the study. A questionnaire including the Demographic and Family profile, menstrual history, Symptoms of Dysmenorrhea, Effect of pain on daily activities, Faces scale, Practices regarding Dysmenorrhea, Beliefs about menstruation was used. Analysis was done by percentage and chi square prevalance of dysmenorrhea was 61.33%. Sickness absenteeism due to dysmenorrhea was reported in 24.45% girls. Most common symptom experienced by the girls was stomach ache which was experienced by 139 girls; others symptoms experienced during menstruation were backache (107), and general body pain (80). Only 11.63% of the girls ever visited physician due to pain during menstruation. During menstruation only 10 girls use hot water bottle, 71 skip meal. Due to poor knowledge the practices were not optimal for pain management, which affected their school attendance. Formal as well as informal channels of communication, such as mothers and peers, need to be emphasized for the delivery of such information particularly linking instructions on menstrual hygiene to an expanded programme of health education in schools.
Weise, Kathryn L; Daly, Barbara J
Clinical ethics consultants represent a multidisciplinary group of scholars and practitioners with varied training backgrounds, who are integrated into a medical environment to assist in the provision of ethically supportable care. Little has been written about the degree to which such consultants are accountable for the patient care outcome of the advice given. We propose a model for examining degrees of internally motivated accountability that range from restricted to unbounded accountability, and support balanced accountability as a goal for practice. Finally, we explore implications of this model for training of clinical ethics consultants from diverse academic backgrounds, including those disciplines that do not have a formal code of ethics relating to clinical practice.
Dean Deyle, Gail
This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the situations when an MRI is indicated. The advanced competency standard of examination used by physical therapists will be helpful to prevent overuse of musculoskeletal imaging, reduce diagnostic errors, and provide the appropriate clinical context to pathology revealed on MRI. Physical therapists are diagnostically accurate and appropriately conservative in their use of MRI consistent with evidence-based principles of diagnosis and screening. PMID:22851878
Forrest, John B; Dell, Jeffrey R
Primary care physicians, urologists, and gynecologists have the opportunity to detect interstitial cystitis (IC) in its early stages in symptomatic patients and provide effective treatment before the disease progresses. In this article, we present guidelines for clinical practice management and coding for reimbursement for the care of patients with IC. Important issues in the management of IC are presented, including appropriate Current Procedural Terminology (CPT) coding for office visits and procedures associated with diagnosis and treatment of the disease. Excellent IC care can be integrated into a successful clinical practice with appropriate clinical management and coding for reimbursement.
Bjoerkhem, I.; Bergman, A.; Falk, O.; Kallner, A.; Lantto, O.; Svensson, L.; Akerloef, E.; Blomstrand, R.
Serum from patients was pooled, filtered, dispensed, and frozen. This pooled specimen was used for accuracy control in 64 participating laboratories in Sweden. Mean values (state-of-the-art values) were obtained for creatinine, cholesterol, glucose, urea, uric acid, and cortisol. These values were compared with values obtained with highly accurate reference methods based on isotope dilution-mass spectrometry. Differences were marked in the case of determination of creatinine and cortisol. Concerning the other components, the differences between the state-of-the-art value and the values obtained with the reference methods were negligible. Moreover, the glucose oxidase and the oxime methods for determination of glucose and urea were found to give significantly lower values than the hexokinase and urease methods, respectively. Researchers conclude that methods with a higher degree of accuracy are required for routine determination of creatinine and cortisol.
Darte, L; Persson, B R
Gel chromatography columnm scanning (GCS) is a rapid and reliable method for the quality control of 99mTc-radiopharmaceuticals. With this method the labelled compound and various impurities such as free pertechnetate, hydrolyzed reduced technetium or other 99mTc-complexes are obtained in one testing procedure. Using minicolumns results can be obtained with a simple testing procedure within a few minutes after the sample is taken; this is significant in routine radiopharmaceutical work. The resolution of the recording system is important, so as to be able to utilize fully the good separation ability of the minicolumn. Minicolumns were studied with some commonly used radiopharmaceuticals. A scintillation camera was used to record minicolumn data under various conditions and the results were conpared to those obtained using a scanner to reveal optimal recording conditions for the scintillation camera.
Balla, John I; Heneghan, Carl; Glasziou, Paul; Thompson, Matthew; Balla, Margaret E
Rationale and aim The rapidly changing knowledge base of clinical practice highlights the need to keep abreast of knowledge changes that are most relevant for the practitioner. We aimed to develop a model for reflection on clinical practice that identified the key elements of medical knowledge needed for good medical practice. Method The dual theory of cognition, an integration of intuitive and analytic processes, provided the framework for the study. The design looked at the congruence between the clinical thinking process and the dual theory. A one-year study was conducted in general practice clinics in Oxfordshire, UK. Thirty-five general practitioners participated in 20-minute interviews to discuss how they worked through recently seen clinical cases. Over a one-year period 72 cases were recorded from 35 interviews. These were categorized according to emerging themes, which were manually coded and substantiated with verbatim quotations. Results There was a close fit between the dual theory and participants' clinical thinking processes. This included instant problem framing, consistent with automatic intuitive thinking, focusing on the risk and urgency of the case. Salient features accounting for these choices were recognizable. There was a second reflective phase, leading to the review of initial judgements. Conclusions The proposed model highlights the critical steps in decision making. This allows regular recalibration of knowledge that is most critical at each of these steps. In line with good practice, the model also links the crucial knowledge used in decision making, to value judgments made in relation to the patient.
Gao, Mei; Rejaei, Damoon; Liu, Hong
After nearly half a century on the market, ketamine still occupies a unique corner in the medical armamentarium of anesthesiologists or clinicians treating pain. Over the last two decades, much research has been conducted highlighting the drug's mechanisms of action, specifically those of its enantiomers. Nowadays, ketamine is also being utilized for pediatric pain control in emergency department, with its anti-hyperalgesic and anti-inflammatory effects being revealed in acute and chronic pain management. Recently, new insights have been gained on ketamine's potential anti-depressive and antisuicidal effects. This article provides an overview of the drug's pharmacokinetics and pharmacodynamics while also discussing the potential benefits and risks of ketamine administration in various clinical settings. PMID:27018176
Mahoney, Megan R; Fogler, Jess; Weber, Shannon; Goldschmidt, Ronald H
An estimated one fourth of persons with human immunodeficiency virus (HIV) are not aware they are infected. Early diagnosis of HIV has the potential to ensure optimal outcomes for infected persons and to limit the spread of the virus. Important barriers to testing among physicians include insufficient time, reimbursement issues, and lack of patient acceptance. Current HIV testing guidelines address many of these barriers by making the testing process more streamlined and less stigmatizing. The opt-out consent process has been shown to improve test acceptance. Formal pretest counseling and written consent are no longer recommended by the Centers for Disease Control and Prevention. Nevertheless, pretest discussions provide an opportunity to give information about HIV, address fears of discrimination, and identify ongoing high-risk activities. With increased HIV screening in the primary care setting, more persons with HIV could be identified earlier, receive timely and appropriate care, and get treatment to prevent clinical progression and transmission.
Kar, Nilamadhab; Barreto, Socorro; Chandavarkar, Rahul
Clozapine is effective in treatment resistant schizophrenia; however, it is underutilised probably because of its side effects. The side effects are also the potential reasons for clozapine discontinuation. A mandatory requirement for its use is regular monitoring of white blood cell count and absolute neutrophil count. However there are many side effects that need monitoring in clinical practice considering their seriousness. This article tries to summarise the clinical concerns surrounding the serious side effects of clozapine some of which are associated with fatalities and presents a comprehensive way to monitor patients on clozapine in clinical practice. It emphasizes the need to broaden the monitoring beyond the mandatory investigations. This may help in improving the safety in clinical practice and increasing clinician confidence for greater and appropriate use of this effective intervention. PMID:27776383
Klinkhardt, U; Harder, S
Dose-finding studies are performed routinely in patients and--if appropriate surrogate models exist--also in healthy volunteers. Such studies aim at establishing the optimal dose range for further clinical studies on the efficacy and the risk-benefit ratio of a new drug. The dose-response relationship of a drug is most often described by a sigmoidal curve. Its parameters include the mean effective dose, the maximal effect and the steepness. Interpretation of such curves should be done in the context of the intended clinical indications of the drug. The risk-benefit ratio of a drug can be assessed by overlapping the dose-response curve of wanted and unwanted clinical effects, again, any overlapping (which can be described e.g. by the therapeutic index) should be seen in the context of the indication and available therapeutic alternatives.
Briko, N I
This article defines clinical epidemiology and describes its goal and objectives. The author claims that clinical epidemiology is a section of epidemiology which underlies the development of evidence-based standards for diagnostics, treatment and prevention and helps to select the appropriate algorithm for each clinical case. The study provides a comprehensive overview of the relationship between clinical epidemiology and evidence-based medicine. Epidemiological research is shown to be methodological basis of clinical epidemiology and evidence-based medicine with randomized controlled trials being the "gold standard" for obtaining reliable data. The key stages in the history of clinical epidemiology are discussed and further development of clinical epidemiology and the integration of courses on clinical epidemiology in education is outlined for progress in medical research and health care practice.
Gubbins, Paul O; Micek, Scott T; Badowski, Melissa; Cheng, Judy; Gallagher, Jason; Johnson, Samuel G; Karnes, Jason H; Lyons, Kayley; Moore, Katherine G; Strnad, Kyle
Clinical pharmacy has a rich history of advancing practice through innovation. These innovations helped to mold clinical pharmacy into a patient-centered discipline recognized for its contributions to improving medication therapy outcomes. However, innovations in clinical pharmacy practice have now waned. In our view, the growth of academic–practice partnerships could reverse this trend and stimulate innovation among the next generation of pioneering clinical pharmacists. Although collaboration facilitates innovation,academic institutions and health care systems/organizations are not taking full advantage of this opportunity. The academic–practice partnership can be optimized by making both partners accountable for the desired outcomes of their collaboration, fostering symbiotic relationships that promote value-added clinical pharmacy services and emphasizing continuous quality improvement in the delivery of these services. Optimizing academic–practice collaboration on a broader scale requires both partners to adopt a culture that provides for dedicated time to pursue innovation, establishes mechanisms to incubate ideas, recognizes where motivation and vision align, and supports the purpose of the partnership. With appropriate leadership and support, a shift in current professional education and training practices, and a commitment to cultivate future innovators, the academic–practice partnership can develop new and innovative practice advancements that will improve patient outcomes.
Platteel, T N; Stuart, J W Cohen; Voets, G M; Scharringa, J; van de Sande, N; Fluit, A C; Leverstein-Van Hall, M A
Since the diagnostic characteristics of the Check-KPC ESBL microarray as a confirmation test on isolates obtained in a routine clinical setting have not been determined, we evaluated the microarray in a random selection of 346 clinical isolates with a positive ESBL screen test (MIC >1 mg/L for cefotaxime or ceftazidime or an ESBL alarm from the Phoenix or Vitek-2 expert system) collected from 31 clinical microbiology laboratories in the Netherlands in 2009. Using sequencing as the reference method the sensitivity of the microarray was 97% (237/245), the specificity 98% (97/99), the positive predictive value 99% (237/239) and the negative predictive value 92% (97/105).
