Bioethics, children, and the environment.

PubMed

Murphy, Timothy F

2018-01-01

Queer perspectives have typically emerged from sexual minorities as a way of repudiating flawed views of sexuality, mischaracterized relationships, and objectionable social treatment of people with atypical sexuality or gender expression. In this vein, one commentator offers a queer critique of the conceptualization of children in regard to their value for people's identities and relationships. According to this account, children are morally problematic given the values that make them desirable, their displacement of other beings and things entitled to moral protection, not to mention the damaging environmental effects that follow in the wake of population growth. Objectionable views of children are said even to have colonized the view of lesbian, gay, bisexual, and trans (LGBT) people who - with the enthusiastic endorsement of bioethics - increasingly turn to assisted reproductive treatments to have children. In the face of these outcomes, it is better - according to this account - that people reconsider their interest in children. This account is not, however, ultimately strong enough to override people's interest in having children, relative to the benefits they confer and relative to the benefits conferred on children themselves. It is certainly not strong enough to justify differential treatment of LGBT people in matters of assisted reproductive treatments. Environmental threats in the wake of population growth might be managed in ways other than devaluing children as such. Moreover, this account ultimately damages the interests of LGBT people in matters of access, equity, and children, which outcome is paradoxical, given the origins of queer perspectives as efforts to assert and defend the social interests of sexual and gender minorities. © 2017 The Authors. Bioethics Published by John Wiley & Sons Ltd.

Bioethics, children, and the environment

PubMed Central

2017-01-01

Abstract Queer perspectives have typically emerged from sexual minorities as a way of repudiating flawed views of sexuality, mischaracterized relationships, and objectionable social treatment of people with atypical sexuality or gender expression. In this vein, one commentator offers a queer critique of the conceptualization of children in regard to their value for people's identities and relationships. According to this account, children are morally problematic given the values that make them desirable, their displacement of other beings and things entitled to moral protection, not to mention the damaging environmental effects that follow in the wake of population growth. Objectionable views of children are said even to have colonized the view of lesbian, gay, bisexual, and trans (LGBT) people who – with the enthusiastic endorsement of bioethics – increasingly turn to assisted reproductive treatments to have children. In the face of these outcomes, it is better – according to this account – that people reconsider their interest in children. This account is not, however, ultimately strong enough to override people's interest in having children, relative to the benefits they confer and relative to the benefits conferred on children themselves. It is certainly not strong enough to justify differential treatment of LGBT people in matters of assisted reproductive treatments. Environmental threats in the wake of population growth might be managed in ways other than devaluing children as such. Moreover, this account ultimately damages the interests of LGBT people in matters of access, equity, and children, which outcome is paradoxical, given the origins of queer perspectives as efforts to assert and defend the social interests of sexual and gender minorities. PMID:28873213

Current approaches to the management of idiopathic pulmonary fibrosis.

PubMed

Raghu, Ganesh; Richeldi, Luca

2017-08-01

Idiopathic pulmonary fibrosis (IPF) is a progressive and ultimately fatal lung disease associated with dyspnoea, cough and impaired quality of life. Currently, the aims of patient care are to improve outcomes for patients by slowing the progression of the disease, extending life, and improving quality of life. A prompt, accurate diagnosis is important to enable patients to receive treatment early in the course of the disease and to be considered for lung transplantation. Two anti-fibrotic drugs, nintedanib and pirfenidone, have been shown to reduce decline in lung function in patients with IPF. In addition to pharmacological therapy, optimal management of IPF includes treatment of comorbidities, symptom relief, pulmonary rehabilitation, and palliative care. Patient education is important to enable patients to make decisions about their care and to help them manage their disease and the side-effects of anti-fibrotic drugs. Research continues into new treatments and combinations of treatments that may improve outcomes for patients with this devastating disease. Copyright © 2017. Published by Elsevier Ltd.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial.

PubMed

Hutchings, Natalie; Wood, Wendy; Reading, Isabel; Walker, Erin; Blazeby, Jane M; Van't Hoff, William; Young, Bridget; Crawley, Esther M; Eaton, Simon; Chorozoglou, Maria; Sherratt, Frances C; Beasant, Lucy; Corbett, Harriet; Stanton, Michael P; Grist, Simon; Dixon, Elizabeth; Hall, Nigel J

2018-03-02

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial. The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery. In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design. ISRCTN15830435 . Registered on 8 February 2017.

The SBIRT program matrix: a conceptual framework for program implementation and evaluation.

PubMed

Del Boca, Frances K; McRee, Bonnie; Vendetti, Janice; Damon, Donna

2017-02-01

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of services to those at risk for the adverse consequences of alcohol and other drug use, and for those with probable substance use disorders. Research on successful SBIRT implementation has lagged behind studies of efficacy and effectiveness. This paper (1) outlines a conceptual framework, the SBIRT Program Matrix, to guide implementation research and program evaluation and (2) specifies potential implementation outcomes. Overview and narrative description of the SBIRT Program Matrix. The SBIRT Program Matrix has five components, each of which includes multiple elements: SBIRT services; performance sites; provider attributes; patient/client populations; and management structure and activities. Implementation outcomes include program adoption, acceptability, appropriateness, feasibility, fidelity, costs, penetration, sustainability, service provision and grant compliance. The Screening, Brief Intervention and Referral to Treatment Program Matrix provides a template for identifying, classifying and organizing the naturally occurring commonalities and variations within and across SBIRT programs, and for investigating which variables are associated with implementation success and, ultimately, with treatment outcomes and other impacts. © 2017 Society for the Study of Addiction.

Does Collaborative Case Conceptualisation enhance engagement and outcome in the treatment of anorexia nervosa? Rational, design and methods.

PubMed

Mitchell, Sarah A; Newton, Richard; Harrison, Philippa; Castle, David; Brennan, Leah

2016-03-01

Anorexia Nervosa (AN) is a severe and potentially chronic disorder characterised by low body weight and persistent behaviours that interfere with weight gain. Individuals with AN are often difficult to engage in treatment and display high rates of drop out. The Collaborative Case Conceptualisation (CCC) assessment approach was developed to target proposed AN maintaining factors with the aim of improving treatment motivation and engagement and consequently treatment outcomes in individuals with AN. The proposed study aims to examine the efficacy of CCC in improving a range of outcomes including Body Mass Index, eating disorder symptomatology, general psychopathology, quality of life and future treatment motivation and participation. Potential mediators will also be explored. Thirty-two participants will be recruited from Melbourne based specialist eating disorder services, community and university clinics, and health practitioner networks. Participants will be randomised to three individual sessions of either CCC or a standardised assessment condition (assessment as usual; AAU). The AAU assessment will include; a mental status examination, assessment of current disordered eating behaviours and cognitions, assessment of clinical history, and a physical examination. The CCC condition combines the AAU assessment components with shared collaborative formulation and tailored psychoeducation highlighting the consequences of the eating disorder on wellbeing and future goals in a supportive and motivating way. This intervention may provide an effective and feasible method of improving treatment engagement and outcomes for individuals suffering from AN, with the ultimate outcome of reducing the negative biopsychosocial impacts of this potentially severe and chronic disorder. Copyright © 2016 Elsevier Inc. All rights reserved.

Instability of the Null Steady State: The Fundamental Problem of Inhibiting Malignant Cell Growth

NASA Astrophysics Data System (ADS)

Varfolomeev, S. D.; Lukovenkov, A. V.

2018-07-01

Mathematical modeling of the process of inhibiting malignant growth by common chemotherapeutic agents and biological therapeutics is used to investigate the effect kinetic parameters of the model have on the outcome of treatment. It is shown that the ultimate suppression of growth, i.e., the formation of a stable steady-state with no cancer cells, cannot be attained if only the means of classical chemotherapy are used.

Invited commentary on Quality of care indicators for the rehabilitation of children with traumatic brain injury, and Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury.

PubMed

Whyte, John

2012-03-01

Measures of structure and process in health care have been shown to be associated with care outcomes in prior research. Two articles in this issue propose measures of structure and process that may be relevant to pediatric traumatic brain injury rehabilitation. This commentary considers how these potential measures may be related to the actual treatments and services that ultimately affect patient outcomes. Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Development and Evaluation of a Pilot Nurse Case Management Model to Address Multidrug-Resistant Tuberculosis (MDR-TB) and HIV in South Africa

PubMed Central

Farley, Jason E.; Kelly, Ana M.; Reiser, Katrina; Brown, Maria; Kub, Joan; Davis, Jeane G.; Walshe, Louise; Van der Walt, Martie

2014-01-01

Setting Multidrug-resistant tuberculosis (MDR-TB) unit in KwaZulu-Natal, South Africa. Objective To develop and evaluate a nurse case management model and intervention using the tenets of the Chronic Care Model to manage treatment for MDR-TB patients with a high prevalence of human immunodeficiency virus (HIV) co-infection. Design A quasi-experimental pilot programme utilizing a nurse case manager to manage care for 40 hospitalized MDR-TB patients, 70% HIV co-infected, during the intensive phase of MDR-TB treatment. Patients were followed for six months to compare proximal outcomes identified in the model between the pre- and post-intervention period. Results The greatest percent differences between baseline and six-month MDR-TB proximal outcomes were seen in the following three areas: baseline symptom evaluation on treatment initiation (95% improvement), baseline and monthly laboratory evaluations completed per guidelines (75% improvement), and adverse drug reactions acted upon by medical and/or nursing intervention (75% improvement). Conclusion Improvements were identified in guideline-based treatment and monitoring of adverse drug reactions following implementation of the nurse case management intervention. Further study is required to determine if the intervention introduced in this model will ultimately result in improvements in final MDR-TB treatment outcomes. PMID:25405988

Pharmacogenetics in type 2 diabetes: influence on response to oral hypoglycemic agents

PubMed Central

Dawed, Adem Yesuf; Zhou, Kaixin; Pearson, Ewan Robert

2016-01-01

Type 2 diabetes is one of the leading causes of morbidity and mortality, consuming a significant proportion of public health spending. Oral hypoglycemic agents (OHAs) are the frontline treatment approaches after lifestyle changes. However, huge interindividual variation in response to OHAs results in unnecessary treatment failure. In addition to nongenetic factors, genetic factors are thought to contribute to much of such variability, highlighting the importance of the potential of pharmacogenetics to improve therapeutic outcome. Despite the presence of conflicting results, significant progress has been made in an effort to identify the genetic markers associated with pharmacokinetics, pharmacodynamics, and ultimately therapeutic response and/or adverse outcomes to OHAs. As such, this article presents a comprehensive review of current knowledge on pharmacogenetics of OHAs and provides insights into knowledge gaps and future directions. PMID:27103840

Augmentation treatment in major depressive disorder: focus on aripiprazole

PubMed Central

Nelson, J Craig; Pikalov, Andrei; Berman, Robert M

2008-01-01

Major depressive disorder (MDD) is a disabling psychiatric condition for which effective treatment remains an outstanding need. Antidepressants are currently the mainstay of treatment for depression; however, almost two-thirds of patients will fail to achieve remission with initial treatment. As a result, a range of augmentation and combination strategies have been used in order to improve outcomes for patients. Despite the popularity of these approaches, limited data from double-blind, randomized, placebo-controlled studies are available to allow clinicians to determine which are the most effective augmentation options or which patients are most likely to respond to which options. Recently, evidence has shown that adjunctive therapy with atypical antipsychotics has the potential for beneficial antidepressant effects in the absence of psychotic symptoms. In particular, aripiprazole has shown efficacy as an augmentation option with standard antidepressant therapy in two, large, randomized, double-blind studies. Based on these efficacy and safety data, aripiprazole was recently approved by the FDA as adjunctive therapy for MDD. The availability of this new treatment option should allow more patients with MDD to achieve remission and, ultimately, long-term, successful outcomes. PMID:19183784

Early glottic cancer involving the anterior commissure treated by transoral laser cordectomy.

PubMed

Hoffmann, Caroline; Cornu, Nicolas; Hans, Stéphane; Sadoughi, Babak; Badoual, Cécile; Brasnu, Daniel

2016-08-01

Anterior commissure involvement is considered to be a risk factor for poorer outcomes after transoral laser cordectomy (TLC) for early glottic cancer. The objective of this study was to determine the outcomes and relevance of the tumor-node-metastasis (TNM) classification in a large series of patients with early glottic cancer involving the anterior commissure treated by TLC. The clinical and surgical parameters, as well as follow-up results, of the patients treated consecutively for early-stage glottic squamous cell carcinoma involving the anterior commissure (Tis, T1a, T1b, and T2) by transoral CO2 laser cordectomy in an urban academic medical center from January 2001 to March 2013 were analyzed retrospectively. The main outcomes measures were: 5-year disease free survival (DFS), ultimate local control with laser alone, laryngeal preservation, overall-survival (OS) rates, and disease-specific survival (DSS) rates (Kaplan-Meier). Ninety-six patients treated from January 2001 to March 2013 were included. The 5-year DFS and ultimate local control with laser alone rates were 61.7% and 74.4%, respectively. The laryngeal preservation rate was 93.4%; and the OS and DSS rates were 79.2% and 91.5%, respectively. Postoperative T classification (pT) status was not found to be a significant predictor of recurrences, but was predictive of more severe recurrences requiring other treatments than laser. TLC is an effective treatment for early stage glottic cancer involving the anterior commissure. The TNM classification is a relevant prognosis factor for severe recurrences. 4. Laryngoscope, 126:1817-1822, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

In silico modelling of radiation effects towards personalised treatment in radiotherapy

NASA Astrophysics Data System (ADS)

Marcu, Loredana G.; Marcu, David

2017-12-01

In silico models applied in medical physics are valuable tools to assist in treatment optimization and personalization, which represent the ultimate goal of today's radiotherapy. Next to several biological and biophysical factors that influence tumour response to ionizing radiation, hypoxia and cancer stem cells are critical parameters that dictate the final outcome. The current work presents the results of an in silico model of tumour growth and response to radiation developed using Monte Carlo techniques. We are presenting the impact of partial oxygen tension and repopulation via cancer stem cells on tumour control after photon irradiation, highlighting some of the gaps that clinical research needs to fill for better customized treatment.

Optimal medical outcomes with limited liability: risk management principles for medical practices at the intersection of medicine, law, and business.

PubMed

Paterick, Timothy J; Paterick, Timothy E; Waterhouse, Blake E

2007-01-01

Physicians practice at the intersection of medicine, law, and business. Each discipline creates its own challenges for the practicing physician: to practice efficient, effective medicine; to limit potential liability; and to create a positive financial outcome. Those challenges increase with escalating costs and reduced reimbursements. In this paper, the common clinical presentation of chest pain has been used to create a paradigm to educate physicians to understand efficient and effective approaches to diagnosis and treatment, and how effective communication with patients and meticulous documentation of all medical encounters can limit the potential for liability. Ultimately, given today's reimbursement formulas, physicians must also understand the cost of testing, in relation to its benefits, in an attempt to yield a positive financial outcome.

Therapeutic Management of Feline Chronic Gingivostomatitis: A Systematic Review of the Literature

PubMed Central

Winer, Jenna N.; Arzi, Boaz; Verstraete, Frank J. M.

2016-01-01

Feline chronic gingivostomatitis (FCGS) is a disease characterized by protracted and potentially debilitating oral inflammation in cats, the etiology of which is currently unknown. The purpose of this review is to apply an evidence-based medicine approach to systematically review and critically evaluate the scientific literature reporting the outcome of medical and surgical management of FCGS. Those articles meeting inclusion criteria were reviewed and assigned an “Experimental Design Grade” (EDG) and an “Evidence Grade” (EG) in order to score relative strength of study design and produced data. Studies were evaluated and compared, especially highlighting the treatments, the outcomes, and the therapeutic success rates. This review found a lack of consistency between articles’ data, rendering direct comparison of results unreliable. The field of FCGS research, and ultimately patient care, would benefit from standardizing studies by adopting use of a consistent semi-quantitative scoring system and extending follow-up duration. Future researchers should commit to large prospective studies that compare existing treatments and demonstrate the promise of new treatments. PMID:27486584

Future Directions for the Early Detection of Colorectal Cancer Recurrence

PubMed Central

Walker, Avery S.; Johnson, Eric K.; Maykel, Justin A.; Stojadinovic, Alex; Nissan, Aviram; Brucher, Bjorn; Champagne, Bradley J.; Steele, Scott R.

2014-01-01

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence. PMID:24790655

Diabetic foot infection treatment and care.

PubMed

Cigna, Emanuele; Fino, Pasquale; Onesti, Maria G; Amorosi, Vittoria; Scuderi, Nicolò

2016-04-01

Foot infections in diabetic patients are a common, complex and costly problem. They are potentially adverse with progression to deeper spaces and tissues and are associated with severe complications. The management of diabetic foot infection (DFI) requires a prompt and systematic approach to achieve more successful outcomes and to ultimately avoid amputations. This study reviews a multi-step treatment for DFIs. Between September 2010 and September 2012, a total of about 37 patients were consulted for DFI. The treatment algorithm included four steps, that is, several types of debridement according to the type of wound, the application of negative pressure therapy (NPT), other advanced dressings, a targeted antibiotic therapy local or systemic as the case may, and, if necessary, reconstructive surgery. This treatment protocol showed excellent outcomes, allowing us to avoid amputation in most difficult cases. Only about 8% of patients require amputation. This treatment protocol and a multidisciplinary approach with a specialised team produced excellent results in the treatment of DFI and in the management of diabetic foot in general, allowing us to improve the quality of life of diabetic patients and also to ensure cost savings. © 2014 The Authors. International Wound Journal © 2014 Medicalhelplines.com Inc and John Wiley & Sons Ltd.

Outcome following physician supervised prehospital resuscitation: a retrospective study

PubMed Central

Mikkelsen, Søren; Krüger, Andreas J; Zwisler, Stine T; Brøchner, Anne C

2015-01-01

Background Prehospital care provided by specially trained, physician-based emergency services (P-EMS) is an integrated part of the emergency medical systems in many developed countries. To what extent P-EMS increases survival and favourable outcomes is still unclear. The aim of the study was thus to investigate ambulance runs initially assigned ‘life-saving missions’ with emphasis on long-term outcome in patients treated by the Mobile Emergency Care Unit (MECU) in Odense, Denmark Methods All MECU runs are registered in a database by the attending physician, stating, among other parameters, the treatment given, outcome of the treatment and the patient's diagnosis. Over a period of 80 months from May 1 2006 to December 31 2012, all missions in which the outcome of the treatment was registered as ‘life saving’ were scrutinised. Initial outcome, level of competence of the caretaker and diagnosis of each patient were manually established in each case in a combined audit of the prehospital database, the discharge summary of the MECU and the medical records from the hospital. Outcome parameters were final outcome, the aetiology of the life-threatening condition and the level of competences necessary to treat the patient. Results Of 25 647 patients treated by the MECU, 701 (2.7%) received prehospital ‘life saving treatment’. In 596 (2.3%) patients this treatment exceeded the competences of the attending emergency medical technician or paramedic. Of these patients, 225 (0.9%) were ultimately discharged to their own home. Conclusions The present study demonstrates that anaesthesiologist administrated prehospital therapy increases the level of treatment modalities leading to an increased survival in relation to a prehospital system consisting of emergency medical technicians and paramedics alone and thus supports the concept of applying specialists in anaesthesiology in the prehospital setting especially when treating patients with cardiac arrest, patients in need of respiratory support and trauma patients. PMID:25567065

Spontaneous bilateral chylothorax with fatal outcome in a patient with melorheostosis.

PubMed

Leuenberger, Michèle; Braunwalder, Jan; Schmid, Ralph A; Stanga, Zeno

2008-11-01

We report a case of progressive, multifocal melorheostosis in a 28-year-old woman, with involvement of the left arm, chest, spine, and impressive soft tissue involvement. In the past, she had undergone multiple vascular interventions. She presented with spontaneous massive bilateral chylothorax. After conservative treatment without success, we conducted bilateral pleurodesis. This resulted in a clear reduction of pleural effusions, but her medical condition subsequently worsened due to progressive parenchymatous infiltrates, and increased interlobal pleural effusions. She ultimately died of global respiratory insufficiency. In patients with melorheostosis, involvement of the soft tissue can result in distinctive morbidity, and whenever possible, treatment should be conservative.

Social context, parental monitoring, and multisystemic therapy outcomes.

PubMed

Robinson, Brittany A; Winiarski, D Anne; Brennan, Patricia A; Foster, Sharon L; Cunningham, Phillippe B; Whitmore, Elizabeth A

2015-03-01

Multisystemic therapy (MST) and other evidence-based treatments targeting juvenile delinquency have been well substantiated in the literature. Although these treatments have been demonstrated to be effective overall at reducing juvenile delinquency, it is well known that they do not benefit all treated youth. Research has yet to examine the potential influence of contextual factors, such as socioeconomic status (SES) and neighborhood characteristics, on treatment outcomes, particularly as they influence parental monitoring, which is often a focus of interventions targeting juvenile delinquency. A primary goal of these treatments is to help parents develop the requisite skills to adequately monitor and discipline their children; however, this goal may be compromised by contextual factors affecting parental effectiveness and, ultimately, treatment efficacy. The objective of this study was to explore the role of SES and neighborhood factors in moderating the effects of parental monitoring across treatment. Using hierarchical linear modeling (HLM), we analyzed these contextual and family predictors of response to MST treatment within a sample of 185 youth (65.4% male) ages 12-18 (M = 15.35; SD = 1.28). Neighborhood factors interacted with parental monitoring, such that monitoring predicted decreases in externalizing behavior only for youth residing in better neighborhoods. In contrast, SES was unrelated to changes in externalizing behaviors in response to MST. Taken together, these results demonstrate a need for further understanding the potential role of the youth's larger social context in predicting MST outcomes. (PsycINFO Database Record (c) 2015 APA, all rights reserved).

Sources of medical error in refractive surgery.

PubMed

Moshirfar, Majid; Simpson, Rachel G; Dave, Sonal B; Christiansen, Steven M; Edmonds, Jason N; Culbertson, William W; Pascucci, Stephen E; Sher, Neal A; Cano, David B; Trattler, William B

2013-05-01

To evaluate the causes of laser programming errors in refractive surgery and outcomes in these cases. In this multicenter, retrospective chart review, 22 eyes of 18 patients who had incorrect data entered into the refractive laser computer system at the time of treatment were evaluated. Cases were analyzed to uncover the etiology of these errors, patient follow-up treatments, and final outcomes. The results were used to identify potential methods to avoid similar errors in the future. Every patient experienced compromised uncorrected visual acuity requiring additional intervention, and 7 of 22 eyes (32%) lost corrected distance visual acuity (CDVA) of at least one line. Sixteen patients were suitable candidates for additional surgical correction to address these residual visual symptoms and six were not. Thirteen of 22 eyes (59%) received surgical follow-up treatment; nine eyes were treated with contact lenses. After follow-up treatment, six patients (27%) still had a loss of one line or more of CDVA. Three significant sources of error were identified: errors of cylinder conversion, data entry, and patient identification error. Twenty-seven percent of eyes with laser programming errors ultimately lost one or more lines of CDVA. Patients who underwent surgical revision had better outcomes than those who did not. Many of the mistakes identified were likely avoidable had preventive measures been taken, such as strict adherence to patient verification protocol or rigorous rechecking of treatment parameters. Copyright 2013, SLACK Incorporated.

Patient-reported outcomes in obsessive-compulsive disorder

PubMed Central

Subramaniam, Mythily; Soh, Pauline; Ong, Clarissa; Esmond Seow, Lee Seng; Picco, Louisa; Vaingankar, Janhavi Ajit; Chong, Siow Ann

2014-01-01

The purpose of the article was to provide an overview of patient-reported outcomes (PROs) and related measures that have been examined in the context of obsessive-compulsive disorder (OCD). The current review focused on patient-reported outcome measures (PROMs) that evaluated three broad outcome domains: functioning, health-related quality of life (HRQoL), and OCD-related symptoms. The present review ultimately included a total of 155 unique articles and 22 PROMs. An examination of the PROs revealed that OCD patients tend to suffer from significant functional disability, and report lower HRQoL than controls. OCD patients report greater symptom severity than patients with other mental disorders and evidence indicates that PROMs are sensitive to change and may be even better than clinician-rated measures at predicting treatment outcomes. Nonetheless, it should be noted that the measures reviewed lacked patient input in their development. Future research on PROMs must involve patient perspectives and include rigorous psychometric evaluation of these measures. PMID:25152661

Primary repair of the anterior cruciate ligament: A paradigm shift.

PubMed

van der List, Jelle P; DiFelice, Gregory S

2017-06-01

Over the last century, many surgical treatments have been developed in the orthopedic field, including treatments of anterior cruciate ligament (ACL) injuries. These treatments ideally evolve in a process of trial and error with prospective comparison of new treatments to the current treatment standard. However, these evolutions are sometimes not linear and periodically undergo paradigm shifts. In this article, we review the evolution of ACL treatment and explain how it underwent a paradigm shift. Open primary ACL repair was the most common treatment in the 1970s and 1980s, but because multiple studies noted deterioration of outcomes at mid-term follow-up, in addition to several randomized clinical trials (RCTs) that noted better outcomes following ACL reconstruction, the open primary repair technique was abandoned. At the end of the primary repair era, however, several studies showed that outcomes of open primary repair were good to excellent and did not deteriorate when this technique was selectively performed in patients with proximal ACL tears, whereas primary repair led to disappointing and unpredictable results in patients with mid-substance tears. Unfortunately, enrollment of patients in the aforementioned RCTs was already finished, ultimately leading to abandoning of open primary repair, despite the advantages of ligament preservation. In this review, we discuss (I) why the evolution of ACL treatment underwent a paradigm shift, (II) which factors may have played a role in this and (III) what the future role of arthroscopic primary ACL repair is in the evolution of ACL treatments. Copyright © 2016. Published by Elsevier Ltd.

Outcome following nonoperative treatment of brachial plexus birth injuries.

PubMed

DiTaranto, Patricia; Campagna, Liliana; Price, Andrew E; Grossman, John A I

2004-02-01

Ninety-one infants who sustained a brachial plexus birth injury were treated with only physical and occupational therapy. The children were evaluated at 3-month intervals and followed for a minimum of 2 years. Sixty-three children with an upper or upper-middle plexus injury recovered good to excellent shoulder and hand function. In all of these children, critical marker muscles recovered M4 by 6 months of age. Twelve infants sustained a global palsy, with critical marker muscles remaining at M0-M1 at 6 months, resulting in a useless extremity. Sixteen infants with upper and upper-middle plexus injuries failed to recover greater than M1-M2 deltoid and biceps by 6 months, resulting in a very poor final outcome. These data provide useful guidelines for selection of infants for surgical reconstruction to improve ultimate outcome.

Safety and efficacy of flow diverter treatment for blood blister-like aneurysm: A systematic review and meta-analysis.

PubMed

Zhu, Deyuan; Yan, Yazhou; Zhao, Puyuan; Duan, Guoli; Zhao, Rui; Liu, Jianmin; Huang, Qinghai

2018-06-23

To clarify the safety and efficacy of flow diverter (FD) treatment for blood blister-like aneurysm (BBA), we conducted a systematic review and literature analyzing perioperative and long-term clinical and angiographic outcomes. A comprehensive review of the up-to-date literature for studies with >2 patients related to FD treatment of BBAs published was performed. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, aneurysm recurrence, rebleeding, perioperative mortality, perioperative stroke, procedure-related morbidity and mortality, long-term neurological morbidity and mortality, and overall good neurological outcome. We included 15 non-comparative studies with 165 target BBAs. Complete occlusion rates were 72% (95%CI= 0.59-0.85). Recurrence occurred in 13% (95%CI= -0.04-0.29) and rebleeding in 3% (95%CI = -0.02-0.07) of patients. Procedure-related morbidity and mortality were 26% (95%CI =0.19-0.33) and 3% (95%CI= -0.01-0.07), respectively. Long-term good outcome was 83% (95% CI = 0.77-0.89). Subgroup analysis indicated that single FD strategy for BBA seemed to have a higher good outcome rate compared to overlapped FD strategy (89.9% versus 61.9%, OR=1.42, 95%CI=1.25-14.98, P=0.02). Complete occlusion rate and procedure-related morbidity rate did not see any significant difference between these two strategies. Our meta-analysis suggests that in select cases, FD can be safe and effective. Single FD strategy may result in a higher good outcome rate compared to overlapped FD strategy. Ultimately, treatment of BBA should be considered on a case-by-case basis to maximize patient benefits and limit the risk of perioperative complications. Copyright © 2018. Published by Elsevier Inc.

A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: the SwiveLock-FiberChain construct versus standard double-row repair.

PubMed

Burkhart, Stephen S; Adams, Christopher R; Burkhart, Sarah S; Schoolfield, John D

2009-03-01

The purpose of this study was to compare the biomechanical fixation parameters of a standard double-row rotator cuff repair with those of a knotless footprint reconstruction using the double-row SwiveLock-FiberChain technique (Arthrex, Naples, FL). Seven matched pairs of human cadaveric shoulders were used for testing (mean age, 48 +/- 10.3 years). A shoulder from each matched pair was randomly selected to receive a standard 4-anchor double-row repair of the supraspinatus tendon, and the contralateral shoulder received a 4-anchor double-row SwiveLock-FiberChain repair. The tendon was cycled from 10 N to 100 N at 1 Hz for 500 cycles, followed by a single-cycle pull to failure at 33 mm/s. Yield load, ultimate load, cyclic displacement, and mode of failure were recorded. Yield load and ultimate load were higher for the SwiveLock-FiberChain repair compared with the standard double-row repair for 6 of the 7 treatment pairs; however, 1 cadaver had a contrary outcome, so the overall mean differences in yield load and ultimate load were not significantly different from 0 by Student t test (P > .15). Furthermore, smaller differences between yield load and ultimate load for the SwiveLock-FiberChain repair in 5 of the 7 treatment pairs showed a self-reinforcing mechanism. Double-row footprint reconstruction with the knotless SwiveLock-FiberChain system in this study had yield loads, ultimate loads, and cyclic displacements that were statistically equivalent to those of standard double-row rotation cuff reconstructions. The SwiveLock-FiberChain system's combination of strength, self-reinforcement, and decreased operating time may offer advantages to the surgeon, particularly when dealing with older patients in whom poor tissue quality and total operative time are important considerations.