Fisher, S I; Nandedkar, M A; Williams, B H; Abbondanzo, S L
We studied a series of 60 telepathology cases sent in consultation to the Department of Hematopathology from January 1, 1995, through July 31, 2000. Cases from the United States and the world representing academic, private, military, and federal sectors were reviewed. Ninety percent of patients were adults (54 of 60), and male patients outnumbered female patients 2 to 1. Ages were from 1 to 79 years (mean, 42 years). Forty-three cases were lymph nodes (72%), 14 were bone marrow or peripheral blood (23%), and 3 were from other sites (5%). Twenty-seven of the consultant diagnoses were benign (27 of 60). Twenty-nine were malignant (non-Hodgkin lymphoma, Hodgkin disease, and "other malignancy" groups), and 4 were nondiagnostic. Glass slide/paraffin tissue blocks were available in only 35 (58%) of 60 cases. The concordance rate for diagnostic telehematopathology cases with subsequent glass slide/paraffin block follow-up was 91% (29 of 32 cases). The discordance rate was 9% (3 of 32). This finding shows a high degree of diagnostic accuracy for consultative telehematopathology. Of 118 images analyzed, 58 were considered very good/good (49%), 32 were poor/very poor (27%), and 28 were fair (24%). Poor images had suboptimal resolution, color, or technical quality of transmission, and most poor images were low-power images. Additional case problems included insufficient immunoperoxidase stain availability, selection, and labeling; transmitted field selection; specimen preparation and staining; presence or absence of accompanying clinical data; and availability of ancillary studies such as flow cytometric, cytogenetic, and molecular data. From this analysis, the following recommendations are offered. To optimize telehematopathology consultation, include any additional information that have a significant influence on the final consultant diagnosis. Include any pertinent clinical information, laboratory data, special stains, immunoperoxidase stains, and molecular data. Select
Grare, Marion; Prere, Marie-Françoise; Segonds, Christine; Marty, Nicole; Oswald, Eric
Rapid and cost-effective matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS)-based systems will replace conventional phenotypic methods for routine identification of bacteria. We report here the first evaluation of the new MALDI-TOF MS-based Vitek MS system in a large clinical microbiology laboratory. This system uses an original spectrum classifier algorithm and a specific database designed for the identification of clinically relevant species. We have tested 767 routine clinical isolates representative of 50 genera and 124 species. Vitek MS-based identifications were performed by means of a single deposit on a MALDI disposable target without any prior extraction step and compared with reference identifications obtained mainly with the VITEK2 phenotypic system; if the identifications were discordant, molecular techniques provided reference identifications. The Vitek MS system provided 96.2% correct identifications to the species level (86.7%), to the genus level (8.2%), or within a range of species belonging to different genera (1.3%). Conversely, 1.3% of isolates were misidentified and 2.5% were unidentified, partly because the species was not included in the database; a second deposit provided a successful identification for 0.8% of isolates unidentified with the first deposit. The Vitek MS system is a simple, convenient, and accurate method for routine bacterial identification with a single deposit, considering the high bacterial diversity studied and as evidenced by the low prevalence of species without correct identification. In addition to a second deposit in uncommon cases, expanding the spectral database is expected to further enhance performances. PMID:22593596
Dubois, Damien; Grare, Marion; Prere, Marie-Françoise; Segonds, Christine; Marty, Nicole; Oswald, Eric
Rapid and cost-effective matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based systems will replace conventional phenotypic methods for routine identification of bacteria. We report here the first evaluation of the new MALDI-TOF MS-based Vitek MS system in a large clinical microbiology laboratory. This system uses an original spectrum classifier algorithm and a specific database designed for the identification of clinically relevant species. We have tested 767 routine clinical isolates representative of 50 genera and 124 species. Vitek MS-based identifications were performed by means of a single deposit on a MALDI disposable target without any prior extraction step and compared with reference identifications obtained mainly with the VITEK2 phenotypic system; if the identifications were discordant, molecular techniques provided reference identifications. The Vitek MS system provided 96.2% correct identifications to the species level (86.7%), to the genus level (8.2%), or within a range of species belonging to different genera (1.3%). Conversely, 1.3% of isolates were misidentified and 2.5% were unidentified, partly because the species was not included in the database; a second deposit provided a successful identification for 0.8% of isolates unidentified with the first deposit. The Vitek MS system is a simple, convenient, and accurate method for routine bacterial identification with a single deposit, considering the high bacterial diversity studied and as evidenced by the low prevalence of species without correct identification. In addition to a second deposit in uncommon cases, expanding the spectral database is expected to further enhance performances.
The whole spectrum of medicine consists of complex non-linear systems that are balanced and interact with each other. How non-linearity confers stability on a system and explains variation and uncertainty in clinical medicine is discussed. A major theme is that a small alteration in initial conditions may have a major effect on the end result. In the context of non-linearity, it is argued that 'evidence-based medicine' (EBM) as it exists today can only ever be relevant to a small fraction of the domain of medicine, that the 'art of medicine' consists of an intuitive 'tuning in' to these complex systems and as such is not so much an art as an expression of non-linear science. The main cause of iatrogenic disease is interpreted as a failure to understand the complexity of the systems being treated. Case study examples are given and analysed in non-linear terms. It is concluded that good medicine concerns individualized treatment of an individual patient whose body functions are governed by non-linear processes. EBM as it exists today paints with a broad and limited brush, but it does promise a fresh new direction. In this context, we need to expand the spectrum of scientific medicine to include non-linearity, and to look upon the 'art of medicine' as a historical (but unstated) legacy in this domain.
De Deyn, P P; D'Hooge, R
The main current application of placebo is in clinical research. The term placebo effect refers to diverse non-specific, desired or non-desired effects of substances or procedures and interactions between patient and therapist. Unpredictability of the placebo effect necessitates placebo-controlled designs for most trials. Therapeutic and diagnostic use of placebo is ethically acceptable only in few well-defined cases. While "therapeutic" application of placebo almost invariably implies deception, this is not the case for its use in research. Conflicts may exist between the therapist's Hippocratic and scientific obligations. The authors provide examples in neuropsychiatry, illustrating that objective scientific data and well-considered guidelines may solve the ethical dilemma. Placebo control might even be considered an ethical obligation but some provisos should be kept in mind: (a) no adequate therapy for the disease should exist and/or (presumed) active therapy should have serious side-effects; (b) placebo treatment should not last too long; (c) placebo treatment should not inflict unacceptable risks, and (d) the experimental subject should be adequately informed and informed consent given. PMID:8798935
Reyna, Valerie F.; Fagerlin, Angela; Lipkus, Isaac; Peters, Ellen
Background Low numeracy is pervasive and constrains informed patient choice, reduces medication compliance, limits access to treatments, impairs risk communication, and affects medical outcomes; therefore, it is incumbent upon providers to minimize its adverse effects. Purpose We provide an overview of research on health numeracy and discuss its implications in clinical contexts. Conclusions Low numeracy cannot be reliably inferred on the basis of patients’ education, intelligence, or other observable characteristics. Objective and subjective assessments of numeracy are available in short forms and could be used to tailor health communication. Low scorers on these assessments are subject to cognitive biases, irrelevant cues (e.g., mood), and sharper temporal discounting. Because prevention of the leading causes of death (e.g., cancer and cardiovascular disease) depends on taking action now to prevent serious consequences later, those low in numeracy are likely to require more explanation of risk to engage in prevention behaviors. Visual displays can be used to make numerical relations more transparent, and different types of displays have different effects (e.g., greater risk avoidance). Ironically, superior quantitative processing seems to be achieved by focusing on qualitative gist and affective meaning, which has important implications for empowering patients to take advantage of the evidence in evidence-based medicine. PMID:18677452
Bisht, Veena; Voort, Judith VanDer
Renal candidiasis is an increasingly common condition affecting predominantly premature infants receiving neonatal intensive care or term infants with urogenital tract anomalies. Multiple risk factors are usually present. Although rare, some infants develop an obstructive uropathy due to fungal balls, and this requires prompt detection and intervention to preserve kidney function. The management of obstructive renal bezoars is challenging and not well summarised in the past. This is mainly due to scarce literature confined to case reports or case series only. This review clarifies various definitions used in relation to renal candidiasis and identifies infants particularly at risk of obstruction. Clinical presentation, diagnosis and the role of imaging are discussed. A summary of the recent literature is provided to outline the range of existing treatment options available with published drug dosages and mode of delivery used. No single approach is successful in all cases and clinicians need to be aware of the different options available: apart from adequate urinary drainage and use of systemic +/- local antifungal agents, additional treatment with fibrinolytic agents and/or endoscopic or open surgical removal may be required. A new simplified algorithm for use in management is proposed. We hope this review will help clinicians in their management of patients presenting with this complex and challenging diagnosis.
Littlewood, S J; Kandasamy, S; Huang, G
Maintaining teeth in their corrected positions following orthodontic treatment can be extremely challenging. Teeth have a tendency to move back towards the original malocclusion as a result of periodontal, gingival, occlusal and growth related factors. However, tooth movement can also occur as a result of normal age changes. Because orthodontics is unable to predict which patients are at risk of relapse, those which will remain stable and the extent of relapse that will occur in the long-term, clinicians need to treat all patients as if they have a high potential to relapse. To reduce this risk, long term retention is advocated. This can be a significant commitment for patients, and so retention and the potential for relapse must form a key part of the informed consent process prior to orthodontic treatment. It is vital that patients are made fully aware of their responsibilities in committing to wear retainers as prescribed in order to reduce the chance of relapse. If patients are unable or unwilling to comply as prescribed, they must be prepared to accept that there will be tooth positional changes following treatment. There is currently insufficient high quality evidence regarding the best type of retention or retention regimen, and so each clinician's approach will be affected by their personal, clinical experience and expertise, and guided by their patients' expectations and circumstances.
Pauroso, S.; Di Leo, N.; Fulle, I.; Di Segni, M.; Alessi, S.; Maggini, E.
Introduction Varicoceles are abnormal dilatations of the pampiniform venous plexus. They are classified as primary or secondary, depending on their cause, and staged clinically on the basis of their extension and on the presence or the absence of spontaneous or induced reversal of blood flow. Materials and methods We examined 95 patients (age range: 3–77 years) using Color Doppler ultrasound with settings optimized for the study of slow flow. All patients found to have varicoceles underwent ultrasonographic assessment of the kidneys and retroperitoneum. Findings were classified with a simplified version of the Sarteschi system. Results 41 (43.1%) of the patients were found to have varicoceles, which were classified as grade 1 in 11 cases, grade 2 in 13, grade 3 in 10, and grade 4 in 7 according to the simplified Sarteschi classification. Discussion Our results are with those reported in the literature. They confirm that varicoceles are a frequent finding and ultrasonography is currently the best imaging technique for its diagnosis and also for the post-surgery follow-up. PMID:23396816
Despas, Noémie; Larock, Anne-Sophie; Jacqmin, Hugues; Douxfils, Jonathan; Chatelain, Bernard; Chatelain, Marc; Mullier, François
Traditional anticoagulant agents such as unfractionated heparin (UFH), low molecular weight heparins (LMWHs), fondaparinux, danaparoid and bivalirudine are used in the prevention and treatment of thromboembolic diseases. However, these agents have limitations: their constraining parenteral route of administration and the need for regular coagulation monitoring for HNF. The LMWHs, with their more predictable anticoagulant response, don't require a systematic monitoring. The usefulness of LMWHs monitoring in several clinical situations such as pregnancy, obesity and renal insufficiency is a matter of debate. Indeed, there is no agreement between French and American recommendations on this question. Others aspects are also controversial: the measure of trough anti-Xa activity during pregnancy and the optimal monitoring of LMWHs for patients with antithrombin deficiency (hepatic disease, new-borns). Different tests are available to ensure the monitoring of these drugs, we will see in this review their principle, their advantages and inconvenients. The management of heparin induced thrombocytopenia also needs parenteral anticoagulants: danaparoïd, bivalirudine or argatroban. The modalities of their monitoring are relatively unknown and are presented. Furthermore, platelet monitoring is capital. This article aims to provide guidance about laboratory testing of classic parenteral anticoagulants.