Quantitative and qualitative trophectoderm grading allows for prediction of live birth and gender.

PubMed

Ebner, Thomas; Tritscher, Katja; Mayer, Richard B; Oppelt, Peter; Duba, Hans-Christoph; Maurer, Maria; Schappacher-Tilp, Gudrun; Petek, Erwin; Shebl, Omar

2016-01-01

Prolonged in vitro culture is thought to affect pre- and postnatal development of the embryo. This prospective study was set up to determine whether quality/size of inner cell mass (ICM) (from which the fetus ultimately develops) and trophectoderm (TE) (from which the placenta ultimately develops) is reflected in birth and placental weight, healthy live-birth rate, and gender after fresh and frozen single blastocyst transfer. In 225 patients, qualitative scoring of blastocysts was done according to the criteria expansion, ICM, and TE appearance. In parallel, all three parameters were quantified semi-automatically. TE quality and cell number were the only parameters that predicted treatment outcome. In detail, pregnancies that continued on to a live birth could be distinguished from those pregnancies that aborted on the basis of TE grade and cell number. Male blastocysts had a 2.53 higher chance of showing TE of quality A compared to female ones. There was no correlation between the appearance of both cell lineages and birth or placental weight, respectively. The presented correlation of TE with outcome indicates that TE scoring could replace ICM scoring in terms of priority. This would automatically require a rethinking process in terms of blastocyst selection and cryopreservation strategy.

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial.

PubMed

Palermo, Tonya M; Law, Emily F; Fales, Jessica; Bromberg, Maggie H; Jessen-Fiddick, Tricia; Tai, Gabrielle

2016-01-01

Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = -1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = -2.66, P = 0.007) and protective behaviors (b = -0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent's pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families.

Developing Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT): protocol for a pilot randomized controlled trial.

PubMed

Watson, Dennis P; Ray, Bradley; Robison, Lisa; Xu, Huiping; Edwards, Rhiannon; Salyers, Michelle P; Hill, James; Shue, Sarah

2017-01-01

There is a lack of evidence-based substance use disorder treatment and services targeting returning inmates. Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT) is a community-driven, recovery-oriented approach to substance abuse care which has the potential to address this service gap. SUPPORT is modeled after Indiana's Access to Recovery program, which was closed due to lack of federal support despite positive improvements in clients' recovery outcomes. SUPPORT builds on noted limitations of Indiana's Access to Recovery program. The ultimate goal of this project is to establish SUPPORT as an effective and scalable recovery-oriented system of care. A necessary step we must take before launching a large clinical trial is pilot testing the SUPPORT intervention. The pilot will take place at Public Advocates in Community Re-Entry (PACE), nonprofit serving individuals with felony convictions who are located in Marion County, Indiana (Indianapolis). The pilot will follow a basic parallel randomized design to compare clients receiving SUPPORT with clients receiving standard services. A total of 80 clients within 3 months of prison release will be recruited to participate and randomly assigned to one of the two intervention arms. Quantitative measures will be collected at multiple time points to understand SUPPORT's impact on recovery capital and outcomes. We will also collect qualitative data from SUPPORT clients to better understand their program and post-discharge experiences. Successful completion of this pilot will prepare us to conduct a multi-site clinical trial. The ultimate goal of this future work is to develop an evidence-based and scalable approach to treating substance use disorder among persons returning to society after incarceration. ClinicalTrials.gov (Clinical Trials ID: NCT03132753 and Protocol Number: 1511731907). Registered 28 April 2017.

Cognitive Impairment in Bipolar Disorder: Treatment and Prevention Strategies

PubMed Central

Solé, Brisa; Jiménez, Esther; Torrent, Carla; Reinares, Maria; Bonnin, Caterina del Mar; Torres, Imma; Varo, Cristina; Grande, Iria; Valls, Elia; Salagre, Estela; Sanchez-Moreno, Jose; Martinez-Aran, Anabel; Carvalho, André F

2017-01-01

Abstract Over the last decade, there has been a growing appreciation of the importance of identifying and treating cognitive impairment associated with bipolar disorder, since it persists in remission periods. Evidence indicates that neurocognitive dysfunction may significantly influence patients’ psychosocial outcomes. An ever-increasing body of research seeks to achieve a better understanding of potential moderators contributing to cognitive impairment in bipolar disorder in order to develop prevention strategies and effective treatments. This review provides an overview of the available data from studies examining treatments for cognitive dysfunction in bipolar disorder as well as potential novel treatments, from both pharmacological and psychological perspectives. All these data encourage the development of further studies to find effective strategies to prevent and treat cognitive impairment associated with bipolar disorder. These efforts may ultimately lead to an improvement of psychosocial functioning in these patients. PMID:28498954

An innovative outcome-based care and procurement model of hemophilia management.

PubMed

Gringeri, Alessandro; Doralt, Jennifer; Valentino, Leonard A; Crea, Roberto; Reininger, Armin J

2016-06-01

Hemophilia is a rare bleeding disorder associated with spontaneous and post-traumatic bleeding. Each hemophilia patient requires a personalized approach to episodic or prophylactic treatment, but self-management can be challenging for patients, and avoidable bleeding may occur. Patient-tailored care may provide more effective prevention of bleeding, which in turn, may decrease the likelihood of arthropathy and associated chronic pain, missed time from school or work, and progressive loss of mobility. A strategy is presented here aiming to reduce or eliminate bleeding altogether through a holistic approach based on individual patient characteristics. In an environment of budget constraints, this approach would link procurement to patient outcome, adding incentives for all stakeholders to strive for optimal care and, ultimately, a bleed-free world.

Outcome Prediction of Treatment of Graves' Hyperthyroidism with Antithyroid Drugs.

PubMed

Piantanida, E; Lai, A; Sassi, L; Gallo, D; Spreafico, E; Tanda, M L; Bartalena, L

2015-09-01

Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas and is ultimately due to antibodies interacting with the TSH receptor on thyroid follicular cells [TSH-receptor antibody (TRAb)]. Antithyroid drugs (ATDs) belonging to the family of thionamides are the first-line treatment in Europe. ATD treatment is commonly continued for 18-24 months. Its major limitation is the high rate of relapses after drug withdrawal. Factors particularly bound to subsequent relapses are the large thyroid volume, smoking habit, persistence of TRAb in the circulation at the end of treatment, and the post-partum period. Under these conditions, consideration should be given to a definitive therapy for hyperthyroidism (radioiodine treatment, thyroidectomy), particularly if the patient is at risk of cardiovascular complications that might be exacerbated by persistence or recurrence of hyperthyroidism. © Georg Thieme Verlag KG Stuttgart · New York.

Dental caries and pulpal disease.

PubMed

Zero, Domenick T; Zandona, Andrea Ferreira; Vail, Mychel Macapagal; Spolnik, Kenneth J

2011-01-01

This article reviews the diagnostic process, from the first clinically evident stages of the caries process to development of pulpal pathosis. The caries diagnostic process includes 4 interconnected components-staging caries lesion severity, assessing caries lesion activity, and risk assessments at the patient and tooth surface level - which modify treatment decisions for the patient. Pulpal pathosis is diagnosed as reversible pulpitis, irreversible pulpitis (asymptomatic), irreversible pulpitis (symptomatic), and pulp necrosis. Periapical disease is diagnosed as symptomatic apical periodontitis, asymptomatic apical periodontitis, acute apical abscess, and chronic apical abscess. Ultimately, the goal of any diagnosis should be to achieve better treatment decisions and health outcomes for the patient. Copyright © 2011 Elsevier Inc. All rights reserved.

Imaging macrophages with nanoparticles

NASA Astrophysics Data System (ADS)

Weissleder, Ralph; Nahrendorf, Matthias; Pittet, Mikael J.

2014-02-01

Nanomaterials have much to offer, not only in deciphering innate immune cell biology and tracking cells, but also in advancing personalized clinical care by providing diagnostic and prognostic information, quantifying treatment efficacy and designing better therapeutics. This Review presents different types of nanomaterial, their biological properties and their applications for imaging macrophages in human diseases, including cancer, atherosclerosis, myocardial infarction, aortic aneurysm, diabetes and other conditions. We anticipate that future needs will include the development of nanomaterials that are specific for immune cell subsets and can be used as imaging surrogates for nanotherapeutics. New in vivo imaging clinical tools for noninvasive macrophage quantification are thus ultimately expected to become relevant to predicting patients' clinical outcome, defining treatment options and monitoring responses to therapy.

Treatment choices and outcomes of patients with manometrically diagnosed achalasia.

PubMed

Yeung, J C; Finley, C; Hanna, W C; Miller, L; Ferri, L; Urbach, D R; Darling, G E

2016-07-01

This prospective population-based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre-diagnosis and Medical Outcomes Study 36-item Short-Form (SF-36) survey. Treatment decisions were made by the referring physician and the patient. Follow-up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1-year follow-up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty-four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/- 12.2, 17 +/- 10.9, and 9 +/- 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of -3.5 +/- 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF-36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment. © 2015 International Society for Diseases of the Esophagus.

Successful Continuation of Pregnancy After Treatment of Group A Streptococci Sepsis.

PubMed

Alhousseini, Ali; Layne, Mia E; Gonik, Bernard; Bryant, David; Patwardhan, Sanjay; Patwardhan, Manasi

2017-05-01

Invasive group A streptococci infections in pregnancy have historically led to severe maternal and neonatal morbidity and mortality. We are reporting a rare and novel case of successful treatment of third-trimester group A streptococci infection with early, aggressive intervention and maintenance of the pregnancy to term. A 35 year old woman initially presented with fever, flu-like symptoms, and preterm contractions at 34 weeks of gestation. She demonstrated signs of early stages of septic shock, ultimately attributed to group A streptococci bacteremia. Early, aggressive intervention allowed the pregnancy to continue until 38 weeks of gestation with normal maternal and neonatal outcomes. Early and aggressive treatment of invasive group A streptococci infection during pregnancy can potentially avoid severe maternal and perinatal morbidity and mortality with a successful continuation of pregnancy.

Therapy-related Myeloid Leukemia

PubMed Central

Godley, Lucy A.; Larson, Richard A.

2008-01-01

Therapy-related myelodysplastic syndrome and acute myeloid leukemia (t-MDS/t-AML) are thought to be the direct consequence of mutational events induced by chemotherapy, radiation therapy, immunosuppressive therapy, or a combination of these modalities, given for a pre-existing condition. The outcomes for these patients have been poor historically compared to people who develop de novo AML. The spectrum of cytogenetic abnormalities in t-AML is similar to de novo AML, but the frequency of unfavorable cytogenetics, such as a complex karyotype or deletion or loss of chromosomes 5 and/or 7, is considerably higher in t-AML. Survival varies according to cytogenetic risk group in t-AML patients, with better outcomes being observed in those with favorable-risk karyotypes. Treatment recommendations should be based on performance status and karyotype. A deeper understanding of the factors that predispose patients to the development of therapy-related myeloid leukemia would help clinicians monitor patients more carefully after treatment for a primary condition. Ultimately, this knowledge could influence initial treatment strategies with the goal of decreasing the incidence of this serious complication. PMID:18692692

Favorable Outcomes of Pediatric Patients Treated With Radiotherapy to the Central Nervous System Who Develop Radiation-Induced Meningiomas

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

Galloway, Thomas J.; Indelicato, Daniel J., E-mail: dindelicato@floridaproton.or; University of Florida Proton Therapy Institute, Jacksonville, FL

Purpose: To report the outcome of patients treated at the University of Florida who developed meningiomas after radiation to the central nervous system (CNS) for childhood cancer. Methods and Materials: We retrospectively identified 10 patients aged {<=}19 years who received radiotherapy to sites in the craniospinal axis and subsequently developed a meningioma. We report the histology of the radiation-induced meningioma, treatment received, and ultimate outcome among this cohort of patients. Results: Meningioma was diagnosed at a median of 23.5 years after completion of the primary radiation. Fifty percent of second meningiomas were World Health Organization Grade 2 (atypical) or higher.more » All cases were managed with a single modality: resection alone (n = 7), fractionated radiotherapy (n = 2), and stereotactic radiosurgery (n = 1). The actuarial event-free survival and overall survival rate at 5 years after treatment for a radiation-induced meningioma was 89%. Three patients who underwent resection for retreatment experienced a Grade 3 toxicity. Conclusions: Radiation-induced meningiomas after treatment of pediatric CNS tumors are effectively managed with single-modality therapy. Such late-effect data inform the overall therapeutic ratio and support the continued role of selective irradiation in managing pediatric CNS malignancies.« less

Fred Hutch's Paulovich Laboratory to Lead Protein Assay Work for National Beau Biden Cancer Moonshot | Office of Cancer Clinical Proteomics Research

Cancer.gov

The Applied Proteogenomics OrganizationaL Learning and Outcomes (APOLLO) network, which is a partnership among the National Cancer Institute, Department of Defense, and Department of Veterans Affairs, has tapped the Paulovich Laboratory at Fred Hutchinson Cancer Research Center to create a panel of tests to measure key proteins that can serve as markers for tumors. The effort could ultimately lead to treatments that are more specifically targeted to a patient’s distinct type of cancer.  

Retinoic acid plus arsenic trioxide, the ultimate panacea for acute promyelocytic leukemia?

PubMed

Lallemand-Breitenbach, Valérie; de Thé, Hugues

2013-09-19

Rarely in the field of cancer treatment did we experience as many surprises as with acute promyelocytic leukemia (APL). Yet, the latest clinical trial reported by Lo-Coco et al in the New England Journal of Medicine is a practice-changing study, as it reports a very favorable outcome of virtually all enrolled low-intermediate risk patients with APL without any DNA-damaging chemotherapy. Although predicted from previous small pilot studies, these elegant and stringently controlled results open a new era in leukemia therapy.

How to customize a bona fide psychotherapy for generalized anxiety disorder? A two-arms, patient blinded, ABAB crossed-therapist randomized clinical implementation trial design [IMPLEMENT 2.0].

PubMed

Flückiger, Christoph; Wolfer, Christine; Held, Judith; Hilpert, Peter; Rubel, Julian; Allemand, Mathias; Zinbarg, Richard E; Vîslă, Andreea

2018-04-03

Bona fide psychotherapy approaches are effective treatments for generalized anxiety disorder (GAD) compared to no-treatment conditions. Treatment manuals and protocols allow a relatively high degree of freedom for the way therapists implement these overall treatment packages and there is a systematic lack of knowledge on how therapists should customize these treatments. The present study experimentally examines two implementation strategies of customizing a bona fide psychotherapy approach based on a 16 session time-limited cognitive-behavioral therapy (CBT) protocol and their relation to the post-session and ultimate treatment outcomes. This trial contrasts two different implementation strategies of how to customize the in-session structure of a manual-based CBT-protocol for GAD. The patients will be randomly assigned to two implementation conditions: (1) a systematic focus on subtle changes lasting from 7 to 20 min at the check-in phase of every psychotherapy session and (2) a state-of-the-art (SOTA) check-in phase lasting several minutes mainly focused on the session goals. Potential therapist effects will be examined based on an ABAB crossed-therapist design. Treatment outcomes will be assessed at the following times: post-session outcomes, treatment outcome at post assessment and 6- as well as 12-month follow-up. The proposed randomized clinical implementation trial addresses the clinically relevant question of how to customize a bona fide psychotherapy protocol experimentally contrasting two implementation strategies. Through the development and testing of the proposed implementation design, this trial has the potential to inform therapists about efficacious implementation strategies of how to customize a manual-based treatment protocol in respect to the timing of the in-session structure. This trial was registered at ClinicalTrials.gov ( NCT03079336 ) at March 14, 2017.

Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest.

PubMed

Lin, Yan-Ren; Syue, Yuan-Jhen; Buddhakosai, Waradee; Lu, Huai-En; Chang, Chin-Fu; Chang, Chih-Yu; Chen, Cheng Hsu; Chen, Wen-Liang; Li, Chao-Jui

2016-03-01

The postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA.Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003-2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15-30, and late: >30 minutes after collapse) were analyzed.Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome.Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration.

Impact of Different Initial Epinephrine Treatment Time Points on the Early Postresuscitative Hemodynamic Status of Children With Traumatic Out-of-hospital Cardiac Arrest

PubMed Central

Lin, Yan-Ren; Syue, Yuan-Jhen; Buddhakosai, Waradee; Lu, Huai-En; Chang, Chin-Fu; Chang, Chih-Yu; Chen, Cheng Hsu; Chen, Wen-Liang; Li, Chao-Jui

2016-01-01

Abstract The postresuscitative hemodynamic status of children with traumatic out-of-hospital cardiac arrest (OHCA) might be impacted by the early administration of epinephrine, but this topic has not been well addressed. The aim of this study was to analyze the early postresuscitative hemodynamics, survival, and neurologic outcome according to different time points of first epinephrine treatment among children with traumatic OHCA. Information on 388 children who presented to the emergency departments of 3 medical centers and who were treated with epinephrine for traumatic OHCA during the study period (2003–2012) was retrospectively collected. The early postresuscitative hemodynamic features (cardiac functions, end-organ perfusion, and consciousness), survival, and neurologic outcome according to different time points of first epinephrine treatment (early: <15, intermediate: 15–30, and late: >30 minutes after collapse) were analyzed. Among 165 children who achieved sustained return of spontaneous circulation, 38 children (9.8%) survived to discharge and 12 children (3.1%) had good neurologic outcomes. Early epinephrine increased the postresuscitative heart rate and blood pressure in the first 30 minutes, but ultimately impaired end-organ perfusion (decreased urine output and initial creatinine clearance) (all P < 0.05). Early epinephrine treatment increased the chance of achieving sustained return of spontaneous circulation, but did not increase the rates of survival and good neurologic outcome. Early epinephrine temporarily increased heart rate and blood pressure in the first 30 minutes of the postresuscitative period, but impaired end-organ perfusion. Most importantly, the rates of survival and good neurologic outcome were not significantly increased by early epinephrine administration. PMID:27015217

Living in a Patient-Centric Universe.

PubMed

Kraus, Dennis H

2016-12-01

Patients with head and neck cancer face a number of challenges in terms of treatment, cure of their underlying malignant condition, and quality of survivorship. This presentation will focus on the patient perception of both the quality of care and the empathy and availability of the head and neck oncology team. It has become evident that the quality of survivorship plays a central role in the patient's decision-making process. The process of decision making by the patient facing head and neck cancer and the impact on treatment choices will be explored. The ability of the patient and her or his support system to navigate through the increasingly complicated health care system will be considered, with an emphasis on strategies for success. Finally, the role of the of the head and neck surgeon, and the need for physician wellness in predicating successful patient outcomes will be considered. The ultimate goal of achieving optimal care, superior patient outcomes, and patient satisfaction is the true objective of the concept of living in a patient-centric universe.

Childhood obesity and cardiovascular disease: links and prevention strategies

PubMed Central

Nadeau, Kristen J.; Maahs, David M.; Daniels, Stephen R.; Eckel, Robert H.

2015-01-01

The prevalence and severity of pediatric obesity have dramatically increased since the late 1980s, raising concerns about a subsequent increase in cardiovascular outcomes. Strong evidence, particularly from autopsy studies, supports the concept that precursors of adult cardiovascular disease (CVD) begin in childhood, and that pediatric obesity has an important influence on overall CVD risk. Lifestyle patterns also begin early and impact CVD risk. In addition, obesity and other CVD risk factors tend to persist over time. However, whether childhood obesity causes adult CVD directly, or does so by persisting as adult obesity, or both, is less clear. Regardless, sufficient data exist to warrant early implementation of both obesity prevention and treatment in youth and adults. In this Review, we examine the evidence supporting the impact of childhood obesity on adult obesity, surrogate markers of CVD, components of the metabolic syndrome, and the development of CVD. We also evaluate how obesity treatment strategies can improve risk factors and, ultimately, adverse clinical outcomes. PMID:21670745

Graft-versus-Host Disease Treatment: Predictors of Survival

PubMed Central

Levine, John E.; Logan, Brent; Wu, Juan; Alousi, Amin M.; Ho, Vincent; Bolaños-Meade, Javier; Weisdorf, Daniel

2010-01-01

Acute graft-versus-host disease (aGVHD) following allogeneic hematopoietic cell transplant (HCT) is the major reason for non-relapse mortality and thus is a major determinant of long term survival. Clinical trials of new aGVHD treatments are needed in order to identify approaches that will ultimately improve upon HCT survival. At present it is not clear how quickly response to GVHD treatment needs to be established in order to reliably categorize patients at high risk for death or to promptly identify those who might benefit from alternate treatment. Therefore, we analyzed time to response from onset of aGVHD treatment in 180 patients who were enrolled on a national, randomized, phase II aGVHD treatment clinical trial whose initial treatment of GVHD consisted of high dose steroids plus a second immunosuppressive agent. The aim of this analysis was to determine whether time to aGVHD treatment response predicts patient outcomes, especially survival. We used response at 14, 28 and 56 days from initiation of aGVHD treatment to categorize patients for non-relapse mortality and survival. Multivariate analyses and specificity/sensitivity analyses identified that day 28 response (complete or partial response) best categorized patients by non-relapse mortality and survival at 9 months from start of aGVHD treatment. If verified as a reliable predictor of late outcomes following other aGVHD treatment approaches, day 28 response should serve as a standard early endpoint for future trials of aGVHD therapy. PMID:20541024

Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: a randomized controlled multicenter trial

PubMed Central

Palermo, Tonya M.; Law, Emily F.; Fales, Jessica; Bromberg, Maggie H.; Jessen-Fiddick, Tricia; Tai, Gabrielle

2016-01-01

Internet-delivered interventions are emerging as a strategy to address barriers to care for individuals with chronic pain. This is the first large multicenter randomized controlled trial of Internet-delivered cognitive-behavioral therapy (CBT) for pediatric chronic pain. Participants included were 273 adolescents (205 females and 68 males), aged 11 to 17 years with mixed chronic pain conditions and their parents, who were randomly assigned in a parallel-group design to Internet-delivered CBT (n = 138) or Internet-delivered Education (n = 135). Assessments were completed before treatment, immediately after treatment, and at 6-month follow-up. All data collection and procedures took place online. The primary analysis used linear growth models. Results demonstrated significantly greater reduction on the primary outcome of activity limitations from baseline to 6-month follow-up for Internet CBT compared with Internet education (b = −1.13, P = 0.03). On secondary outcomes, significant beneficial effects of Internet CBT were found on sleep quality (b = 0.14, P = 0.04), on reducing parent miscarried helping (b = −2.66, P = 0.007) and protective behaviors (b = −0.19, P = 0.001), and on treatment satisfaction (P values < 0.05). On exploratory outcomes, benefits of Internet CBT were found for parent-perceived impact (ie, reductions in depression, anxiety, self-blame about their adolescent’s pain, and improvement in parent behavioral responses to pain). In conclusion, our Internet-delivered CBT intervention produced a number of beneficial effects on adolescent and parent outcomes, and could ultimately lead to wide dissemination of evidence-based psychological pain treatment for youth and their families. PMID:26335910

Effects of a Home-Based Family-Centred Early Habilitation Program on Neurobehavioural Outcomes of Very Preterm Born Infants: A Retrospective Cohort Study

PubMed Central

Poggioli, Michela; Minichilli, Fabrizio; Bononi, Tiziana; Meghi, Pasquina; Andre, Paolo; Crecchi, Alessandra; Rossi, Bruno; Carboncini, Maria Chiara; Ottolini, Alberto

2016-01-01

Preterm children have an increased risk of neurodevelopmental impairments which include psychomotor and language retardation. The objectives of the present retrospective cohort study were to examine the effects of an individually adapted, home-based, and family-centred early developmental habilitation program on neurodevelopmental and behavioural outcomes of very preterm children compared with a standard follow-up at 2 years' corrected age. Enrolled infants were retrospectively assigned to the intervention group (61 subjects) or to the control group (62 subjects) depending on whether they had or had not carried out a home-based family-centred early developmental habilitation program focused on environmental enrichment, parent-guided environmental interaction, and infant development. Developmental outcome was assessed for both groups at 24 months' corrected age using the Bayley Scales of Infant Development 2nd Edition. Intervention significantly improved both cognitive and behavioural outcomes. In addition, males had significantly lower scores than females either before or after treatment. However, the treatment was effective in both genders to the same extent. In conclusion, a timely updated environment suitable to the infant's developmental needs could provide the best substrate where the parent-infant relationship can be practised with the ultimate goal of achieving further developmental steps. PMID:28090357

Effects of a Home-Based Family-Centred Early Habilitation Program on Neurobehavioural Outcomes of Very Preterm Born Infants: A Retrospective Cohort Study.

PubMed

Poggioli, Michela; Minichilli, Fabrizio; Bononi, Tiziana; Meghi, Pasquina; Andre, Paolo; Crecchi, Alessandra; Rossi, Bruno; Carboncini, Maria Chiara; Ottolini, Alberto; Bonfiglio, Luca

2016-01-01

Preterm children have an increased risk of neurodevelopmental impairments which include psychomotor and language retardation. The objectives of the present retrospective cohort study were to examine the effects of an individually adapted, home-based, and family-centred early developmental habilitation program on neurodevelopmental and behavioural outcomes of very preterm children compared with a standard follow-up at 2 years' corrected age. Enrolled infants were retrospectively assigned to the intervention group (61 subjects) or to the control group (62 subjects) depending on whether they had or had not carried out a home-based family-centred early developmental habilitation program focused on environmental enrichment, parent-guided environmental interaction, and infant development. Developmental outcome was assessed for both groups at 24 months' corrected age using the Bayley Scales of Infant Development 2nd Edition. Intervention significantly improved both cognitive and behavioural outcomes. In addition, males had significantly lower scores than females either before or after treatment. However, the treatment was effective in both genders to the same extent. In conclusion, a timely updated environment suitable to the infant's developmental needs could provide the best substrate where the parent-infant relationship can be practised with the ultimate goal of achieving further developmental steps.

Improving the Reporting of Clinical Trials of Infertility Treatments (IMPRINT): modifying the CONSORT statement.

PubMed

2014-10-01

Clinical trials testing infertility treatments often do not report on the major outcomes of interest to patients and clinicians and the public (such as live birth) nor on the harms, including maternal risks during pregnancy and fetal anomalies. This is complicated by the multiple participants in infertility trials which may include a woman (mother), a man (father), and a third individual if successful, their offspring (child), who is also the desired outcome of treatment. The primary outcome of interest and many adverse events occur after cessation of infertility treatment and during pregnancy and the puerperium, which creates a unique burden of follow-up for clinical trial investigators and participants. In 2013, because of the inconsistencies in trial reporting and the unique aspects of infertility trials not adequately addressed by existing Consolidated Standards of Reporting Trials (CONSORT) statements, we convened a consensus conference in Harbin, China, with the aim of planning modifications to the CONSORT checklist to improve the quality of reporting of clinical trials testing infertility treatment. The consensus group recommended that the preferred primary outcome of all infertility trials is live birth (defined as any delivery of a live infant after ≥20 weeks' gestation) or cumulative live birth, defined as the live birth per women over a defined time period (or number of treatment cycles). In addition, harms to all participants should be systematically collected and reported, including during the intervention, any resulting pregnancy, and the neonatal period. Routine information should be collected and reported on both male and female participants in the trial. We propose to track the change in quality that these guidelines may produce in published trials testing infertility treatments. Our ultimate goal is to increase the transparency of benefits and risks of infertility treatments to provide better medical care to affected individuals and couples. Copyright © 2014 The Author. Published by Elsevier Inc. All rights reserved.

Cognitive Impairment in Bipolar Disorder: Treatment and Prevention Strategies.

PubMed

Solé, Brisa; Jiménez, Esther; Torrent, Carla; Reinares, Maria; Bonnin, Caterina Del Mar; Torres, Imma; Varo, Cristina; Grande, Iria; Valls, Elia; Salagre, Estela; Sanchez-Moreno, Jose; Martinez-Aran, Anabel; Carvalho, André F; Vieta, Eduard

2017-08-01

Over the last decade, there has been a growing appreciation of the importance of identifying and treating cognitive impairment associated with bipolar disorder, since it persists in remission periods. Evidence indicates that neurocognitive dysfunction may significantly influence patients' psychosocial outcomes. An ever-increasing body of research seeks to achieve a better understanding of potential moderators contributing to cognitive impairment in bipolar disorder in order to develop prevention strategies and effective treatments. This review provides an overview of the available data from studies examining treatments for cognitive dysfunction in bipolar disorder as well as potential novel treatments, from both pharmacological and psychological perspectives. All these data encourage the development of further studies to find effective strategies to prevent and treat cognitive impairment associated with bipolar disorder. These efforts may ultimately lead to an improvement of psychosocial functioning in these patients. © The Author 2017. Published by Oxford University Press on behalf of CINP.