Asai, Atsushi; Kadooka, Yasuhiro
A placebo is a substance or intervention believed to be inactive, but is administered by the healthcare professional as if it was an active medication. Unlike standard treatments, clinical use of placebo usually involves deception and is therefore ethically problematic. Our attitudes toward the clinical use of placebo, which inevitably includes deception or withholding information, have a tremendous effect on our practice regarding truth-telling and informed consent. A casual attitude towards it weakens the current practice based on shared decision-making and mutual trust between patients and healthcare professionals. Issues concerning the clinical use of placebo are thus intimately related to patient-provider relationships, the public's trust in medicine, and medical education. A review of recent survey studies suggests that the clinical use of placebo appears to be fairly well accepted among healthcare professionals and is common in clinical settings in various countries. However, we think that an ethical discussion is urgently needed because of its controversial nature. If judged to be ethically wrong, the practice should end. In the present paper, we discuss the ethicality of the clinical use of placebo with deception and argue against it, concluding that it is unethical and should be banned. We will show that most arguments in favor of the clinical use of placebo can be refuted and are therefore incorrect or weak. These arguments will be presented and examined individually. Finally, we will briefly consider issues relevant to the clinical use of placebo without deception.
CHEN, JONATHAN H; GOLDSTEIN, MARY K; ASCH, STEVEN M; ALTMAN, RUSS B
Automatically data-mining clinical practice patterns from electronic health records (EHR) can enable prediction of future practices as a form of clinical decision support (CDS). Our objective is to determine the stability of learned clinical practice patterns over time and what implication this has when using varying longitudinal historical data sources towards predicting future decisions. We trained an association rule engine for clinical orders (e.g., labs, imaging, medications) using structured inpatient data from a tertiary academic hospital. Comparing top order associations per admission diagnosis from training data in 2009 vs. 2012, we find practice variability from unstable diagnoses with rank biased overlap (RBO)<0.35 (e.g., pneumonia) to stable admissions for planned procedures (e.g., chemotherapy, surgery) with comparatively high RBO>0.6. Predicting admission orders for future (2013) patients with associations trained on recent (2012) vs. older (2009) data improved accuracy evaluated by area under the receiver operating characteristic curve (ROC-AUC) 0.89 to 0.92, precision at ten (positive predictive value of the top ten predictions against actual orders) 30% to 37%, and weighted recall (sensitivity) at ten 2.4% to 13%, (P<10−10). Training with more longitudinal data (2009-2012) was no better than only using recent (2012) data. Secular trends in practice patterns likely explain why smaller but more recent training data is more accurate at predicting future practices. PMID:26776186
Lilienfeld, Scott O; Ritschel, Lorie A; Lynn, Steven Jay; Cautin, Robin L; Latzman, Robert D
Psychotherapists are taught that when a client expresses resistance repeatedly, they must understand and address its underlying sources. Yet proponents of evidence-based practice (EBP) have routinely ignored the root causes of many clinical psychologists' reservations concerning the use of scientific evidence to inform clinical practice. As a consequence, much of the resistance to EBP persists, potentially widening the already large scientist-practitioner gap. Following a review of survey data on psychologists' attitudes toward EBP, we examine six sources underpinning resistance toward EBP in clinical psychology and allied domains: (a) naïve realism, which can lead clinicians to conclude erroneously that client change is due to an intervention itself rather than to a host of competing explanations; (b) deep-seated misconceptions regarding human nature (e.g., mistaken beliefs regarding the causal primacy of early experiences) that can hinder the adoption of evidence-based treatments; (c) statistical misunderstandings regarding the application of group probabilities to individuals; (d) erroneous apportioning of the burden of proof on skeptics rather than proponents of untested therapies; (e) widespread mischaracterizations of what EBP entails; and (f) pragmatic, educational, and attitudinal obstacles, such as the discomfort of many practitioners with evaluating the increasingly technical psychotherapy outcome literature. We advance educational proposals for articulating the importance of EBP to the forthcoming generation of clinical practitioners and researchers, and constructive remedies for addressing clinical psychologists' objections to EBP.
van der Veeken, Frida C. A.
Background Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Methods Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results and Conclusions Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources. PMID:27517721
Casino, F G; Lomonte, C; Russo, R; Di Iorio, B; Chiarulli, G; Manno, C; Lopez, T
Recently, a modified algorithm of the Two-BUN method (MA2p), avoiding dialyzer clearance measurement, was presented for routine assessment of Kt/V and NPCR. To validate MA2p in patients on a free diet (FDP), we studied 120 stable dialysis FDP by measuring Kt/V and NPCR with both MA2p and a modified version of the standard Three-BUN method (MA3p), for the 3 weekly sessions. The NPCR values (g/kg/day), calculated by MA3p for the 3 interdialyses were: 1.286 +/- 0.274, 1.256 +/- 0.276, and 1.116 +/- 0.230, respectively. The correlation coefficient (r) for averaged Kt/V values obtained by the two methods was 0.999 and the percent error (Error%) for MA2p vs. MA3p results ranged from -1.5 to +0.78%. The respective results for NPCR were: r = 0.967, Error% range from -11.7 to +13.9%. In conclusion, MA2p can be safely used in patients on a free diet. The lowest NPCR values were observed during the long interdialysis.
Among medical researchers and clinicians the dominant view is that it is unethical to deceive patients by prescribing a placebo. This opinion is formalized in a recent policy issued by the American Medical Association (AMA [Chicago, IL]). Although placebos can be shown to be always safe, often effective, and sometimes necessary, doctors are now effectively prohibited from using them in clinical practice. I argue that the deceptive administration of placebos is not subject to the same moral objections that face other forms of deception in clinical practice and medical research. Although deception is normally objectionable on the grounds that it limits autonomy and breaches trust, these grounds do not apply to placebos when they are prescribed within appropriate ethical limits. Patients have reason to prefer that doctors can prescribe placebos in ethically responsible ways. Hence, the AMA has an obligation to endorse and to promote the responsible use of deceptive placebos in clinical practice.
Galvez-Olortegui, José Kelvin; Álvarez-Vargas, Mayita Lizbeth; Galvez-Olortegui, Tomas Vladimir; Godoy-Palomino, Armando; Camacho-Saavedra, Luis
The aim of this study is the methodological evaluation of Clinical Practice Guidelines (CPG) in atrial fibrillation. This is the second in a series of articles of review, analysis, assessment in methodology and content of clinical practice guidelines in Cardiology. Among all clinical practice guidelines, we selected the American, Canadian and NICE (National Institute for Health and Care Excellence) guidelines. We used the AGREE (Appraisal of Guidelines for Research and Evaluation) II instrument for the assessment. In general, the guidelines obtained the lowest score in the applicability domain (mean 36.1%); while the highest score was for clarity of presentation (mean 93.5%). The lowest percentage was found in the editorial independence domain (Canadian guideline) and the highest of all scores in the applicability domain (NICE guideline). Regarding global quality, the NICE guideline obtained the AGREE II instrument best scores, followed by the American guideline, both recommended for use without modifications.
Pasquet, A.; Garcia, M. J.; Thomas, J. D.
Over the past decade, Doppler echocardiography has become a well-established tool for the diagnosis of left ventricular diastolic dysfunction. Unfortunately, in many clinical situations traditional Doppler indices of transmittal and pulmonary venous flow are inconclusive, primarily due to their dependence on left atrial pressure. Recently, new Doppler indices that are much less dependent on preload have been developed, based on intraventricular flow propagation and intrinsic myocardial velocity. These methodologies provide direct assessment of ventricular relaxation and the small intraventricular pressure gradients essential to efficient filling of the ventricle. We review in this article the theoretical and experiment background of these new echo techniques as well as how they can be implemented in routine clinical practice.
Botero, Juliana Perez; Thanarajasingam, Gita; Warsame, Rahma
Patient centeredness as the focus of healthcare delivery requires the incorporation of patient-reported outcomes into clinical trials. Clearly defining measurable outcomes as well as selecting the most appropriate validated collection tool to use is imperative for success. Creating and validating one's own instrument is also possible, albeit more cumbersome. Meticulous data collection to avoid missing data is key, as is limiting the number of data collection points to prevent survey fatigue and using electronic systems to facilitate data gathering and analysis. Working in a multidisciplinary team that includes statisticians with expertise in patient reported outcomes is essential to navigate the complexities of statistical analysis of these variables. Use of available and emerging technologies for data collection and analysis as well as data sharing will greatly facilitate the process of incorporating patient-reported outcomes into trials and routine clinical practice.
Santra, Amburanjan; Kumar, Rakesh
Brain single photon emission computed tomography (SPECT) is a well-established and reliable method to assess brain function through measurement of regional cerebral blood flow (rCBF). It can be used to define a patient's pathophysiological status when neurological or psychiatric symptoms cannot be explained by anatomical neuroimaging findings. Though there is ample evidence validating brain SPECT as a technique to track human behavior and correlating psychiatric disorders with dysfunction of specific brain regions, only few psychiatrists have adopted brain SPECT in routine clinical practice. It can be utilized to evaluate the involvement of brain regions in a particular patient, to individualize treatment on basis of SPECT findings, to monitor the treatment response and modify treatment, if necessary. In this article, we have reviewed the available studies in this regard from existing literature and tried to present the evidence for establishing the clinical role of brain SPECT in major psychiatric illnesses. PMID:25400359
Dickson, Geri L; Flynn, Linda
In this article, we describe the depth of knowledge and skill nurses used in making decisions regarding the safe processes and practices of medication administration. Using grounded theory, we identified the essence of medication safety by nurses as the theme of clinical reasoning. Nurses used two medication safety processes within the clinical reasoning theme-maintaining medication safety and managing the environment-together with six categories of patient-focused medication safety practices in the first process and four categories of environmental-focused safety practices within the second process. These processes and practices present an emerging model of safe medication administration developed from the narratives of 50 medical-surgical nurses. This model provides researchers with the basis for the development of systemic policies for safer medication administration for patients. Health care professional educators might also find the results useful in developing curricula focused on patient safety as the foundation of quality care.
Hernández-Bello, Jimmy; D'Souza, Derek; Rossenberg, Ivan
A method to determine the electron beam energy and an electron audit based on the current IPEM electron Code of Practice has been devised. During the commissioning on the new Varian 2100CD linear accelerator in The Middlesex Hospital, two methods were devised for the determination of electron energy. The first method involves the use of a two-depth method, whereby the ratio of ionisation (presented as a percentage) measured by an ion chamber at two depths in solid water is used to compare against the baseline ionisation depth value for that energy. The second method involves the irradiation of an X-ray film in solid water to obtain a depth dose curve and, hence determine the half value depth and practical range of the electrons. The results showed that the two-depth method has a better accuracy, repeatability, reliability and consistency than the X-ray method. The results for the electron audit showed that electron absolute outputs are obtained from ionisation measurements in solid water, where the energy-range parameters such as practical range and the depth at which ionisation is 50% of that at the maximum for the depth-ionisation curve are determined.
Capiau, Sara; Stove, Veronique V; Lambert, Willy E; Stove, Christophe P
The potential of dried blood spot (DBS) sampling as an alternative for classical venous sampling is increasingly recognized, with multiple applications in, e.g., therapeutic drug monitoring and toxicology. Although DBS sampling has many advantages, it is associated with several issues, the hematocrit (Hct) issue being the most widely discussed challenge, given its possible strong impact on DBS-based quantitation. Hitherto, no approaches allow Hct prediction from nonvolumetrically applied DBS. Following a simple and rapid extraction protocol, K(+) levels from 3 mm DBS punches were measured via indirect potentiometry, using the Roche Cobas 8000 routine chemistry analyzer. The extracts' K(+) concentrations were used to calculate the approximate Hct of the blood used to generate DBS. A linear calibration line was established, with a Hct range of 0.19 to 0.63 (lower limit of quantification, LLOQ, to upper limit of quantification, ULOQ). The procedure was fully validated; the bias and imprecision of quality controls (QCs) at three Hct levels and at the LLOQ and ULOQ was less than 5 and 12%, respectively. In addition, the influence of storage (pre- and postextraction), volume spotted, and punch homogeneity was evaluated. Application on DBS from patient samples (n = 111), followed by Bland and Altman, Passing and Bablok, and Deming regression analysis, demonstrated a good correlation between the "predicted Hct" and the "actual Hct". After correcting for the observed bias, limits of agreement of ±0.049 were established. Incurred sample reanalysis demonstrated assay reproducibility. In conclusion, potassium levels in extracts from 3 mm DBS punches can be used to get a good prediction of the Hct, one of the most important "unknowns" in DBS analysis.
Seme, Katja; Mocilnik, Tina; Poljak, Mario
The usefulness of combined anti-HCV and 24 mini-pool HCV RNA screening strategy was re-evaluated after a six-year continuous routine use in a clinical virology laboratory, at which more than half of newly diagnosed hepatitis C patients are intravenous drug users. Pools of 24 samples were prepared from 20,448 anti-HCV negative serum samples and tested using an automated commercial PCR assay with a lower limit of detection of 50 IU/ml. After detection of anti-HCV negative/HCV RNA positive patients, responsible physicians provided follow-up samples. Thirty-eight (0.19%) anti-HCV negative/HCV RNA positive samples from 30 patients (28 intravenous drug users) were detected. Follow-up samples were available for 27/30 patients. Twenty, six and one patient seroconverted in the second, third and fourth available samples, respectively. The interval between the first HCV RNA positive and the first available anti-HCV positive sample was 17-517 days. The costs of detecting a single anti-HCV negative/HCV RNA positive patient were 1227 Euros. Combined anti-HCV and 24 mini-pool HCV RNA screening is a useful and cost effective strategy, not only in blood-transfusion settings but also in a routine clinical virology laboratory, at which a significant proportion of the tested population belongs to a high-risk population.
Cuper, Natasha J.; Verdaasdonk, Rudolf M.; de Roode, Rowland; Septer, Erica
Venipunctures to draw blood for diagnostics can be cumbersome. Multiple puncture attempts are distressing, painful and traumatic, especially for small children. Drawing blood from babies, in particular, is a problem, due to the cutaneous baby fat, tiny veins and, worst case, a pigmented skin. We developed a practical vein viewing system based on IR translumination that, contrary to commercial systems available, has the advantage of: a) low cost, b) easily implemented in routine practice, c) normal and IR image simultaneously available, d) small add-on, e) child friendly IR illuminator and f) efficient IR light coupling. Before introducing the vessel viewer for clinical application in the children's department, parameters were measured in 194 patients (age 0-17 yrs): time to draw blood, number of attempts, skin characteristics, discomfort of patient, and experience of nurse. In this control group, time to draw blood increases significantly with decreasing age of the children. The instant feedback from the nurses has been valuable for the improvements of especially the illumination sources. A clinical trial has been performed in 125 patients (age 0-6 yrs) to prove effectivity of the system in the blood withdrawal procedure. There was a significant decrease from 13% to 2% in failure rate. Also time needed to search for a vein was significantly decreased. A practical and accessible vein viewing system has been developed and is being introduced for clinical application. Although the concept of patient friendliness is already accepted, measurements need to show the effectiveness for particular groups of patients.
Sanabria, Andrea Juliana; Rigau, David; Rotaeche, Rafael; Selva, Anna; Marzo-Castillejo, Mercè; Alonso-Coello, Pablo
Clinical practice guidelines (CPG) provide recommendations on the benefits and harms of different healthcare interventions. Proper CPG development and implementation can potentially reduce variability in clinical practice while improving its quality and safety. The GRADE system is used to assess the quality of evidence and to grade the strength of recommendations in the context of the development of CPGs, systematic reviews or health technology assessments. The aim of this article is to describe the main characteristics of the GRADE system through relevant examples in the context of primary care.
Cragin, Casey A.; Straus, Martha B.; Blacker, Dawn; Tully, Laura M.; Niendam, Tara A.
Despite high rates of trauma-related disorders among individuals with early psychosis, no clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders exist to date. Indeed, the routine exclusion of individuals with past and current psychosis from participation in trauma research and practice has limited the accumulation of research that could support such clinical practice guidelines. While preliminary research evidence suggests that traditional, evidence-based treatments for trauma-related disorders can be safely and effectively employed to reduce symptoms of posttraumatic stress and chronic psychosis, it remains unclear whether such treatments are appropriate for individuals in the early stages of psychotic illness. Clinical experts (N = 118) representing 121 early psychosis programs across 28 states were surveyed using the expert consensus method. Forty-nine clinical experts responded and reached consensus on 46 of 49 expert consensus items related to the treatment of comorbid early psychosis and trauma-related disorders. Conjoint or family therapy and individual therapy were rated as treatment approaches of choice. Anxiety or stress management and psychoeducation were rated as treatment interventions of choice for addressing both trauma symptoms and psychotic symptoms. In addition, case management was rated as a treatment intervention of choice for addressing psychotic symptoms. No consensus was reached on expert consensus items regarding the appropriateness of a parallel treatment approach exposure interventions for addressing psychotic symptoms, or sensorimotor or movement interventions for addressing trauma symptoms. In areas where expert consensus exists and is supported by current research, preliminary clinical practice guidelines for the treatment of comorbid early psychosis and trauma-related disorders are offered. In areas where expert consensus does not exist, recommendations for future research are
Daubländer, Monika; Kämmerer, Peer W; Willershausen, Brita; Leckel, Michael; Lauer, Hans-Christoph; Buff, Siegmar; Rösl, Benita
The addition of epinephrine in dental local anaesthesia results in a longer and deeper anaesthesia under almost ischemic conditions. For short-time dental treatments, epinephrine-reduced anaesthetics may offer shorter and more individual anaesthesia with reduced potential side effects. The aim of this study was a clinical evaluation of anaesthetic potency and adverse effects of an epinephrine-reduced articaine formulation in dental patients undergoing short-time routine treatment. In a prospective clinical, not interventional, study between January 2008 and February 2009, 908 patients undergoing short-time dental treatment in five medical centers were anaesthetized with 4% articaine 1:400,000 epinephrine (Ubistesin, 3M/ESPE, Seefeld, Germany). Efficacy and safety in clinical use were evaluated. A follow-up after 1 day was conducted by telephone survey. A mean amount of 1.3-ml anaesthetic solution was needed to achieve a complete or sufficient anaesthesia in 97% (n = 876) of cases. A second injection had to be done in 3.7% (n = 34) before and in 11.9% (n = 108) during treatment. Here, the second injection had to be applied after a mean of 48.6 min. The mean duration of soft tissue anaesthesia after infiltration was 146.6 min, after nerve block 187.7 min. The painful treatment took a mean of 50.2 min and the total treatment time summed up to 68.8 min. In 1.7% cases (n = 15), unwanted side effects were observed. The results indicate that a lower concentration of epinephrine in combination with the 4% articaine solution leads to a high success rate of efficacy. The clinical use of a 4% articaine 1:400,000 epinephrine solution can be stated as safe and effective in short dental routine treatments. Reconsiderations concerning limitations of indication or additional contraindications are not necessary.
Asphyxia in the Newborn: Evaluating the Accuracy of ICD Coding, Clinical Diagnosis and Reimbursement: Observational Study at a Swiss Tertiary Care Center on Routinely Collected Health Data from 2012-2015
Rimle, Carole; Zwahlen, Marcel; Triep, Karen; Raio, Luigi; Nelle, Mathias
Background The ICD-10 categories of the diagnosis “perinatal asphyxia” are defined by clinical signs and a 1-minute Apgar score value. However, the modern conception is more complex and considers metabolic values related to the clinical state. A lack of consistency between the former clinical and the latter encoded diagnosis poses questions over the validity of the data. Our aim was to establish a refined classification which is able to distinctly separate cases according to clinical criteria and financial resource consumption. The hypothesis of the study is that outdated ICD-10 definitions result in differences between the encoded diagnosis asphyxia and the medical diagnosis referring to the clinical context. Methods Routinely collected health data (encoding and financial data) of the University Hospital of Bern were used. The study population was chosen by selected ICD codes, the encoded and the clinical diagnosis were analyzed and each case was reevaluated. The new method categorizes the diagnoses of perinatal asphyxia into the following groups: mild, moderate and severe asphyxia, metabolic acidosis and normal clinical findings. The differences of total costs per case were determined by using one-way analysis of variance. Results The study population included 622 cases (P20 “intrauterine hypoxia” 399, P21 “birth asphyxia” 233). By applying the new method, the diagnosis asphyxia could be ruled out with a high probability in 47% of cases and the variance of case related costs (one-way ANOVA: F (5, 616) = 55.84, p < 0.001, multiple R-squared = 0.312, p < 0.001) could be best explained. The classification of the severity of asphyxia could clearly be linked to the complexity of cases. Conclusion The refined coding method provides clearly defined diagnoses groups and has the strongest effect on the distribution of costs. It improves the diagnosis accuracy of perinatal asphyxia concerning clinical practice, research and reimbursement. PMID:28118380
Powell, Thomas W
The emergence of clinical phonetics and linguistics as an area of scientific inquiry gives rise to the need for guidelines that define ethical and responsible conduct. The diverse membership of the International Clinical Phonetics and Linguistics Association (ICPLA) and the readership of this journal are uniquely suited to consider ethical issues from diverse perspectives. Accordingly, this paper introduces a multi-tiered six-factor model for ethical practices to stimulate discussion of ethical issues.
Spurr, Shelley; Bally, Jill; Ogenchuk, Marcella; Peternelj-Taylor, Cindy
This article presents a proposed holistic Framework for Exploring Adolescent Wellness specific to the discipline of nursing. Conceptualized as a practical adolescent wellness assessment tool, the framework attends to the physical, spiritual, psychological and social dimensions of adolescent health. Through the discussion of a reconstructed case study the framework's application to nursing practice is illustrated. Nurses are distinctly positioned to promote adolescent wellness. This approach facilitates the exploration of the multiple influences on the health of adolescents, across a variety of clinical practice specialties and settings, by nurses of varying experiences.
Mentz, Robert J; Hernandez, Adrian F; Berdan, Lisa G; Rorick, Tyrus; O'Brien, Emily C; Ibarra, Jenny C; Curtis, Lesley H; Peterson, Eric D
Randomized, clinical trials are commonly regarded as the highest level of evidence to support clinical decisions. Good Clinical Practice guidelines have been constructed to provide an ethical and scientific quality standard for trials that involve human subjects in a manner aligned with the Declaration of Helsinki. Originally designed to provide a unified standard of trial data to support submission to regulatory authorities, the principles may also be applied to other studies of human subjects. Although the application of Good Clinical Practice principles generally led to improvements in the quality and consistency of trial operations, these principles have also contributed to increasing trial complexity and costs. Alternatively, the growing availability of electronic health record data has facilitated the possibility for streamlined pragmatic clinical trials. The central tenets of Good Clinical Practice and pragmatic clinical trials represent potential tensions in trial design (stringent quality and highly efficient operations). In the present article, we highlight potential areas of discordance between Good Clinical Practice guidelines and the principles of pragmatic clinical trials and suggest strategies to streamline study conduct in an ethical manner to optimally perform clinical trials in the electronic age.