Pseudomonas aeruginosa Infective Endocarditis Following Aortic Valve Implantation: A Note of Caution

PubMed Central

Dapás, Juan Ignacio; Rivero, Cynthia; Burgos, Pablo; Vila, Andrea

2016-01-01

Transcatheter aortic valve implantation (TAVI) is an alternative treatment for severe aortic valve stenosis (AS) in patients with prohibitive risk for surgical aortic valve replacement (SAVR). Prosthetic valve endocarditis (PVE) is a rare complication of this relatively novel procedure and current guidelines do not include specific recommendations for its treatment. We report a case of PVE due to Pseudomonas aeruginosa after TAVI that required SAVR, with successful outcome. PVE usually occurs during the first year after TAVI and entails a high mortality risk because patients eligible for this min-imally invasive procedure are fragile (i.e. advanced age and/or severe comorbidities). Additionally, clinical presentation may be atypical or subtle and transesophageal echocardiogram (TEE) may not be conclusive, which delays diagnosis and treatment worsening the prognosis. This case highlights that open SAVR might be ultimately indicated as part of treatment for TAVI-PVE despite a high-risk surgery score. PMID:27014375

A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope.

PubMed

Fehlings, Michael G; Tetreault, Lindsay A; Wilson, Jefferson R; Kwon, Brian K; Burns, Anthony S; Martin, Allan R; Hawryluk, Gregory; Harrop, James S

2017-09-01

Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient's physical, psychological, and social well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.

Childhood Arthritis and Rheumatology Research Alliance Consensus Clinical Treatment Plans for Juvenile Dermatomyositis with Persistent Skin Rash.

PubMed

Huber, Adam M; Kim, Susan; Reed, Ann M; Carrasco, Ruy; Feldman, Brian M; Hong, Sandy D; Kahn, Philip; Rahimi, Homaira; Robinson, Angela Byun; Vehe, Richard K; Weiss, Jennifer E; Spencer, Charles

2017-01-01

Juvenile dermatomyositis (JDM) is the most common form of idiopathic inflammatory myopathy in children. While outcomes are generally thought to be good, persistence of skin rash is a common problem. The goal of this study was to describe the development of clinical treatment plans (CTP) for children with JDM characterized by persistent skin rash despite complete resolution of muscle involvement. The Childhood Arthritis and Rheumatology Research Alliance, a North American consortium of pediatric rheumatologists and other healthcare providers, used a combination of Delphi surveys and nominal group consensus meetings to develop CTP that reflected consensus on typical treatments for patients with JDM with persistent skin rash. Consensus was reached on patient characteristics and outcome assessment. Patients should have previously received corticosteroids and methotrexate (MTX). Three consensus treatment plans were developed. Plan A added intravenous immunoglobulin (IVIG) if it was not already being used. Plan B added mycophenolate mofetil, while Plan C added cyclosporine. Continuation of previous treatments, including corticosteroids, MTX, and IVIG, was permitted in plans B and C. Three consensus CTP were developed for use in children with JDM and persistent skin rash despite complete resolution of muscle disease. These CTP reflect typical treatment approaches and are not to be considered treatment recommendations or standard of care. Using prospective data collection and statistical methods to account for nonrandom treatment assignment, it is expected that these CTP will be used to allow treatment comparisons, and ultimately determine the best treatment for these patients.

The costs and consequences of assisted reproductive technology: an economic perspective.

PubMed

Connolly, Mark P; Hoorens, Stijn; Chambers, Georgina M

2010-01-01

Despite the growing use of assisted reproductive technologies (ART) worldwide, there is only a limited understanding of the economics of ART to inform policy about effective, safe and equitable financing of ART treatment. A review was undertaken of key studies regarding the costs and consequences of ART treatment, specifically examining the direct and indirect costs of treatment, economic drivers of utilization and clinical practice and broader economic consequences of ART-conceived children. The direct costs of ART treatment vary substantially between countries, with the USA standing out as the most expensive. The direct costs generally reflect the costliness of the underlying healthcare system. If unsubsidized, direct costs represent a significant economic burden to patients. The level of affordability of ART treatment is an important driver of utilization, treatment choices, embryo transfer practices and ultimately multiple birth rates. The costs associated with caring for multiple-birth ART infants and their mothers are substantial, reflecting the underlying morbidity associated with such pregnancies. Investment analysis of ART treatment and ART-conceived children indicates that appropriate funding of ART services appears to represent sound fiscal policy. The complex interaction between the cost of ART treatment and how treatments are subsidized in different healthcare settings and for different patient groups has far-reaching consequences for ART utilization, clinical practice and infant outcomes. A greater understanding of the economics of ART is needed to inform policy decisions and to ensure the best possible outcomes from ART treatment.

Enhancing the patient involvement in outcomes: a study protocol of personalised outcome measurement in the treatment of substance misuse

PubMed Central

2013-01-01

Background Involving patients in treatment is becoming increasingly popular in mental health [Sales & Alves: Personalized evaluation of psychological treatments: A review of tools and research designs, submitted]. However, in substance misuse treatment settings, the patient perspective about treatment tends to be overlooked. This has been cited as a key priority by Orford et al. [Addiction, 103: 875-885, 2008] who included patient feedback about treatment as one of ten areas requiring an urgent paradigm shift in addiction research and practice. This project will apply an innovative method to involve substance misuse patients in psychological therapies, by asking them to suggest topics to evaluate their treatment. These topics suggested by patients can be written as a list of personalised items, so-called as patient-generated outcome measures (PGOM). Despite its patient-friendly features, PGOM’s have never been used in this population, which is what this project aims to overcome. Methods/design This project is part of an International Exchange Platform on Personalising Addiction Treatment. Data will be collected in two phases (pre-post study and focus groups with patients) to explore the following: 1). How reliable and sensitive to change are PGOM’s and standardised measures in substance misuse treatment? 2). Do PGOM’s add relevant information to standardised measures? 3). What are the views of substance misuse patients about personalised outcome assessment? 4). Development of guidelines on using PGOM’s in this population Discussion This research will potentially demonstrate the diversity of personal problems among patients seeking substance misuse treatment, suggesting the relevance of PGOM as a method to personalise outcome measurement and, ultimately, guiding treatment provision. It is expected that, as in previous studies, PGOM’s will be perceived as helpful and patient-friendly tools, where patients may express their own concerns in a semi-structured setting. Similarly to other populations, we also expect PGOM’s to be reliable, valid and sensitive to clinical changes in substance misuse treatment, as well as more content informative than their standardised counterparts. If these results are achieved, we might hypothesize that PGOM’s are a potentially valid supplement to traditional standardised scales, by providing a closer insight to what motivates patients to participate in substance misuse treatment programmes. PMID:24341378

B-acute lymphoblastic leukemia and cystinuria in a patient with duplication 22q11.21 detected by chromosomal microarray analysis.

PubMed

Chang, Vivian Y; Quintero-Rivera, Fabiola; Baldwin, Erin E; Woo, Kathy; Martinez-Agosto, Julian A; Fu, Cecilia; Gomperts, Brigitte N

2011-03-01

Duplication 22q11.2 syndrome is the result of a microduplication of the same chromosomal region that is deleted in DiGeorge and Velocardiofacial syndromes. We describe a patient with dysmorphic features who was diagnosed with pre-B acute lymphoblastic leukemia, and developed cystinuria and pancreatitis during treatment. Duplication 22q11.2 has not been previously described in association with hematologic abnormalities. Chromosomal microarray technology was used to diagnose duplication 22q11.2 syndrome. In this era of advanced genomics, this technology has become an important method for helping to determine the molecular basis of diseases, best treatments and ultimately patient outcomes. Copyright © 2010 Wiley-Liss, Inc.

The future of pharmacogenetics in the treatment of heart failure.

PubMed

Anwar, Mohamed Subhan; Iskandar, Muhammad Zaid; Parry, Helen M; Doney, Alex S; Palmer, Colin N; Lang, Chim C

2015-11-01

Heart failure is a common disease with high levels of morbidity and mortality. Current treatment comprises β-blockers, ACE inhibitors, aldosterone antagonists and diuretics. Variation in clinical response seen in patients begs the question of whether there is a pharmacogenetic component yet to be identified. To date, the genes most studied involve the β-1, β-2, α-2 adrenergic receptors and the renin-angiotensin-aldosterone pathway, mainly focusing on SNPs. However results have been inconsistent. Genome-wide association studies and next-generation sequencing are seen as alternative approaches to discovering genetic variations influencing drug response. Hopefully future research will lay the foundations for genotype-led drug management in these patients with the ultimate aim of improving their clinical outcome.

Genomic variants in the ASS1 gene, involved in the nitric oxide biosynthesis and signaling pathway, predict hydroxyurea treatment efficacy in compound sickle cell disease/β-thalassemia patients.

PubMed

Chalikiopoulou, Constantina; Tavianatou, Anastasia-Gerasimoula; Sgourou, Argyro; Kourakli, Alexandra; Kelepouri, Dimitra; Chrysanthakopoulou, Maria; Kanelaki, Vasiliki-Kaliopi; Mourdoukoutas, Evangelos; Siamoglou, Stavroula; John, Anne; Symeonidis, Argyris; Ali, Bassam R; Katsila, Theodora; Papachatzopoulou, Adamantia; Patrinos, George P

2016-03-01

Hemoglobinopathies exhibit a remarkable phenotypic diversity that restricts any safe association between molecular pathology and clinical outcomes. Herein, we explored the role of genes involved in the nitric oxide biosynthesis and signaling pathway, implicated in the increase of fetal hemoglobin levels and response to hydroxyurea treatment, in 119 Hellenic patients with β-type hemoglobinopathies. We show that two ASS1 genomic variants (namely, rs10901080 and rs10793902) can serve as pharmacogenomic biomarkers to predict hydroxyurea treatment efficacy in sickle cell disease/β-thalassemia compound heterozygous patients. These markers may exert their effect by inducing nitric oxide biosynthesis, either via altering splicing and/or miRNA binding, as predicted by in silico analysis, and ultimately, increase γ-globin levels, via guanylyl cyclase targeting.

How Comparative Effectiveness Research Can Help To Advance ‘Personalized Medicine’ In Cancer Treatment

PubMed Central

Ramsey, Scott D.; Veenstra, David L.; Tunis, Sean R.; Garrison, Louis P.; Crowley, John J.; Baker, Laurence H.

2012-01-01

The use of biomarkers to “personalize” cancer treatment —identifying discrete genes, proteins, or other indicators that can differentiate one type of cancer from another and enable the use of highly tailored therapies -- offers tremendous potential for improved outcomes and lower treatment costs. However, the rapid development of cancer biomarker, or genomic, tests— combined with a paucity of evidence to support the effectiveness of the tests—presents a challenge for patients, clinicians and other stakeholders. In this article, we propose that comparative effectiveness research be used to strengthen what is now a haphazard process for developing and marketing cancer biomarker tests. We suggest novel funding approaches and a systematic process for moving from regulatory approval to the generation of evidence that meets the needs of stakeholders and, ultimately, patients. PMID:22147853

Leveraging Epidemiology and Clinical Studies of Cancer Outcomes: Recommendations and Opportunities for Translational Research

PubMed Central

2013-01-01

As the number of cancer survivors continues to grow, research investigating the factors that affect cancer outcomes, such as disease recurrence, risk of second malignant neoplasms, and the late effects of cancer treatments, becomes ever more important. Numerous epidemiologic studies have investigated factors that affect cancer risk, but far fewer have addressed the extent to which demographic, lifestyle, genomic, clinical, and psychosocial factors influence cancer outcomes. To identify research priorities as well as resources and infrastructure needed to advance the field of cancer outcomes and survivorship research, the National Cancer Institute sponsored a workshop titled “Utilizing Data from Cancer Survivor Cohorts: Understanding the Current State of Knowledge and Developing Future Research Priorities” on November 3, 2011, in Washington, DC. This commentary highlights recent findings presented at the workshop, opportunities to leverage existing data, and recommendations for future research, data, and infrastructure needed to address high priority clinical and research questions. Multidisciplinary teams that include epidemiologists, clinicians, biostatisticians, and bioinformaticists will be essential to facilitate future cancer outcome studies focused on improving clinical care of cancer patients, identifying those at high risk of poor outcomes, and implementing effective interventions to ultimately improve the quality and duration of survival. PMID:23197494

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

PubMed

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

2017-01-01

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

Fourier analysis of mitochondrial distribution in oocytes

NASA Astrophysics Data System (ADS)

Hollmann, Joseph L.; Brooks, Dana H.; Newmark, Judith A.; Warner, Carol M.; DiMarzio, Charles A.

2011-03-01

This paper describes a novel approach to quantifying mitochondrial patterns which are typically described using the qualitative terms "diffuse" "aggregated" and are potentially key indicators for an oocyte's health and survival potential post-implantation. An oocyte was isolated in a confocal image and a coarse grid was superimposed upon it. The spatial spectrum was calculated and an aggregation factor was generated. A classifier for healthy cells was developed and verified. The aggregation factor showed a clear distinction between the healthy and unhealthy oocytes. The ultimate goal is to screen oocytes for viability preimplantation, thus improving the outcome of in vitro fertilization (IVF) treatments.

Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience.

PubMed

Shwaartz, Chaya; Fields, Adam C; Sobrero, Maximiliano; Cohen, Brian D; Divino, Celia M

2016-09-01

Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery. This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out. Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups. The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.

Are quantitative cultures useful in the diagnosis of hospital-acquired pneumonia?

PubMed

San Pedro, G

2001-02-01

Noninvasive and invasive tests have been developed and studied for their utility in diagnosing and guiding the treatment of hospital-acquired pneumonia, a condition with an inherently high mortality. Early empiric antibiotic treatment has been shown to reduce mortality, so delaying this treatment until test results are available is not justifiable. Furthermore, tailoring therapy based on results of either noninvasive or invasive tests has not been clearly shown to affect morbidity and mortality. This may be related to quantitative limitations of these tests or possibly to a high false-negative rate in patients who receive early antibiotic treatment and may therefore have suppressed bacterial counts. Results of these tests, however, do influence treatment. It is therefore hoped that they may ultimately provide a rational basis for making therapeutic decisions. In the future, outcomes research should be a part of large-scale clinical trials, and noninvasive and invasive tests should be incorporated into the design in an attempt to provide a better understanding of the value of such tests.

The role of multiparametric flow cytometry in the detection of minimal residual disease in acute leukaemia.

PubMed

Lee, Denise; Grigoriadis, George; Westerman, David

2015-12-01

Flow cytometry is the most accessible method for minimal residual disease (MRD) detection due to its availability in most haematological centres. Using a precise combination of different antibodies, immunophenotypic detection of MRD in acute leukaemia can be performed by identifying abnormal combinations or expressions of antigens on malignant cells at diagnosis, during and post treatment. These abnormal phenotypes, referred to as leukaemia-associated immunophenotypes (LAIPs) are either absent or expressed at low frequency in normal bone marrow (BM) cells and are used to monitor the behaviour and quantitate the amount of residual disease following treatment. In paediatric acute lymphoblastic leukaemia (ALL), the level of MRD by multiparametric flow cytometry (MPFC) during therapy is recognised as an important predictor of outcome. Although less extensively studied, adult ALL and adult and paediatric acute myeloid leukaemia (AML) have also demonstrated similar findings. The challenge now is incorporating this information for risk-stratification so that therapy can be tailored individually and ultimately improve outcome while also limiting treatment-related toxicity. In this review we will elaborate on the current and future role of MPFC in MRD in acute leukaemia while also addressing its limitations.