.5%). We have now discontinued routine attendance for a test of cure and encourage our patients to telephone for their results with recall only of patients whose antimicrobial susceptibility indicate inappropriate first line therapy or who are still symptomatic.
Sicras-Mainar, Antoni; Rejas, Javier; Navarro, Ruth; Blanca, Milagrosa; Morcillo, Ángela; Larios, Raquel; Velasco, Soledad; Villarroya, Carme
Introduction The objective of this study was to analyze health care and non-health care resource utilization under routine medical practice in a primary care setting claims database and to estimate the incremental average cost per patient per year of fibromyalgia syndrome (FMS) compared with a reference population. Methods A 12-month cross-sectional and retrospective study was completed using computerized medical records from a health provider database. Analyses were conducted from the perspective of the provider and from the viewpoint of society. Health care and non-health care resource utilization included drugs, complementary tests, all types of medical visits, referrals, hospitalizations, sick leave, and early retirement because of disability due to FMS. Patients with a diagnosis of FMS in accordance with ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) criteria were included in the analysis if they had at least one claim for FMS during the 12 months prior to the end of May 2007. A non-FMS comparison group was also created with the remaining subjects. Results Of the 63,526 patients recruited for the study, 1,081 (1.7%) (96.7% of whom were women, 54.2 [10.1] years old) met the criteria for FMS. After an adjustment for age and gender, FMS subjects used significantly more health care resources than the reference population and had more sick leave and the percentage of subjects with premature retirement was also significantly higher (P < 0.001 in all cases). As a result, FMS subjects showed an incremental adjusted per-patient per-year total cost of €5,010 (95% confidence interval [CI] 3,494 to 6,076, +153%, P < 0.001) on average compared with non-FMS subjects. Significantly higher differences were observed in both health care and non-health care adjusted costs: €614 (404 to 823, +66%) and €4,394 (3,373 to 5,420, +189%), respectively (P < 0.001 in both cases). Annual drug expenditure per patient on
The first two articles in the series were about the definition of quality in healthcare, the quality approach, the importance of quality assurance, the advantages of quality management systems and the basic concepts and necessity of evidence based medicine. In the third article the importance and basic steps of clinical audit are summarised. Clinical audit is an integral part of quality assurance and quality improvement in healthcare, that is the responsibility of any practitioner involved in medical practice. Clinical audit principally measures the clinical practice against clinical guidelines, protocols and other professional standards, and sometimes induces changes to ensure that all patients receive care according to principles of the best practice. The clinical audit can be defined also as a quality improvement process that seeks to identify areas for service improvement, develop and carry out plans and actions to improve medical activity and then by re-audit to ensure that these changes have an effect. Therefore, its aims are both to stimulate quality improvement interventions and to assess their impact in order to develop clinical effectiveness. At the end of the article key points of quality assurance and improvement in medical practice are summarised.
Keeling, Aoife N.; Reekers, Jim A.; Lee, Michael J.
The purpose of this study was to determine the current clinical environment in which interventional radiology (IR) is practiced throughout Europe. A survey, comprising 12 questions on IR clinical practice, was sent to 1800 CIRSE members. Members were asked to return one survey per department. Two hundred seventy-four departments returned completed questionnaires, 22% from the United Kingdom (n = 60), 11% from Germany (n = 30), 8% from Austria (n = 23), and the remainder spread over Europe. Experts, with more than 10 years of IR experience, comprised 74% of the survey group. Almost one-third of the radiologists dedicated more than 80% of their clinical sessions to IR alone (27%; n = 75), with two-thirds practicing in a university teaching hospital setting (66%; n = 179). Few institutions have dedicated IR inpatient hospital beds (17%; n = 46), however, to compensate, day case beds are available (31%), IR admitting rights are in place (64% overall, 86% for in-patients, and 89% for day cases), and elective IR admissions can be made through other clinicians (87%). IR outpatient clinics are run at 26% of departments, with an average of two sessions per week. Dedicated nurses staff the majority of IR suites (82%), but clinical junior doctors are lacking (46%). Hospital management's refusing access to beds was the most commonly cited reason for not developing a clinical IR service (41%). In conclusion, there is marked variation across European centers in the current practice of IR. Half do not have dedicated junior doctors and only a small minority have inpatient hospital beds. If IR is to be maintained as a dedicated clinical specialty, these issues need to be addressed urgently.
Jacobi, Judith; Ray, Shaunta'; Danelich, Ilya; Dodds Ashley, Elizabeth; Eckel, Stephen; Guharoy, Roy; Militello, Michael; O'Donnell, Paul; Sam, Teena; Crist, Stephanie M; Smidt, Danielle
This paper describes the goals of the American Society of Health-System Pharmacists' Pharmacy Practice Model Initiative (PPMI) and its recommendations for health-system pharmacy practice transformation to meet future patient care needs and elevate the role of pharmacists as patient care providers. PPMI envisions a future in which pharmacists have greater responsibility for medication-related outcomes and technicians assume greater responsibility for product-related activities. Although the PPMI recommendations have elevated the level of practice in many settings, they also potentially affect existing clinical pharmacists, in general, and clinical pharmacy specialists, in particular. Moreover, although more consistent patient care can be achieved with an expanded team of pharmacist providers, the role of clinical pharmacy specialists must not be diminished, especially in the care of complex patients and populations. Specialist practitioners with advanced training and credentials must be available to model and train pharmacists in generalist positions, residents, and students. Indeed, specialist practitioners are often the innovators and practice leaders. Negotiation between hospitals and pharmacy schools is needed to ensure a continuing role for academic clinical pharmacists and their contributions as educators and researchers. Lessons can be applied from disciplines such as nursing and medicine, which have developed new models of care involving effective collaboration between generalists and specialists. Several different pharmacy practice models have been described to meet the PPMI goals, based on available personnel and local goals. Studies measuring the impact of these new practice models are needed.
Peters, D; Davies, P; Pietroni, P
BACKGROUND. A musculoskeletal clinic, staffed by a general practitioner trained in osteopathy, medical acupuncture and intralesional injections, was set up in an inner London general practice in 1987. AIM. A retrospective study was undertaken of one year's referrals to the clinic in 1989-90 to determine how general practitioners were using the clinic in terms of problems referred; consultation patterns of patients attending the clinic and 12 months after initially being seen; and how access to the clinic influenced referrals to relevant hospital departments. METHOD. Day sheets were studied which recorded information on demographic characteristics of patients referred to the clinic and their problems, diagnoses made, duration of symptoms, number and range of treatments given, and recurrence of problems. Use of secondary referral sources was also examined. RESULTS. During the study year 154 of 3264 practice patients were referred to the musculoskeletal clinic, and attended a mean of 3.5 times each. Of all the attenders 64% were women and 52% were 30-54 years old. Eighty one patients (53%) presented with neck, back or sciatic pain. A specific traumatic, inflammatory or other pathological process could be ascribed to only 19% of patients. Regarding treatment, 88% of patients received osteopathic manual treatment or acupuncture, or a combination of these treatments and 4% received intralesional injections. Nine patients from the clinic (6%) were referred to an orthopaedic specialist during the year, two with acute back pain. Referrals to orthopaedic specialists by the practice as a whole were not significantly lower than the national average, although the practice made fewer referrals to physiotherapy and rheumatology departments than national figures would have predicted. Seventeen patients (11%) returned to the clinic with a recurrence of their main complaint within a year of their initial appointment; second courses of treatment were usually brief. CONCLUSION. The
Browne-Ferrigno, Tricia; Muth, Rodney
This paper discusses two important elements in the preparation of K-12 school leaders: (1) role transformation through clinical practice during administrator preparation programs; and (2) reconceptualization of traditional internship experiences to enhance role transformation. Data analyzed for this study originally were collected in doctoral…
Depeursinge, Adrien; Fischer, Benedikt; Müller, Henning; Deserno, Thomas M
Content-based image retrieval (CBIR) has been proposed as key technology for computer-aided diagnostics (CAD). This paper reviews the state of the art and future challenges in CBIR for CAD applied to clinical practice. We define applicability to clinical practice by having recently demonstrated the CBIR system on one of the CAD demonstration workshops held at international conferences, such as SPIE Medical Imaging, CARS, SIIM, RSNA, and IEEE ISBI. From 2009 to 2011, the programs of CADdemo@CARS and the CAD Demonstration Workshop at SPIE Medical Imaging were sought for the key word “retrieval” in the title. The systems identified were analyzed and compared according to the hierarchy of gaps for CBIR systems. In total, 70 software demonstrations were analyzed. 5 systems were identified meeting the criterions. The fields of application are (i) bone age assessment, (ii) bone fractures, (iii) interstitial lung diseases, and (iv) mammography. Bridging the particular gaps of semantics, feature extraction, feature structure, and evaluation have been addressed most frequently. In specific application domains, CBIR technology is available for clinical practice. While system development has mainly focused on bridging content and feature gaps, performance and usability have become increasingly important. The evaluation must be based on a larger set of reference data, and workflow integration must be achieved before CBIR-CAD is really established in clinical practice. PMID:21892374
Gottschalk, Shelby; Hake, Megan M.; Cook-Benjamin, Lorie
The purpose of the study was to determine if offering a virtual clinical-based practice would affect teacher candidates' level of confidence in teaching diverse students. During 2012-2014, data were collected using a pre- and post-Likert scale questionnaire. A paired two sample t-test was utilized to determine if there was a significant difference…
DeJarnette, Nancy K.; Sudeck, Maria
The purpose of this qualitative research study was to monitor pre-service teacher candidates' progression and implementation of the learning community philosophy along with classroom management strategies. The study took place during their final semester of clinical practice. Data were collected from self-reports, surveys, university supervisor…
Mars, Maurice; Scott, Richard E
Several spontaneous telemedicine services using WhatsApp Messenger have started in South Africa raising issues of confidentiality, data security and storage, record keeping and reporting. This study reviewed the literature on WhatsApp in clinical practice, to determine how it is used, and users' satisfaction.
Ikah, December S. K.; Finn, Gabrielle M.; Swamy, Meenakshi; White, Pamela M.; McLachlan, John C.
Although medical curricula now adopt an integrated teaching approach, this is not adequately reflected in assessment of anatomy knowledge and skills. In this study, we aimed to explore the impact of the addition of clinical vignette to item stems on students' performance in anatomy practical examinations. In this study, 129 undergraduate medical…
Depeursinge, Adrien; Fischer, Benedikt; Müller, Henning; Deserno, Thomas M
Content-based image retrieval (CBIR) has been proposed as key technology for computer-aided diagnostics (CAD). This paper reviews the state of the art and future challenges in CBIR for CAD applied to clinical practice.We define applicability to clinical practice by having recently demonstrated the CBIR system on one of the CAD demonstration workshops held at international conferences, such as SPIE Medical Imaging, CARS, SIIM, RSNA, and IEEE ISBI. From 2009 to 2011, the programs of CADdemo@CARS and the CAD Demonstration Workshop at SPIE Medical Imaging were sought for the key word "retrieval" in the title. The systems identified were analyzed and compared according to the hierarchy of gaps for CBIR systems.In total, 70 software demonstrations were analyzed. 5 systems were identified meeting the criterions. The fields of application are (i) bone age assessment, (ii) bone fractures, (iii) interstitial lung diseases, and (iv) mammography. Bridging the particular gaps of semantics, feature extraction, feature structure, and evaluation have been addressed most frequently.In specific application domains, CBIR technology is available for clinical practice. While system development has mainly focused on bridging content and feature gaps, performance and usability have become increasingly important. The evaluation must be based on a larger set of reference data, and workflow integration must be achieved before CBIR-CAD is really established in clinical practice.
Lind, Marianne; Kristoffersen, Kristian Emil; Moen, Inger; Simonsen, Hanne Gram
Functionally relevant assessment of the language production of speakers with aphasia should include assessment of connected speech production. Despite the ecological validity of everyday conversations, more controlled and monological types of texts may be easier to obtain and analyse in clinical practice. This article discusses some simple…
Seidel, David Ulrich; Flemming, Tobias Angelo; Park, Jonas Jae-Hyun; Remmert, Stephan
Objective hearing threshold estimation by auditory steady-state responses (ASSR) can be accelerated by the use of narrow-band chirps and adaptive stimulus patterns. This modification has been examined in only a few clinical studies. In this study, clinical data is validated and extended, and the applicability of the method in audiological diagnostics routine is examined. In 60 patients (normal hearing and hearing impaired), ASSR and pure tone audiometry (PTA) thresholds were compared. ASSR were evoked by binaural multi-frequent narrow-band chirps with adaptive stimulus patterns. The precision and required testing time for hearing threshold estimation were determined. The average differences between ASSR and PTA thresholds were 18, 12, 17 and 19 dB for normal hearing (PTA ≤ 20 dB) and 5, 9, 9 and 11 dB for hearing impaired (PTA > 20 dB) at the frequencies of 500, 1,000, 2,000 and 4,000 Hz, respectively, and the differences were significant in all frequencies with the exception of 1 kHz. Correlation coefficients between ASSR and PTA thresholds were 0.36, 0.47, 0.54 and 0.51 for normal hearing and 0.73, 0.74, 0.72 and 0.71 for hearing impaired at 500, 1,000, 2,000 and 4,000 Hz, respectively. Mean ASSR testing time was 33 ± 8 min. In conclusion, auditory steady-state responses with narrow-band-chirps and adaptive stimulus patterns is an efficient method for objective frequency-specific hearing threshold estimation. Precision of threshold estimation is most limited for slighter hearing loss at 500 Hz. The required testing time is acceptable for the application in everyday clinical routine.
Oh, Jinju; Lee, Hyun Joo; Lee, Tae Sung; Kim, Ju Hyun; Koh, Suk Bong
Objective The objective of this study was to evaluate the clinical benefits of routine squamous cell carcinoma antigen (SCC-Ag) monitoring of patients with locally advanced cervical squamous cell carcinoma treated with radiation or chemoradiation. Methods A total of 53 patients with recurrent cervical squamous cell carcinoma treated with radiotherapy or chemoradiation were enrolled in this study. A retrospective review of medical records was conducted. The role of routine monitoring of serum SCC-Ag was evaluated in terms of cost effectiveness and effect on survival after diagnosis of recurrence. Results Serum SCC-Ag abnormality (≥2.5 ng/mL) was observed in 62.3% of patients when recurrent disease was diagnosed. The first indicator of relapse was abnormal serum SCC-Ag level in 21 patients (39.6%), 10 of whom had asymptomatic recurrent disease amenable to salvage therapy. Adding SCC-Ag measurement to the basic follow up protocol improved the sensitivity for detecting recurrence (The sensitivity of the basic protocol vs. addition of SCC-Ag: 49.1% vs. 88.7%, P<0.001). Twenty-three patients who were candidates for salvage therapy with curative intent showed better survival compared with those who were not candidates for therapy (5-year survival: 36.6% vs. 0%, P=0.012). Conclusion Surveillance with routine serum SCC-Ag monitoring can better detect asymptomatic recurrent disease that is potentially amenable to salvage therapy with curative intent. Early diagnosis of recurrent disease that can be treated with salvage therapy may lead to better survival. PMID:27462593
Fritz, Jimena; Walker, Dilys M.; Cohen, Susanna; Angeles, Gustavo; Lamadrid-Figueroa, Hector
impact on adopting EBP at birth, contributing to an increased quality of care. Long lasting impacts on these practices are possible if there were to be a widespread adoption of the training techniques including simulation, team-training and facilitated discussions regarding routine care. PMID:28319122
Spasovski, Goce; Vanholder, Raymond; Allolio, Bruno; Annane, Djillali; Ball, Steve; Bichet, Daniel; Decaux, Guy; Fenske, Wiebke; Hoorn, Ewout J; Hoorn, Ewout; Ichai, Carole; Joannidis, Michael; Soupart, Alain; Zietse, Robert; Haller, Maria; van der Veer, Sabine; Van Biesen, Wim; Nagler, Evi
Hyponatraemia, defined as a serum sodium concentration <135 mmol/L, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. Hyponatraemia is present in 15-20% of emergency admissions to hospital and occurs in up to 20% of critically ill patients. Symptomatology may vary from subtle to severe or even life threatening. Despite this, the management of patients remains problematic. Against this background, the European Society of Intensive Care Medicine, the European Society of Endocrinology and the European Renal Association-European Dialysis and Transplant Association, represented by European Renal Best Practice have developed a Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia.
Fleischmann, Robert; Duhm, Julian; Hupperts, Hagen; Brandt, Stephan A
Demographic changes require physicians to deliver needed services with fewer resources. Neurology as an interdisciplinary domain involves complex diagnostic procedures and time-consuming data handling. Tablet PCs might streamline clinical workflow through mobile access to patient data. This study examined the impact of tablets running an electronic medical record on ward round performance. We hypothesised that tablet use should reduce ward round time and decrease the time needed to check medical records thereby increasing physicians' bedside availability. Nine resident neurologists participated in a controlled prospective crossover trial over 14 weeks. In the experimental condition, tablets were used in addition to the established medical record. In the control condition, physicians used established systems only. The combined primary outcome measure included changes in total ward round time and relative time shifts between associated work processes. The secondary outcome measure was physicians' time required to check a medical record vs. physicians' bedside time. There was a significant main effect on the primary outcome measure (p = 0.01). Tablet use accelerated preparing (p = 0.004) and post-processing (p < 0.001) of ward rounds. Time for conducting ward rounds was unaffected (p = 0.19). Checking medical records was faster with tablets (p = 0.001) increasing physicians' bedside time (p < 0.001). Tablet use led to significant time savings during preparing and post-processing of ward rounds. It was further associated with time savings during checking medical data and an increase in physicians' bedside time. Tablets may facilitate clinical data handling and promote workflow.
Berger, Jeffrey T; DeRenzo, Evan G; Schwartz, Jack
The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.
Gill, P. S.; Dowell, A.; Harris, C. M.
OBJECTIVES: To test whether Asian general practitioners who qualified in the Indian subcontinent prescribe items more often, more expensive items, and fewer generic drugs than their British trained Asian and non-Asian counterparts. DESIGN: Linkage study using data collected by questionnaire and from routine sources. SETTING: General practices in England. SUBJECTS: 155 single handed general practitioners: 42 Asian doctors qualified in United Kingdom (group 1), 58 white doctors qualified in United Kingdom (group 2), and 55 Asian doctors qualified in Indian subcontinent (group 3). MAIN OUTCOME MEASURES: Prescribing cost (cost per ASTRO-PU), prescribing frequency (number of items per ASTRO-PU), and generic prescribing (percentage of drugs prescribed that are generic). RESULTS: Doctors in group 1 were significantly younger than those in the other groups and had a higher proportion of patients who were from deprived wards. There was no difference between the groups in the proportion of female doctors and total list size. After adjustment for confounding factors, there were no significant differences between the three groups for prescribing cost (16.58 (95% confidence interval 6.39 to 26.77) for group 1, 17.31 (6.92 to 27.69) for group 2, 17.80 (7.22 to 28.38) for group 3, P = 0.55); prescribing frequency (6.58 (4.60 to 8.40), 6.45 (4.70 to 8.30), 7.89 (6.16 to 9.64), P = 0.34); and generic prescribing (44.44 (38.95 to 49.93), 47.41 (42.12 to 52.70), 44.04 (38.75 to 49.33), P = 0.37). CONCLUSIONS: Asian doctors qualified from the Indian subcontinent did not differ from British trained doctors in their prescribing practice. This study refutes the common belief that Asian doctors are high volume and high cost prescribers. PMID:9437279
Tárnok, Attila; Bocsi, Jozsef
The latest development of commercial routine flow cytometers (FCM) is that they are equipped with three (blue, red, violet) or more lasers and many PMT detectors. Nowadays routine clinical instruments are capable of detecting 10 or more fluorescence colors simultaneously. Thereby, presenting opportunities for getting detailed information on the single cell level for cytomics and systems biology for improve diagnostics and monitoring of patients. The University Leipzig, Germany) recently started a cluster of excellence to study the molecular background of life style and environment associated diseases, enrolling 25000 individuals (LIFE). To this end the most comprehensive FCM protocol has to be developed for this study. We aimed to optimize fluorochrome and antibody combinations to the characteristics of the instrument for successful 10-color FCM. Systematic review of issues related to sampling, preparation, instrument settings, spillover and compensation matrix, reagent performance, and general principles of panel construction was performed. 10-color FCM enables for increased accuracy in cell subpopulation identification, the ability to obtain detailed information from blood specimens, improved laboratory efficiency, and the means to consistently detect major and rare cell populations. Careful attention to details of instrument and reagent performance allows for the development of panels suitable for screening of samples from healthy and diseased donors. The characteristics of this technique are particularly well suited for the analysis of broad human population cohorts and have the potential to reach the everyday practice in a standardized way for the clinical laboratory.
Patient questionnaires are the quantitative tools available to rheumatologists to monitor their patients' health status and responses to therapy. The Health Assessment Questionnaire (HAQ) and its derivatives have been shown to be the most significant predictors of functional and work disability, costs, joint replacement surgery, and mortality; generally at higher levels of significance than joint counts, radiographs, and laboratory tests. Every encounter of a patient with a rheumatologist provides an opportunity to collect data. Yet patient questionnaires, which can be used in all rheumatic diseases, including osteoarthritis, systemic lupus erythematosus, fibromyalgia, scleroderma, and ankylosing spondylitis, are not included in routine care by most rheumatologists. Questionnaires can be adapted to include a simple subjective-objective-assessment-plan (SOAP) clinical encounter note that helps with data entry and also provides all the necessary information for clinical decision making in one sheet of paper. Data that are feasible to collect in clinical care provide the optimal approach to assessing quantitatively how patients are doing. If data are not collected and recorded, that opportunity, on that day, is lost forever. Rheumatologists would find it valuable to adapt questionnaires to the care they provide for all their patients, to document and improve the care they provide, and add quantitative data to standard clinical care.