Diffusion MRI in early cancer therapeutic response assessment

PubMed Central

Galbán, C. J.; Hoff, B. A.; Chenevert, T. L.; Ross, B. D.

2016-01-01

Imaging biomarkers for the predictive assessment of treatment response in patients with cancer earlier than standard tumor volumetric metrics would provide new opportunities to individualize therapy. Diffusion-weighted MRI (DW-MRI), highly sensitive to microenvironmental alterations at the cellular level, has been evaluated extensively as a technique for the generation of quantitative and early imaging biomarkers of therapeutic response and clinical outcome. First demonstrated in a rodent tumor model, subsequent studies have shown that DW-MRI can be applied to many different solid tumors for the detection of changes in cellularity as measured indirectly by an increase in the apparent diffusion coefficient (ADC) of water molecules within the lesion. The introduction of quantitative DW-MRI into the treatment management of patients with cancer may aid physicians to individualize therapy, thereby minimizing unnecessary systemic toxicity associated with ineffective therapies, saving valuable time, reducing patient care costs and ultimately improving clinical outcome. This review covers the theoretical basis behind the application of DW-MRI to monitor therapeutic response in cancer, the analytical techniques used and the results obtained from various clinical studies that have demonstrated the efficacy of DW-MRI for the prediction of cancer treatment response. PMID:26773848

Therapeutic strategies of meconium obstruction of the small bowel in very-low-birthweight neonates.

PubMed

Koshinaga, Tsugumichi; Inoue, Mikiya; Ohashi, Kensuke; Sugito, Kiminobu; Ikeda, Taro; Tomita, Ryouichi

2011-06-01

Meconium obstruction without cystic fibrosis in low-birthweight neonates is a distinct clinical entity. We aimed to determine what therapeutic strategies work best in very-low-birthweight neonates with meconium obstruction of the small bowel under varied clinical conditions caused by the associated diseases of prematurity. Medical records of very-low-birthweight neonates with meconium obstruction of the small bowel treated from 1998 to 2008 were retrospectively reviewed. Pre- and postnatal data, treatments, and clinical outcomes were assessed. Nine patients with perinatal complications were identified. Mean gestational age and birthweight were 26.9 weeks and 863 g, respectively. Abdominal distension developed from 1 to 7 days of life. Five patients were initially treated with Gastrografin enema, three of whom had successful outcomes. Two hemodynamically unstable patients failed to respond to Gastrografin treatment; they ultimately died of sepsis. The remaining four without Gastrografin treatment underwent enterostomy to resolve the obstructions with good results. Gastrografin and surgical treatments should be appropriately selected based on the underlying pathologies of meconium obstruction of the small bowel. Therapeutic Gastrografin enema is effective, safe and repeatable; however, it is not recommended for hemodynamically unstable patients. Surgical intervention is reserved for those who develop rapid abdominal distension that risks perforation. © 2011 The Authors.Pediatrics International © 2011 Japan Pediatric Society.

The evolution of clinical trials for infant acute lymphoblastic leukemia

PubMed Central

Kotecha, R S; Gottardo, N G; Kees, U R; Cole, C H

2014-01-01

Acute lymphoblastic leukemia (ALL) in infants has a significantly inferior outcome in comparison with older children. Despite initial improvements in survival of infants with ALL since establishment of the first pediatric cooperative group ALL trials, the poor outcome has plateaued in recent years. Historically, infants were treated on risk-adapted childhood ALL protocols. These studies were pivotal in identifying the need for infant-specific protocols, delineating prognostic categories and the requirement for a more unified approach between study groups to overcome limitations in accrual because of low incidence. This subsequently led to the development of collaborative infant-specific studies. Landmark outcomes have included the elimination of cranial radiotherapy following the discovery of intrathecal and high-dose systemic therapy as a superior and effective treatment strategy for central nervous system disease prophylaxis, with improved neurodevelopmental outcome. Universal prospective identification of independent adverse prognostic factors, including presence of a mixed lineage leukemia rearrangement and young age, has established the basis for risk stratification within current trials. The infant-specific trials have defined limits to which conventional chemotherapeutic agents can be intensified to optimize the balance between treatment efficacy and toxicity. Despite variations in therapeutic intensity, there has been no recent improvement in survival due to the equilibrium between relapse and toxicity. Ultimately, to improve the outcome for infants with ALL, key areas still to be addressed include identification and adaptation of novel prognostic markers and innovative therapies, establishing the role of hematopoietic stem cell transplantation in first complete remission, treatment strategies for relapsed/refractory disease and monitoring and timely intervention of late effects in survivors. This would be best achieved through a single unified international trial. PMID:24727996

A multi-marker molecular signature approach for treatment-specific subgroup identification with survival outcomes.

PubMed

Li, L; Guennel, T; Marshall, S; Cheung, L W-K

2014-10-01

Delivering on the promise of personalized medicine has become a focus of the pharmaceutical industry as the era of the blockbuster drug is fading. Central to realizing this promise is the need for improved analytical strategies for effectively integrating information across various biological assays (for example, copy number variation and targeted protein expression) toward identification of a treatment-specific subgroup-identifying the right patients. We propose a novel combination of elastic net followed by a maximal χ(2) and semiparametric bootstrap. The combined approaches are presented in a two-stage strategy that estimates patient-specific multi-marker molecular signatures (MMMS) to identify and directly test for a biomarker-driven subgroup with enhanced treatment effect. This flexible strategy provides for incorporation of business-specific needs, such as confining the search space to a subgroup size that is commercially viable, ultimately resulting in actionable information for use in empirically based decision making.

Right to experimental treatment: FDA new drug approval, constitutional rights, and the public's health.

PubMed

Leonard, Elizabeth Weeks

2009-01-01

On May 2, 2006, a divided panel of the U.S. Court of Appeals for the District of Columbia, in a startling opinion, Abigail Alliance for Better Access to Developmental Drugs v. Eschenbach, held that terminally ill patients who have exhausted all other available options have a constitutional right to experimental treatment that FDA has not yet approved. Although ultimately overturned by the full court, Abigail Alliance generated considerable interest from various constituencies. Meanwhile, FDA proposed similar regulatory amendments, as have lawmakers on both sides of the aisle in Congress. But proponents of expanded access fail to consider public health and consumer safety concerns. In particular, allowing patients to try unproven treatments, outside of controlled clinical trials risks both the study's outcome and the health of patients who might benefit from the deliberate, careful process of new drug approval as it currently operates under FDA's auspices.

Endpoints and cutpoints in head and neck oncology trials: methodical background, challenges, current practice and perspectives.

PubMed

Hezel, Marcus; von Usslar, Kathrin; Kurzweg, Thiemo; Lörincz, Balazs B; Knecht, Rainald

2016-04-01

This article reviews the methodical and statistical basics of designing a trial, with a special focus on the process of defining and choosing endpoints and cutpoints as the foundations of clinical research, and ultimately that of evidence-based medicine. There has been a significant progress in the treatment of head and neck cancer in the past few decades. Currently available treatment options can have a variety of different goals, depending e.g. on tumor stage, among other factors. The outcome of a specific treatment in clinical trials is measured using endpoints. Besides classical endpoints, such as overall survival or organ preservation, other endpoints like quality of life are becoming increasingly important in designing and conducting a trial. The present work is based on electronic research and focuses on the solid methodical and statistical basics of a clinical trial, on the structure of study designs and on the presentation of various endpoints.

Donations After Circulatory Death in Liver Transplant

PubMed Central

Eren, Emre A.; Latchana, Nicholas; Beal, Eliza; Hayes, Don; Whitson, Bryan; Black, Sylvester M.

2017-01-01

The supply of liver grafts for treatment of end-stage liver disease continues to fall short of ongoing demands. Currently, most liver transplants originate from donations after brain death. Enhanced utilization of the present resources is prudent to address the needs of the population. Donation after circulatory or cardiac death is a mechanism whereby the availability of organs can be expanded. Donations after circulatory death pose unique challenges given their exposure to warm ischemia. Technical principles of donations after circulatory death procurement and pertinent studies investigating patient outcomes, graft outcomes, and complications are highlighted in this review. We also review associated risk factors to suggest potential avenues to achieve improved outcomes and reduced complications. Future considerations and alternative techniques of organ preservation are discussed, which may suggest novel strategies to enhance preservation and donor expansion through the use of marginal donors. Ultimately, without effective measures to bolster organ supply, donations after circulatory death should remain a consideration; however, an understanding of inherent risks and limitations is necessary. PMID:27733105

Donations After Circulatory Death in Liver Transplant.

PubMed

Eren, Emre A; Latchana, Nicholas; Beal, Eliza; Hayes, Don; Whitson, Bryan; Black, Sylvester M

2016-10-01

The supply of liver grafts for treatment of end-stage liver disease continues to fall short of ongoing demands. Currently, most liver transplants originate from donations after brain death. Enhanced utilization of the present resources is prudent to address the needs of the population. Donation after circulatory or cardiac death is a mechanism whereby the availability of organs can be expanded. Donations after circulatory death pose unique challenges given their exposure to warm ischemia. Technical principles of donations after circulatory death procurement and pertinent studies investigating patient outcomes, graft outcomes, and complications are highlighted in this review. We also review associated risk factors to suggest potential avenues to achieve improved outcomes and reduced complications. Future considerations and alternative techniques of organ preservation are discussed, which may suggest novel strategies to enhance preservation and donor expansion through the use of marginal donors. Ultimately, without effective measures to bolster organ supply, donations after circulatory death should remain a consideration; however, an understanding of inherent risks and limitations is necessary.

Integrating Electronic Patient-Reported Outcome Measures into Routine HIV Care and the ANRS CO3 Aquitaine Cohort's Data Capture and Visualization System (QuAliV): Protocol for a Formative Research Study.

PubMed

Barger, Diana; Leleux, Olivier; Conte, Valérie; Sapparrart, Vincent; Gapillout, Marie; Crespel, Isabelle; Erramouspe, Marie; Delveaux, Sandrine; Dabis, Francois; Bonnet, Fabrice

2018-06-07

Effective antiretroviral therapy has greatly reduced HIV-related morbidity and mortality, dramatically changing the demographics of the population of people living with HIV. The majority of people living with HIV in France are well cared for insofar as their HIV infection is concerned but remain at risk for age-associated comorbidities. Their long-term, potentially complex, and growing care needs make the routine, longitudinal assessment of health-related quality of life and other patient-reported outcomes of relevance in the current treatment era. We aim to describe the development of a Web-based electronic patient-reported outcomes system for people living with HIV linked to the ANRS CO3 Aquitaine cohort's data capture and visualization system (ARPEGE) and designed to facilitate the electronic collection of patient-reported data and ultimately promote better patient-physician communication and quality of care (both patient satisfaction and health outcomes). Participants who meet the eligibility criteria will be invited to engage with the Web-based electronic patient-reported outcomes system and provided with the information necessary to create a personal patient account. They will then be able to access the electronic patient-reported outcomes system and complete a set of standardized validated questionnaires covering health-related quality of life (World Health Organization's Quality of Life Instrument in HIV infection, named WHOQOL-HIV BREF) and other patient-reported outcomes. The information provided via questionnaires will ultimately be presented in a summary format for clinicians, together with the patient's HIV care history. The prototype of the Web-based electronic patient-reported outcome system will be finalized and the first 2 formative research phases of the study (prototyping and usability testing) will be conducted from December 2017 to May 2018. We describe the sequential processes planned to ensure that the proposed electronic patient-reported outcome system is ready for formal pilot testing, referred to herein as phases 1a and 1b. We also describe the planned pilot-testing designed to evaluate the acceptability and use of the system from the patient's perspective (phase 2). As the underlying information technology solution, ARPEGE, has being developed in-house, should the feasibility study presented here yield promising results, the panel of services provided via the proposed portal could ultimately be expanded and used to experiment with health-promoting interventions in aging people living with HIV in hospital-based care or adapted for use in other patient populations. ClinicalTrials.gov NCT03296202; https://clinicaltrials.gov/ct2/show/NCT03296202 (Archived by WebCite at http://www.webcitation.org/6zgOBArps). RR1-10.2196/9439. ©Diana Barger, Olivier Leleux, Valérie Conte, Vincent Sapparrart, Marie Gapillout, Isabelle Crespel, Marie Erramouspe, Sandrine Delveaux, Francois Dabis, Fabrice Bonnet. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 07.06.2018.

Iatrogenic vertebral artery pseudoaneurysm due to central venous catheterization

PubMed Central

Vasquez, Jay

2011-01-01

Central venous lines have become an integral part of patient care, but they are not without complications. Vertebral artery pseudoaneurysm formation is one of the rarer complications of central line placement. Presented is a rare case of two pseudoaneurysms of the vertebral and subclavian artery after an attempted internal jugular vein catheterization. These were successfully treated with open surgical repair and bypass. Open surgical repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudoaneurysms has been described with promising outcomes, but long-term results are lacking. Ultimately, the best treatment of these iatrogenic injuries should start with prevention. Well-documented techniques to minimize mechanical complications, including inadvertent arterial puncture, should be practiced and taught in training programs to avoid the potentially devastating consequences. PMID:21566753

Rational treatment for multiple digit congenital absence: case report of nonvascularized toe phalangeal transfers and distraction lengthening for symbrachydactyly.

PubMed

Netscher, David T; Richards, Winston T

2006-02-01

A case is discussed in which a young male was born with symbrachydactyly of multiple digits in whom nonvascularized proximal toe phalanges were transferred to the aphalangic digits when he was an infant. This initial surgical procedure was later followed by webspace deepening and ultimately by distraction lengthening of the digits. At 8 years of age, he has a very functional hand with mobile metacarpophalangeal joints in all reconstructed fingers. In fact, he uses this reconstructed right hand as his dominant extremity. The case is discussed in context of phalangeal growth potential, specific indications for this type of reconstruction, and final long-term outcome. This case also helps to recommend rational treatment protocols for similar congenital hand anomalies.

Localized scleroderma.

PubMed

Kreuter, Alexander

2012-01-01

Localized scleroderma (also called morphea) is a term encompassing a spectrum of sclerotic autoimmune diseases that primarily affect the skin, but also might involve underlying structures such as the fat, fascia, muscle, and bones. Its exact pathogenesis is still unknown, but several trigger factors in genetically predisposed individuals might initially lead to an immunologically triggered release of pro-inflammatory cytokines, resulting in a profound dysregulation of the connective tissue metabolism and ultimately to induction of fibrosis. To date, there are no specific serological markers available for localized scleroderma. Within the last years, several validated clinical scores have been introduced as potential outcome measures for the disease. Given the rarity of localized scleroderma, only few evidence-based therapeutical treatment options exist. So far, the most robust data is available for ultraviolet A1 phototherapy in disease that is restricted to the skin, and methotrexate alone or in combination with systemic corticosteroids in more severe disease that additionally affects extracutaneous structures. This practical review summarizes relevant information on the epidemiology, pathogenesis, clinical subtypes and classifications, differential diagnoses, clinical scores and outcome measures, and current treatment strategies of localized scleroderma. © 2012 Wiley Periodicals, Inc.

Extra-articular hip impingement: a systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement.

PubMed

de Sa, Darren; Alradwan, Hussain; Cargnelli, Stephanie; Thawer, Zoyah; Simunovic, Nicole; Cadet, Edwin; Bonin, Nicolas; Larson, Christopher; Ayeni, Olufemi R

2014-08-01

Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management. We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented. Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P = .008), Hip Outcome Score-Activities of Daily Living (P = .02), and Hip Outcome Score-Sport (P = .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5° improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported. This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes. Systematic review of Level IV and V (case report) studies. Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

What is the most relevant standard of success in assisted reproduction? Defining outcome in ART: a Gordian knot of safety, efficacy and quality.

PubMed

Land, Jolande A; Evers, Johannes L H

2004-05-01

In the course of the present Debate series, several new outcome measures for assisted reproduction have been proposed to encourage the transfer of fewer embryos, in order to diminish the number of multiple pregnancies. The implementation of these recommendations, however, is hampered by the perception that safety and efficacy are communicating vessels: it is presumed that by decreasing the number of embryos transferred, pregnancy rates will decrease as well. Data from national and international registries, however, do not confirm the assumption of the communicating vessels: pregnancy rates tend to be low in countries in which many embryos are transferred, and the highest pregnancy rates occur where the number of embryos per transfer is low. Only top-level clinics (where treatment efficacy is guaranteed) are able to decrease the number of embryos transferred without compromising their pregnancy rate, and to vouch for safety in this way. Elective single embryo transfer (eSET) can never be mandatory in all patients, but the percentage of eSETs performed by a particular assisted reproduction treatment centre does reflect its quality: the ultimate outcome measure of efficacy ánd safety. Therefore, the eSET rate is the most relevant qualifier of performance in assisted reproduction.

Subpopulation Treatment Effect Pattern Plot (STEPP) analysis for continuous, binary and count outcomes

PubMed Central

Yip, Wai-Ki; Bonetti, Marco; Cole, Bernard F; Barcella, William; Wang, Xin Victoria; Lazar, Ann; Gelber, Richard D

2016-01-01

Background For the past few decades, randomized clinical trials have provided evidence for effective treatments by comparing several competing therapies. Their successes have led to numerous new therapies to combat many diseases. However, since their conclusions are based on the entire cohort in the trial, the treatment recommendation is for everyone, and may not be the best option for an individual. Medical research is now focusing more on providing personalized care for patients, which requires investigating how patient characteristics, including novel biomarkers, modify the effect of current treatment modalities. This is known as heterogeneity of treatment effects. A better understanding of the interaction between treatment and patient specific prognostic factors will enable practitioners to expand the availability of tailored therapies, with the ultimate goal of improving patient outcomes. The Subpopulation Treatment Effect Pattern Plot (STEPP) approach was developed to allow researchers to investigate the heterogeneity of treatment effects on survival outcomes across values of a (continuously measured) covariate, such as a biomarker measurement. Methods Here, we extend the STEPP approach to continuous, binary and count outcomes which can be easily modeled using generalized linear models. With this extension of STEPP, these additional types of treatment effects within subpopulations defined with respect to a covariate of interest can be estimated, and the statistical significance of any observed heterogeneity of treatment effect can be assessed using permutation tests. The desirable feature that commonly used models are applied to well-defined patient subgroups to estimate treatment effects is retained in this extension. Results We describe a simulation study to confirm that the proper Type I error rate is maintained when there is no treatment heterogeneity, and a power study to show that the statistics have power to detect treatment heterogeneity under alternative scenarios. As an illustration, we apply the methods to data from the Aspirin/Folate Polyp Prevention Study, a clinical trial evaluating the effect of oral aspirin, folic acid, or both as a chemoprevention agent against colorectal adenomas. The pre-existing R software package stepp has been extended to handle continuous, binary and count data using Gaussian, Bernoulli and Poisson models, and it is available on the Comprehensive R Archive Network. Conclusions The extension of the method and the availability of new software now permit STEPP to be applied to the full range of clinical trial end points. PMID:27094489

Cardiovascular Safety of Biologics and JAK Inhibitors in Patients with Rheumatoid Arthritis.

PubMed

Kang, Eun Ha; Liao, Katherine P; Kim, Seoyoung C

2018-05-30

Increased cardiovascular (CV) risk and associated mortality in rheumatoid arthritis (RA) are not fully explained by traditional CV risk factors. This review discusses the epidemiology and mechanisms of increased CV risk in RA and treatment effects on CV risk focusing on biologic disease-modifying anti-rheumatic drugs (DMARDs) and JAK inhibitors. Intermediary metabolic changes by inflammatory cytokines are observed in body composition, lipid profile, and insulin sensitivity of RA patients, leading to accelerated atherosclerosis and increased CV risk. Successful treatment with DMARDs has shown beneficial effects on these metabolic changes and ultimately CV outcomes, in proportion to the treatment efficacy in general but also with drug-specific mechanisms. Recent data provide further information on comparative CV safety between biologic DMARDs or JAK inhibitors as well as their safety signals for non-atherosclerotic CV events. CV benefits or safety signals associated with DMARD treatments can differ despite similar drug efficacy against RA, suggesting that both anti-inflammatory and drug-specific mechanisms are involved in altering CV risk.

Improving the reporting of clinical trials of infertility treatments (IMPRINT): modifying the CONSORT statement†‡.

PubMed

Legro, Richard S; Wu, Xiaoke; Barnhart, Kurt T; Farquhar, Cynthia; Fauser, Bart C J M; Mol, Ben

2014-10-10

Clinical trials testing infertility treatments often do not report on the major outcomes of interest to patients and clinicians and the public (such as live birth) nor on the harms, including maternal risks during pregnancy and fetal anomalies. This is complicated by the multiple participants in infertility trials which may include a woman (mother), a man (father), and result in a third individual if successful, their offspring (child), who is also the desired outcome of treatment. The primary outcome of interest and many adverse events occur after cessation of infertility treatment and during pregnancy and the puerperium, which create a unique burden of follow-up for clinical trial investigators and participants. In 2013, because of the inconsistencies in trial reporting and the unique aspects of infertility trials not adequately addressed by existing Consolidated Standards of Reporting Trials (CONSORT) statements, we convened a consensus conference in Harbin, China, with the aim of planning modifications to the CONSORT checklist to improve the quality of reporting of clinical trials testing infertility treatment. The consensus group recommended that the preferred primary outcome of all infertility trials is live birth (defined as any delivery of a live infant ≥20 weeks gestations) or cumulative live birth, defined as the live birth per women over a defined time period (or number of treatment cycles). In addition, harms to all participants should be systematically collected and reported, including during the intervention, any resulting pregnancy, and during the neonatal period. Routine information should be collected and reported on both male and female participants in the trial. We propose to track the change in quality that these guidelines may produce in published trials testing infertility treatments. Our ultimate goal is to increase the transparency of benefits and risks of infertility treatments to provide better medical care to affected individuals and couples. © The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Achalasia: Outcome in children.

PubMed

Meyer, Anell; Catto-Smith, Anthony; Crameri, Joe; Simpson, Di; Alex, George; Hardikar, Winita; Cameron, Donald; Oliver, Mark

2017-02-01

Oesophageal achalasia is well-recognized but relatively rare in children, occasionally appearing as the "triple A" syndrome (with adrenal insufficiency and alacrima). Treatment modalities, as in adult practice, are not curative, often needing further interventions and spurring the search for better management. The outcome for syndromic variants is unknown. We sought to define the efficacy of treatments for children with achalasia with and without triple A syndrome. We conducted a retrospective analysis of presentation and outcomes for 42 children with achalasia presenting over three decades to a major pediatric referral center. Long term impact of the diagnosis was assessed by questionnaire. We identified 42 children including six with triple A syndrome. The median overall age at diagnosis was 10.8 years and median follow-up 1593 days. Initial Heller myotomy in 17 required further interventions in 11 (65%), while initial treatment with botulinum toxin (n = 20) was ultimately followed by myotomy in 17 (85%). Ten out of 35 patients who underwent myotomy required a repeat myotomy (29%). Patients with triple A syndrome developed symptoms earlier, but had delayed diagnosis, were more underweight at diagnosis and at last follow up. Questionnaire results suggested a significant long term deleterious impact on the quality of life of children and their families. Many children with achalasia relapse after initial treatment, undergoing multiple, different procedures, despite which symptoms persist and impact on quality of life. Symptoms develop earlier in patients with triple A syndrome, but the diagnosis is delayed and this has substantial nutritional impact. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

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

PubMed Central

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

2017-01-01

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

[Efficacy of epidural steroid injections for chronic lumbar pain syndromes without neurological deficits. A randomized, double blind study as part of a multimodal treatment concept].

PubMed

Niemier, K; Schindler, M; Volk, T; Baum, K; Wolf, B; Eberitsch, J; Seidel, W

2015-07-01

Chronic lumbar pain syndromes without neurological deficits are generated by a multitude of causes. Functional, morphological and psychosocial factors are discussed. In many cases a diseased intervertebral disc is found on radiological examination but the clinical relevance of these findings is not clear. For this study it was postulated that a diseased disc results in a local inflammatory reaction therefore causing pain and impairing treatability of patients. An epidural injection of steroids can reduce inflammation and therefore improve treatability and ultimately treatment outcome. A double blind randomized prospective trial was carried out. Patients treated in hospital for a chronic lumbar pain syndrome without neurological deficits within a multimodal treatment program were screened for indications for an epidural steroid injection (e.g. diseased lumbar disc and intention to treat). Patients eligible for the study were randomized into two groups. The treatment group received an epidural injection of 80 mg triamcinolone and 8 ml bupivacaine 0.25 %. The control group received only an epidural injection of 8 ml bupivacaine 0.25 %. In both groups pain intensity and treatability showed a statistically significant improvement after the epidural injection. The differences between the control and treatment groups were small and not clinically relevant. A small subgroup might profit from the steroid injection. In addition the treatability was dependent on psychometric values and the long-term outcome from a reduction of muscular skeletal dysfunctions. After the epidural injection the decrease in pain and increase in treatability was statistically significant. The mechanism of the improvement is not clear and should be examined further. The epidural injection of a steroid in this subgroup of patients did not lead to a clinical improvement in the outcome.

Overcoming obstacles to establish a multidisciplinary team approach to hepatobiliary diseases: a working model in a Caribbean setting.

PubMed

Cawich, Shamir O; Johnson, Peter B; Shah, Sundeep; Roberts, Patrick; Arthurs, Milton; Murphy, Trevor; Bonadie, Kimon O; Crandon, Ivor W; Harding, Hyacinth E; Abu Hilal, Mohammed; Pearce, Neil W

2014-01-01

By providing a structured forum to exchange information and ideas, multidisciplinary team meetings improve working relationships, expedite investigations, promote evidence-based treatment, and ultimately improve clinical outcomes. This discursive paper reports the introduction of a multidisciplinary team approach to manage hepatobiliary diseases in Jamaica, focusing on the challenges encountered and the methods used to overcome these obstacles. Despite multiple challenges in resource-limited environments, a multidisciplinary team approach can be incorporated into clinical practice in developing nations. Policy makers should make it a priority to support clinical, operational, and governance aspects of the multidisciplinary teams.

Distal Triceps Tendon Injuries.

PubMed

Keener, Jay D; Sethi, Paul M

2015-11-01

Acute triceps ruptures are an uncommon entity, occurring mainly in athletes, weight lifters (especially those taking anabolic steroids), and following elbow trauma. Accurate diagnosis is made clinically, although MRI may aid in confirmation and surgical planning. Acute ruptures are classified on an anatomic basis based on tear location and the degree of tendon involvement. Most complete tears are treated surgically in medically fit patients. Partial-thickness tears are managed according to the tear severity, functional demands, and response to conservative treatment. We favor an anatomic footprint repair of the triceps to provide optimal tendon to bone healing and, ultimately, functional outcome. Copyright © 2015 Elsevier Inc. All rights reserved.

Transcatheter Aortic Valve Replacement: a Kidney’s Perspective

PubMed Central

Cheungpasitporn, Wisit; Thongprayoon, Charat; Kashani, Kianoush

2016-01-01

Transcatheter aortic valve replacement (TAVR) has now emerged as a viable treatment option for high-risk patients with severe aortic stenosis (AS) who are not suitable candidates for surgical aortic valve replacement (SAVR). Despite encouraging published outcomes, acute kidney injury (AKI) is common and lowers the survival of patients after TAVR. The pathogenesis of AKI after TAVR is multifactorial including TAVR specific factors such as the use of contrast agents, hypotension during rapid pacing, and embolization; preventive measures may include pre-procedural hydration, limitation of contrast dye exposure, and avoidance of intraprocedural hypotension. In recent years, the number of TAVR performed worldwide has been increasing, as well as published data on renal perspectives of TAVR including AKI, chronic kidney disease, end-stage kidney disease, and kidney transplantation. This review aims to present the current literature on the nephrology aspects of TAVR, ultimately to improve the patients’ quality of care and outcomes. PMID:27069960

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

PubMed Central

Roch, Alexandra; Teyssedou, Jérome; Mutter, Didier; Marescaux, Jacques; Pessaux, Patrick

2014-01-01

Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis. PMID:25068010

Comprehensive Performance Nutrition for Special Operations Forces.

PubMed

Daigle, Karen A; Logan, Christi M; Kotwal, Russ S

2015-01-01

Special Operations Forces (SOF) training, combat, and contingency operations are unique and demanding. Performance nutrition within the Department of Defense has emphasized that nutrition is relative to factors related to the desired outcome, which includes successful performance of mentally and physically demanding operations and missions of tactical and strategic importance, as well as nonoperational assignments. Discussed are operational, nonoperational, and patient categories that require different nutrition strategies to facilitate category-specific performance outcomes. Also presented are 10 major guidelines for a SOF comprehensive performance nutrition program, practical nutrition recommendations for Special Operators and medical providers, as well as resources for dietary supplement evaluation. Foundational health concepts, medical treatment, and task-specific performance factors should be considered when developing and systematically implementing a comprehensive SOF performance nutrition program. When tailored to organizational requirements, SOF unit- and culture-specific nutrition education and services can optimize individual Special Operator performance, overall unit readiness, and ultimately, mission success. 2015.

Epilepsy and brain tumors

PubMed Central

ENGLOT, DARIO J.; CHANG, EDWARD F.; VECHT, CHARLES J.