Murray, Aja L; McKenzie, Karen; Murray, Kara R; Richelieu, Marc
Mokken scaling is increasingly being applied to assessing the extent to which clinical scales possess clinically useful properties, especially invariant item ordering (IIO). These scales are often used to track progress in symptoms over time to evaluate the success of an intervention. Such interventions are designed to affect psychopathological trait levels overall but may in some cases act disproportionately on some symptoms over others. As a result, there is no guarantee that the item orderings of a clinical scale will be preserved between the point at which individuals begin treatment and the point at which they can be considered recovered. In these situations, many of the potential benefits of IIO are undermined because an IIO identified at either time point will not be informative about changes in symptoms over time. In this study, we aimed to assess the extent to which the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) retained the same item orderings in a sample of individuals when initially presenting for counseling treatment and when discharged. From the 34 items of the CORE-OM we found a subset of 10 items exhibiting monotonicity, invariant item ordering, and highly similar item orderings when measured at both time points.
Somerfield, Mark R; Einhaus, Kaitlin; Hagerty, Karen L; Brouwers, Melissa C; Seidenfeld, Jerome; Lyman, Gary H
The American Society of Clinical Oncology (ASCO) published its first clinical practice guideline, which focused on the use of hematopoietic colony-stimulating factors, in 1994. Since then, ASCO has published 24 additional guidelines or technology assessments on a range of topics and is developing 11 additional guidelines. Guidelines are among ASCO's most valued products, according to membership surveys and data from the JCO.org Web site. However, the same data from ASCO members have highlighted a number of limitations to the guideline program. These relate to the timelines of guideline updates, difficulties locating guidelines and related products, and challenges to implementing ASCO guidelines in everyday clinical practice. This article outlines the concrete steps that the ASCO Health Services Committee (HSC) is taking to address these limitations, including the institution of a more aggressive guideline updating schedule, a transition from narrative to systematic literature reviews to support the practice recommendations, a new Board of Directors-approved policy to permit endorsement of other groups' guidelines, and a robust Clinical Tools and Resources program that offers a range of guideline dissemination and implementation aids. Additional work is underway to establish stronger and deeper collaborations with practicing oncologists to expand their role in the review, field testing, and implementation of guideline clinical tools and resources. Finally, the HSC is discussing evaluation of the guidelines program to maximize the impact of ASCO clinical practice guidelines on clinical decision making and, ultimately, the quality of cancer care.
Wang, Weiping; Xi, Haiyan; Huang, Mei; Wang, Jie; Fan, Ming; Chen, Yong; Shao, Haifeng
Background Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) is an emerging technology newly applied to identifying bacterial and yeast strains. The aim of this study was to evaluate the clinical performance of the VITEK® MS system in the identification of bacteria and yeast strains routinely isolated from clinical samples. Methods We prospectively analyzed routine MALDI-TOF mass spectrometry identification in parallel with conventional phenotypic identification of bacteria and yeasts regardless of phylum or source of isolation. Discordant results were resolved with 16S rDNA or internal transcribed spacer (ITS) gene sequencing. Colonies (a single deposit on a MALDI disposable target without any prior extraction step) were analyzed using the VITEK® MS system. Peptide spectra acquired by the system were compared with the VITEK® MS IVD database Version 2.0, and the identification scores were recorded. Results Of the 1,181 isolates (1,061 bacterial isolates and 120 yeast isolates) analyzed, 99.5% were correctly identified by MALDI-TOF mass spectrometry; 95.7% identified to the species level, 3.6% identified to the genus level, and 0.3% identified within a range of species belonging to different genera. Conversely, 0.1% of isolates were misidentified and 0.4% were unidentified, partly because the species were not included in the database. Re-testing using a second deposit provided a successful identification for 0.5% of isolates unidentified with the first deposit. Our results show that the VITEK® MS system has exceptional performance in identifying bacteria and yeast by comparing acquired peptide spectra to those contained in its database. Conclusions MALDI-TOF mass spectrometry is a rapid, accurate, and relatively inexpensive method for bacterial and yeast identification. Our results demonstrate that the VITEK® MS system is a fast and reliable technique, and has the potential to replace conventional phenotypic
Kanemitsu, Keiji; Kunishima, Hiroyuki; Inden, Ken; Hatta, Masumitsu; Harigae, Hideo; Ishizawa, Kenichi; Kaku, Mitsuo
We evaluated the new BD Phoenix automated microbiology system (Becton Dickinson Diagnostic Systems, Sparks, MD) SMIC/ID-4 panel for routine identification (ID) and antimicrobial susceptibility testing (AST) of streptococci in a university-based laboratory. Clinical isolates of Streptococcus pneumoniae (n = 92), Streptococcus pyogenes (n = 24), and Streptococcus agalactiae (n = 10) were collected, and comparisons were made with the routine manual methods used in our microbiology laboratory for ID and susceptibility testing. ID concordance with manual methods was 85.9%, 95.8%, and 90.0% for S. pneumoniae, S. pyogenes, and S. agalactiae, respectively. With respect to AST concordance for S. pneumoniae and beta-hemolytic streptococci (S. pyogenes and S. agalactiae) using Phoenix and standard broth microdilution panels, overall essential agreement was 93.0% and 97.5%, respectively, whereas overall category agreement was 92.4% and 98.9%, respectively. Major and minor error rates for S. pneumoniae and beta-hemolytic streptococci were 0.5% and 0.3%, and 7.1% and 0.8%, respectively. Very major errors were not observed in this study. Mean time for ID and AST test completion was 13.6 +/- 1.6, 10.7 +/- 2.4, and 11.2 +/- 2.3 h for S. pneumoniae, S. pyogenes, and S. agalactiae, respectively. We have demonstrated that Phoenix ID results show high agreement with manual ID and that AST performance was equivalent to standard broth microdilution in less time.
Ferguson, Alison; Armstrong, Elizabeth
Background: Research into the practices of speech-language therapists in clinical sessions is beginning to identify the way communication in clinical interactions both facilitates and potentially impedes the achievement of therapy goals. Aims: This target article aims to raise the issues that arise from critical reflections on the communication of…
van der Zee, Anneke; Roorda, Lieuwe; Bosman, Gerda; Ossewaarde, Jacobus M.
Background The objective of our study was the development of a semi-quantitative real-time PCR to detect uropathogens. Two multiplex PCR reactions were designed to detect Escherichia coli, Klebsiella spp., Enterobacter spp., Citrobacter spp., Proteus mirabilis, Enterococcus faecalis, and Pseudomonas aeruginosa. 16S based PCR was performed in parallel to detect Gram-positive and Gram-negative bacteria. Firstly to identify non-targeted agents of infection in the same urine specimen, and secondly to quantify background flora. The method was evaluated in comparison with standard bacterial culture, and a commercial PCR kit for detection of uropathogens. Findings Analysis with a known panel of 116 clinical isolates yielded a PCR specificity of 100%. Analysis of urine specimens from 211 patients revealed a high correlation of PCR Cq values with both culture positivity and quantity. Concordance between PCR and culture was 98% when both methods yielded results. PCR was found to be more sensitive than culture. With a cut-off Cq value of 33, the negative predictive value of PCR was 94%. The 16S PCR confirmed most results. One specimen was positive by 16S PCR suggesting another cause of infection not detected by the specific PCR assays. Conclusion We conclude that it is feasible to detect and identify uropathogens by multiplex real-time PCR assay. PMID:26954694
Dacks, Penny A; Armstrong, Joshua J; Brannan, Stephen K; Carman, Aaron J; Green, Allan M; Kirkman, M Sue; Krakoff, Lawrence R; Kuller, Lewis H; Launer, Lenore J; Lovestone, Simon; Merikle, Elizabeth; Neumann, Peter J; Rockwood, Kenneth; Shineman, Diana W; Stefanacci, Richard G; Velentgas, Priscilla; Viswanathan, Anand; Whitmer, Rachel A; Williamson, Jeff D; Fillit, Howard M
Common diseases like diabetes, hypertension, and atrial fibrillation are probable risk factors for dementia, suggesting that their treatments may influence the risk and rate of cognitive and functional decline. Moreover, specific therapies and medications may affect long-term brain health through mechanisms that are independent of their primary indication. While surgery, benzodiazepines, and anti-cholinergic drugs may accelerate decline or even raise the risk of dementia, other medications act directly on the brain to potentially slow the pathology that underlies Alzheimer's and other dementia. In other words, the functional and cognitive decline in vulnerable patients may be influenced by the choice of treatments for other medical conditions. Despite the importance of these questions, very little research is available. The Alzheimer's Drug Discovery Foundation convened an advisory panel to discuss the existing evidence and to recommend strategies to accelerate the development of comparative effectiveness research on how choices in the clinical care of common chronic diseases may protect from cognitive decline and dementia.
Jyränki, Janne; Suominen, Sinikka; Vuola, Jyrki; Bäck, Leif
Clinical examination is still the gold standard of postoperative free flap monitoring, but with intraorally situated and/or buried flaps, it can be difficult or impossible. Microdialysis is a sampling technique which offers the possibility to monitor the metabolism of a flap continuously. Ischemia can be detected by monitoring the changes in glucose, lactate, and pyruvate levels in interstitial fluid of the specific tissue. Our aim was to use microdialysis to monitor the metabolism of free flaps used for reconstructions inside the oral cavity/oropharynx and to evaluate the reliability and usefulness of this new monitoring method.Twenty-five consecutive patients who underwent oral cavity/oropharynx cancer resection and immediate reconstruction with free flap were included in the study. A microdialysis catheter was placed into the subcutaneous adipose tissue of the flap in the end of the surgical procedure. Dialysate samples were taken on an hourly basis for 72 hours postoperatively. Routine clinical monitoring was carried out by experienced nursing staff. Clinical findings were recorded and later compared with microdialysis values. Two flaps out of 25 failed in spite of reoperations. In both problem cases, microdialysis indicated ischemia 1 to 2 hours before it became clinically evident. During flap ischemia, the lactate/pyruvate ratio increased, glucose concentrations reduced, whereas lactate level increased when compared with normal values. Our results indicate that microdialysis is safe for the patient and the flap. It can reliably detect flap ischemia at an early stage. This is especially useful in buried flaps when clinical monitoring is difficult. Microdialysis may also reduce the patient discomfort caused by repeated clinical examination of the flap.
Downie, Laura Elizabeth; Keller, Peter Richard
Objective The primary aim of this study was to examine the self-reported, routine clinical practice behaviors of Australian optometrists with respect to advice regarding smoking, diet and nutritional supplementation. The study also sought to assess the potential influence of practitioner age, gender, practice location (major city versus regional), therapeutic-endorsement status and personal nutritional supplementation habits upon management practices in these areas. Methods A survey was electronically distributed to Australian optometrists (n = 4,242). Respondents anonymously provided information about their personal demographics and lifestyle behaviors (i.e., age, gender, practice location, therapeutic-endorsement status, smoking status, nutritional supplement intake) and routine patient management practices with respect to advice across three domains: smoking, diet and nutritional supplementation. Multivariate logistic regression analyses were performed to assess for potential effects of the listed factors on practitioner behavior. Results A total of 283 completed surveys were received (completed survey response rate: 6.7%). Fewer than half of respondents indicated routinely asking their patients about smoking status. Younger practitioners were significantly (p < 0.05) less likely to enquire about patients’ smoking behaviors, but this did not extend to counseling for smoking cessation. Almost two-thirds of respondents indicated routinely counseling patients about diet. About half of practitioners specified routinely asking their patients about nutritional supplement intake; this form of questioning was significantly more likely if the respondent was female (p < 0.05). Practitioners who recommended nutritional supplements most commonly did so for age-related macular degeneration (91.2%) and dry eye disease (63.9%). The primary source of evidence used to guide practitioners’ nutrition-related patient management was reported to be peer-reviewed publications
Haker, Helene; Schneebeli, Maya; Stephan, Klaas Enno
Diagnosis and individualized treatment of autism spectrum disorder (ASD) represent major problems for contemporary psychiatry. Tackling these problems requires guidance by a pathophysiological theory. In this paper, we consider recent theories that re-conceptualize ASD from a “Bayesian brain” perspective, which posit that the core abnormality of ASD resides in perceptual aberrations due to a disbalance in the precision of prediction errors (sensory noise) relative to the precision of predictions (prior beliefs). This results in percepts that are dominated by sensory inputs and less guided by top-down regularization and shifts the perceptual focus to detailed aspects of the environment with difficulties in extracting meaning. While these Bayesian theories have inspired ongoing empirical studies, their clinical implications have not yet been carved out. Here, we consider how this Bayesian perspective on disease mechanisms in ASD might contribute to improving clinical care for affected individuals. Specifically, we describe a computational strategy, based on generative (e.g., hierarchical Bayesian) models of behavioral and functional neuroimaging data, for establishing diagnostic tests. These tests could provide estimates of specific cognitive processes underlying ASD and delineate pathophysiological mechanisms with concrete treatment targets. Written with a clinical audience in mind, this article outlines how the development of computational diagnostics applicable to behavioral and functional neuroimaging data in routine clinical practice could not only fundamentally alter our concept of ASD but eventually also transform the clinical management of this disorder. PMID:27378955
Barbui, Corrado; Accordini, Simone; Nosè, Michela; Stroup, Scott; Purgato, Marianna; Girlanda, Francesca; Esposito, Eleonora; Veronese, Antonio; Tansella, Michele; Cipriani, Andrea
This multisite study was conducted to compare the efficacy and tolerability of combination treatment with clozapine plus aripiprazole versus combination treatment with clozapine plus haloperidol in patients with schizophrenia who do not have an optimal response to clozapine. Patients continued to take clozapine and were randomly assigned to receive daily augmentation with aripiprazole or haloperidol. Physicians prescribed the allocated treatments according to usual clinical care. Withdrawal from allocated treatment within 3 months was the primary outcome. Secondary outcomes included severity of symptoms on the Brief Psychiatric Rating Scale and antipsychotic subjective tolerability on the Liverpool University Neuroleptic Side Effect Rating Scale. A total of 106 patients with schizophrenia were randomly assigned to treatment. After 3 months, we found no difference in the proportion of patients who discontinued treatment between the aripiprazole and haloperidol groups (13.2% vs 15.1%, P = 0.780). The 3-month change of the Brief Psychiatric Rating Scale total score was similar in the aripiprazole and haloperidol groups (-5.9 vs -4.4 points, P = 0.523), whereas the 3-month decrease of the Liverpool University Neuroleptic Side Effect Rating Scale total score was significantly higher in the aripiprazole group than in the haloperidol group (-7.4 vs -2.0 points, P = 0.006). These results suggest that augmentation of clozapine with aripiprazole offers no benefit with regard to treatment withdrawal and overall symptoms in schizophrenia compared with augmentation with haloperidol. However, an advantage in the perception of adverse effects with aripiprazole treatment may be meaningful for patients.
Spasovski, Goce; Vanholder, Raymond; Allolio, Bruno; Annane, Djillali; Ball, Steve; Bichet, Daniel; Decaux, Guy; Fenske, Wiebke; Hoorn, Ewout J; Ichai, Carole; Joannidis, Michael; Soupart, Alain; Zietse, Robert; Haller, Maria; van der Veer, Sabine; Van Biesen, Wim; Nagler, Evi
Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.
Spasovski, Goce; Vanholder, Raymond; Allolio, Bruno; Annane, Djillali; Ball, Steve; Bichet, Daniel; Decaux, Guy; Fenske, Wiebke; Hoorn, Ewout J; Ichai, Carole; Joannidis, Michael; Soupart, Alain; Zietse, Robert; Haller, Maria; van der Veer, Sabine; Van Biesen, Wim; Nagler, Evi
Hyponatraemia, defined as a serum sodium concentration <135 mmol/l, is the most common disorder of body fluid and electrolyte balance encountered in clinical practice. It can lead to a wide spectrum of clinical symptoms, from subtle to severe or even life threatening, and is associated with increased mortality, morbidity and length of hospital stay in patients presenting with a range of conditions. Despite this, the management of patients remains problematic. The prevalence of hyponatraemia in widely different conditions and the fact that hyponatraemia is managed by clinicians with a broad variety of backgrounds have fostered diverse institution- and speciality-based approaches to diagnosis and treatment. To obtain a common and holistic view, the European Society of Intensive Care Medicine (ESICM), the European Society of Endocrinology (ESE) and the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA), represented by European Renal Best Practice (ERBP), have developed the Clinical Practice Guideline on the diagnostic approach and treatment of hyponatraemia as a joint venture of three societies representing specialists with a natural interest in hyponatraemia. In addition to a rigorous approach to methodology and evaluation, we were keen to ensure that the document focused on patient-important outcomes and included utility for clinicians involved in everyday practice.
Alsuwaidi, Mohammed; Dollinger, Margit; Fleck, Martin; Ehrenstein, Boris
Automated interpretation (AI) systems for antinuclear antibody (ANA) analysis have been introduced based on assessment of indirect immunofluorescence (IIF) patterns. The diagnostic performance of a novel automated IIF reading system was compared with visual interpretation (VI) of IIF in daily clinical practice to evaluate the reduction of workload. ANA-IIF tests of consecutive serum samples from patients with suspected connective tissue disease were carried out using HEp-2 cells according to routine clinical care. AI was performed using a visual analyser (Zenit G-Sight, Menarini, Germany). Agreement rates between ANA results by AI and VI were calculated. Of the 336 samples investigated, VI yielded 205 (61%) negative, 42 (13%) ambiguous, and 89 (26%) positive results, whereas 82 (24%) were determined to be negative, 176 (52%) ambiguous, and 78 (24%) positive by AI. AI displayed a diagnostic accuracy of 175/336 samples (52%) with a kappa coefficient of 0.34 compared to VI being the gold standard. Solely relying on AI, with VI only performed for all ambiguous samples by AI, would have missed 1 of 89 (1%) positive results by VI and misclassified 2 of 205 (1%) negative results by VI as positive. The use of AI in daily clinical practice resulted only in a moderate reduction of the VI workload (82 of 336 samples: 24%).
Fonyakin, A V
The article presents an analytical review of the results of post-registration clinical studies on the efficacy and safety of rivaroxaban in nonvalvular atrial fibrillation (AF) to prevent stroke and other systemic thromboembolic complications. The main purpose of the first large prospective international observational study of rivaroxaban for stroke prevention in patients with non-valvular AF patients XANTUS was the analysis of efficacy and safety of rivaroxaban in clinical practice. Results of one year of observation of 6784 patients confirmed that rivaroxaban is effective and safe in real unselected population of patients with non-valvular AF and various stroke risk. The first Russian multicenter observational study Neuro-Xar dedicated to secondary prevention of stroke and systemic embolism, demonstrated the efficacy and safety of rivaroxaban in routine clinical practice. Lower risk of fatal intracranial and gastrointestinal bleeding was found in retrospective post-marketing studies, of rivaroxaban in the US, such as the PMSS and REVISIT-US. Rivaroxaban therapy was associated with reduced risk of the combined endpoint (ischemic stroke and intracranial hemorrhage).
Non-invasive electrical and magnetic stimulation of the brain, spinal cord, roots and peripheral nerves: Basic principles and procedures for routine clinical and research application. An updated report from an I.F.C.N. Committee.
Rossini, P M; Burke, D; Chen, R; Cohen, L G; Daskalakis, Z; Di Iorio, R; Di Lazzaro, V; Ferreri, F; Fitzgerald, P B; George, M S; Hallett, M; Lefaucheur, J P; Langguth, B; Matsumoto, H; Miniussi, C; Nitsche, M A; Pascual-Leone, A; Paulus, W; Rossi, S; Rothwell, J C; Siebner, H R; Ugawa, Y; Walsh, V; Ziemann, U
These guidelines provide an up-date of previous IFCN report on "Non-invasive electrical and magnetic stimulation of the brain, spinal cord and roots: basic principles and procedures for routine clinical application" (Rossini et al., 1994). A new Committee, composed of international experts, some of whom were in the panel of the 1994 "Report", was selected to produce a current state-of-the-art review of non-invasive stimulation both for clinical application and research in neuroscience. Since 1994, the international scientific community has seen a rapid increase in non-invasive brain stimulation in studying cognition, brain-behavior relationship and pathophysiology of various neurologic and psychiatric disorders. New paradigms of stimulation and new techniques have been developed. Furthermore, a large number of studies and clinical trials have demonstrated potential therapeutic applications of non-invasive brain stimulation, especially for TMS. Recent guidelines can be found in the literature covering specific aspects of non-invasive brain stimulation, such as safety (Rossi et al., 2009), methodology (Groppa et al., 2012) and therapeutic applications (Lefaucheur et al., 2014). This up-dated review covers theoretical, physiological and practical aspects of non-invasive stimulation of brain, spinal cord, nerve roots and peripheral nerves in the light of more updated knowledge, and include some recent extensions and developments.
Cholera, Rushina; Pence, Brian W.; Bengtson, Angela M.; Crane, Heidi M.; Christopoulos, Katerina; Cole, Steven R.; Fredericksen, Rob; Gaynes, Bradley N.; Heine, Amy; Mathews, W. Christopher; Mimiaga, Matthew J.; Moore, Richard; Napravnik, Sonia; O’Clerigh, Conall; Safren, Steven; Mugavero, Michael J.
Background Depression affects 20–30% of HIV-infected patients and is associated with worse HIV outcomes. Although effective depression treatment is available, depression is largely untreated or undertreated in this population. Methods We quantified gaps in antidepressant treatment, treatment adjustments, and outcomes among US patients in routine HIV care in the nationally distributed CNICS observational clinical cohort. This cohort combines detailed clinical data with regular, self-reported depressive severity assessments (Patient Health Questionnaire-9, PHQ-9). We considered whether participants with likely depression received antidepressants, whether participants on antidepressants with persistently high depressive symptoms received timely dose adjustments, and whether participants achieved depression remission. We considered a cross-sectional analysis (6,219 participants in care in 2011–2012) and a prospective analysis (2,936 participants newly initiating CNICS care when PHQ-9 screening was active). Results The cross-sectional sample was 87% male, 53% Caucasian, 25% African American, and 18% Hispanic; the prospective sample was similar. In both samples, 39–44% had likely depression, with 44–60% of those receiving antidepressants. Of participants receiving antidepressants, 20–26% experienced persistently high depressive symptoms; only a small minority of those received antidepressant dose adjustments. Overall, 35–40% of participants on antidepressants achieved full depression remission. Remission among participants with persistently high depressive symptoms was rare regardless of dose adjustments. Conclusions In this large, diverse cohort of US patients engaged in routine HIV care, we observed large gaps in antidepressant treatment, timely dose adjustment to address persistently high depressive symptoms, and antidepressant treatment outcomes. These results highlight the importance of more effective pharmacologic depression treatment models for HIV
Finlay, A Y; Salek, M S; Abeni, D; Tomás-Aragonés, L; van Cranenburgh, O D; Evers, A W M; Jemec, G B E; Linder, D; Manolache, L; Marrón, S E; Prinsen, C A C; Susitaival, P; Chernyshov, P V
The aim of this study was to describe the many ways in which quality of life (QoL) measurement may potentially be advantageous in routine clinical dermatology practice. Thirteen members of the EADV Task Force on Quality of Life, eight dermatologists, three health psychologists, one epidemiologist and one pharmacoepidemiologist, independ