2016-01-01

Seizures are common in patients with brain tumors, and epilepsy can significantly impact patient quality of life. Therefore, a thorough understanding of rates and predictors of seizures, and the likelihood of seizure freedom after resection, is critical in the treatment of brain tumors. Among all tumor types, seizures are most common with glioneuronal tumors (70–80%), particularly in patients with frontotemporal or insular lesions. Seizures are also common in individuals with glioma, with the highest rates of epilepsy (60–75%) observed in patients with low-grade gliomas located in superficial cortical or insular regions. Approximately 20–50% of patients with meningioma and 20–35% of those with brain metastases also suffer from seizures. After tumor resection, approximately 60–90% are rendered seizure-free, with most favorable seizure outcomes seen in individuals with glioneuronal tumors. Gross total resection, earlier surgical therapy, and a lack of generalized seizures are common predictors of a favorable seizure outcome. With regard to anticonvulsant medication selection, evidence-based guidelines for the treatment of focal epilepsy should be followed, and individual patient factors should also be considered, including patient age, sex, organ dysfunction, comorbidity, or cotherapy. As concomitant chemotherapy commonly forms an essential part of glioma treatment, enzyme-inducing anticonvulsants should be avoided when possible. Seizure freedom is the ultimate goal in the treatment of brain tumor patients with epilepsy, given the adverse effects of seizures on quality of life. PMID:26948360

[Quality assurance and quality management in intensive care].

PubMed

Notz, K; Dubb, R; Kaltwasser, A; Hermes, C; Pfeffer, S

2015-11-01

Treatment success in hospitals, particularly in intensive care units, is directly tied to quality of structure, process, and outcomes. Technological and medical advancements lead to ever more complex treatment situations with highly specialized tasks in intensive care nursing. Quality criteria that can be used to describe and correctly measure those highly complex multiprofessional situations have only been recently developed and put into practice.In this article, it will be shown how quality in multiprofessional teams can be definded and assessed in daily clinical practice. Core aspects are the choice of a nursing theory, quality assurance measures, and quality management. One possible option of quality assurance is the use of standard operating procedures (SOPs). Quality can ultimately only be achieved if professional groups think beyond their boundaries, minimize errors, and establish and live out instructions and SOPs.

Intelligibility as a clinical outcome measure following intervention with children with phonologically based speech-sound disorders.

PubMed

Lousada, M; Jesus, Luis M T; Hall, A; Joffe, V

2014-01-01

The effectiveness of two treatment approaches (phonological therapy and articulation therapy) for treatment of 14 children, aged 4;0-6;7 years, with phonologically based speech-sound disorder (SSD) has been previously analysed with severity outcome measures (percentage of consonants correct score, percentage occurrence of phonological processes and phonetic inventory). Considering that the ultimate goal of intervention for children with phonologically based SSD is to improve intelligibility, it is curious that intervention studies focusing on children's phonology do not routinely use intelligibility as an outcome measure. It is therefore important that the impact of interventions on speech intelligibility is explored. This paper investigates the effectiveness of the two treatment approaches (phonological therapy and articulation therapy) using intelligibility measures, both in single words and in continuous speech, as the primary outcome. Fourteen children with phonologically based SSD participated in the intervention. The children were randomly assigned to phonological therapy or articulation therapy (seven children in each group). Two assessment methods were used for measuring intelligibility: a word identification task (for single words) and a rating scale (for continuous speech). Twenty-one unfamiliar adults listened and judged the children's intelligibility. Reliability analyses showed overall high agreement between listeners across both methods. Significant improvements were noted in intelligibility in both single words (paired t(6)=4.409, p=0.005) and continuous speech (asymptotic Z=2.371, p=0.018) for the group receiving phonology therapy pre- to post-treatment, but no differences in intelligibility were found for those receiving the articulation therapy pre- to post-treatment, either for single words (paired t(6)=1.763, p=0.128) or continuous speech (asymptotic Z=1.442, p=0.149). Intelligibility measures were sensitive enough to show changes in the phonological therapy group but not in the articulation therapy group. These findings emphasize the importance of using intelligibility as an outcome measure to complement the results obtained with other severity measures when exploring the effectiveness of speech interventions. This study presents new evidence for the effectiveness of phonological therapy in improving intelligibility with children with SSD. © 2014 Royal College of Speech and Language Therapists.

Cognitive and adaptive measurement endpoints for clinical trials in mucopolysaccharidoses types I, II, and III: A review of the literature.

PubMed

Janzen, Darren; Delaney, Kathleen A; Shapiro, Elsa G

2017-06-01

Sensitive, reliable measurement instruments are critical for the evaluation of disease progression and new treatments that affect the brain in the mucopolysaccharidoses (MPS). MPS I, II, and III have early onset clinical phenotypes that affect the brain during development and result in devastating cognitive decline and ultimately death without treatment. Comparisons of outcomes are hindered by diverse protocols and approaches to assessment including applicability to international trials necessary in rare diseases. We review both cognitive and adaptive measures with the goal of providing evidence to a Delphi panel to come to a consensus about recommendations for clinical trials for various age groups. The results of the consensus panel are reported in an accompanying article. The following data were gathered (from internet resources and from test manuals) for each measure and summarized in the discussion: reliability, validity, date and adequacy of normative data, applicability of the measure's metrics, cross cultural validity including translations and adaptations, feasibility in the MPS population, familiarity to sites, sensitivity to change, and interpretability. If, resulting from this consensus, standard protocols are used for both natural history and treatment studies, patients, their families, and health care providers will benefit from the ability to compare study outcomes. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

The business of addiction treatment: A research agenda.

PubMed

Kimberly, John R; McLellan, A Thomas

2006-10-01

The social and economic costs of addiction are substantial and of great concern to society. Research in the past decade has led to promising therapies that appear to be highly effective but not widely diffused. This leads one to wonder if there is something about the structure, dynamics, or structure and dynamics of the addiction treatment industry that is getting in the way. However, there has been very little research in the areas of organization, finance, or management practices within the substance abuse treatment field-the kinds of issues that reduce the potential impact of addiction treatment industrywide. With this as background, this article introduces the Center for Organization and Management in Addiction Treatment (COMAT) and a special section on research in the "business of addiction treatment." Many other industries have experienced significant problems that are similar, in many respects, to those seen in substance abuse treatment, but research in leadership, innovation, investment, organization, and consolidation strategies has helped to overcome those problems. COMAT is dedicated to implementing and testing evidence-based methods from other industries to improve the outcomes performance and, ultimately, the clinical effectiveness of service providers in the addiction treatment field.

Self-hypnosis for anxiety associated with severe asthma: a case report

PubMed Central

Anbar, Ran D

2003-01-01

Background Management of asthma can be complicated by both medical and psychiatric conditions, such as gastroesophageal reflux, chronic sinusitis, and anxiety. When symptoms of asthma are interpreted without regard to such conditions treatment may yield a suboptimal outcome. For example, anxiety-associated dyspnea, tachypnea, and chest tightness can be mistakenly interpreted as resulting from an exacerbation of asthma. Medical treatment directed only for asthma may thus lead to overuse of asthma medications and increased hospitalizations. Case Presentation The described case illustrates how a systemic steroid-dependent patient with asthma benefited from receiving care from a pediatric pulmonologist who also was well versed in the diagnosis and treatment of anxiety. By using self-hypnosis, the patient was able to reduce her dependence on bronchodilators. Following modification of her medical therapy under supervision of the pulmonologist, and regular use of hypnosis, the patient ultimately was weaned off her systemic steroid therapy. Conclusions This report emphasizes that anxiety must be considered as a comorbid condition in the treatment of asthma. Self-hypnosis can be a useful skill in the treatment of a patient with anxiety and asthma. PMID:12875663

Self-hypnosis for anxiety associated with severe asthma: a case report.

PubMed

Anbar, Ran D

2003-07-22

Management of asthma can be complicated by both medical and psychiatric conditions, such as gastroesophageal reflux, chronic sinusitis, and anxiety. When symptoms of asthma are interpreted without regard to such conditions treatment may yield a suboptimal outcome. For example, anxiety-associated dyspnea, tachypnea, and chest tightness can be mistakenly interpreted as resulting from an exacerbation of asthma. Medical treatment directed only for asthma may thus lead to overuse of asthma medications and increased hospitalizations. The described case illustrates how a systemic steroid-dependent patient with asthma benefited from receiving care from a pediatric pulmonologist who also was well versed in the diagnosis and treatment of anxiety. By using self-hypnosis, the patient was able to reduce her dependence on bronchodilators. Following modification of her medical therapy under supervision of the pulmonologist, and regular use of hypnosis, the patient ultimately was weaned off her systemic steroid therapy. This report emphasizes that anxiety must be considered as a comorbid condition in the treatment of asthma. Self-hypnosis can be a useful skill in the treatment of a patient with anxiety and asthma.

Validation of PROMIS ® Physical Function computerized adaptive tests for orthopaedic foot and ankle outcome research.

PubMed

Hung, Man; Baumhauer, Judith F; Latt, L Daniel; Saltzman, Charles L; SooHoo, Nelson F; Hunt, Kenneth J

2013-11-01

In 2012, the American Orthopaedic Foot & Ankle Society(®) established a national network for collecting and sharing data on treatment outcomes and improving patient care. One of the network's initiatives is to explore the use of computerized adaptive tests (CATs) for patient-level outcome reporting. We determined whether the CAT from the NIH Patient Reported Outcome Measurement Information System(®) (PROMIS(®)) Physical Function (PF) item bank provides efficient, reliable, valid, precise, and adequately covered point estimates of patients' physical function. After informed consent, 288 patients with a mean age of 51 years (range, 18-81 years) undergoing surgery for common foot and ankle problems completed a web-based questionnaire. Efficiency was determined by time for test administration. Reliability was assessed with person and item reliability estimates. Validity evaluation included content validity from expert review and construct validity measured against the PROMIS(®) Pain CAT and patient responses based on tradeoff perceptions. Precision was assessed by standard error of measurement (SEM) across patients' physical function levels. Instrument coverage was based on a person-item map. Average time of test administration was 47 seconds. Reliability was 0.96 for person and 0.99 for item. Construct validity against the Pain CAT had an r value of -0.657 (p < 0.001). Precision had an SEM of less than 3.3 (equivalent to a Cronbach's alpha of ≥ 0.90) across a broad range of function. Concerning coverage, the ceiling effect was 0.32% and there was no floor effect. The PROMIS(®) PF CAT appears to be an excellent method for measuring outcomes for patients with foot and ankle surgery. Further validation of the PROMIS(®) item banks may ultimately provide a valid and reliable tool for measuring patient-reported outcomes after injuries and treatment.

Mathematical modeling of prostate cancer progression in response to androgen ablation therapy.

PubMed

Jain, Harsh Vardhan; Clinton, Steven K; Bhinder, Arvinder; Friedman, Avner

2011-12-06

Prostate cancer progression depends in part on the complex interactions between testosterone, its active metabolite DHT, and androgen receptors. In a metastatic setting, the first line of treatment is the elimination of testosterone. However, such interventions are not curative because cancer cells evolve via multiple mechanisms to a castrate-resistant state, allowing progression to a lethal outcome. It is hypothesized that administration of antiandrogen therapy in an intermittent, as opposed to continuous, manner may bestow improved disease control with fewer treatment-related toxicities. The present study develops a biochemically motivated mathematical model of antiandrogen therapy that can be tested prospectively as a predictive tool. The model includes "personalized" parameters, which address the heterogeneity in the predicted course of the disease under various androgen-deprivation schedules. Model simulations are able to capture a variety of clinically observed outcomes for "average" patient data under different intermittent schedules. The model predicts that in the absence of a competitive advantage of androgen-dependent cancer cells over castration-resistant cancer cells, intermittent scheduling can lead to more rapid treatment failure as compared to continuous treatment. However, increasing a competitive advantage for hormone-sensitive cells swings the balance in favor of intermittent scheduling, delaying the acquisition of genetic or epigenetic alterations empowering androgen resistance. Given the near universal prevalence of antiandrogen treatment failure in the absence of competing mortality, such modeling has the potential of developing into a useful tool for incorporation into clinical research trials and ultimately as a prognostic tool for individual patients.

The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature.

PubMed

Heiser, Rick; O'Brien, Virginia H; Schwartz, Deborah A

2013-01-01

Systematic review. Joint mobilizations are used as an intervention for improving range of motion, decreasing pain and ultimately improving function in patients with a wide variety of upper extremity diagnoses. However, there are only a limited number of studies describing this treatment for conditions affecting the elbow, wrist, and hand. Furthermore, it is unclear as to the most effective joint mobilization technique utilized and the most beneficial functional outcomes gained. Examine the current evidence describing joint mobilizations for treatment of conditions of the elbow, wrist and hand, and offer informative practical clinical guidance. Twenty-two studies dated between 1980 and 2011 were included in the systematic review for analysis. The current evidence provides moderate support for the inclusion of joint mobilizations in the treatment of lateral epicondylalgia (LE). In particular, mobilization with movement as described by Mulligan is supported with evidence from nine randomized clinical trials as an effective technique for the treatment of pain. Other described techniques include those known as Kaltenborn, Cyriax physical therapy, and Maitland, but the evidence for these techniques is limited. There is also limited evidence for the joint mobilizations in the treatment of wrist and hand conditions. The current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for LE. There is moderate support for mobilization with movement. . Copyright © 2013 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

Practical perspectives of personalized healthcare in oncology.

PubMed

Hodgson, Darren R; Wellings, Robert; Harbron, Christopher

2012-09-15

There is an increasing prevalence of drug-diagnostic combinations in oncology. This has placed diagnostic stakeholders directly into the complex benefit-risk, cost, value and uncertainty-driven development paradigm traditionally the preserve of the drug development community. In this review we focus on the delivery of the clinical data required to advance such drug-diagnostic combination development programmes and ultimately satisfy regulators and payors of the value of contemporaneous changes in diagnostic and treatment practice. Ideally all stakeholders would like to initially estimate, and ultimately specify, the comparative benefit-risk for a new treatment option with and without changing diagnostic practice. Hence, in an ideal world clinical trial design is focused on acquiring biomarker treatment interaction data. In this review we describe the key scientific and feasibility inputs required to design and deliver such trials and the drivers, advantages and disadvantages associated with departing from this model. We do not discuss the discovery of new biomarkers nor the analytical validation and marketing of diagnostic products. Following on from trial design we describe how subsequent success then depends upon the concepts that guide trial design being driven into the complex world of large, multinational clinical trial delivery. For every aspect of a traditional clinical drug trial such as supply, recruitment and adherence, there is a corresponding concept for the diagnostic element. In practice, this means that each patient's contribution to the decision making data-set is subject to double jeopardy (attrition on clinical outcome and biomarker status). Historically, this has led to significantly reduced power for detecting biomarker-treatment interactions, reduced decision making confidence and a waste of valuable human and financial resources. We describe recent practice changes and experience that have led to the successful delivery of such trials focusing on both pre- and on trial aspects. The former includes the pivotal role of tissue banks in accurate estimation of evaluability and prevalence for biomarker assays and the latter several practices designed to engage and incentivize key stakeholders particularly CRAs and pathologists. The result is that in the new world of developing personalized treatments for cancer patients the real-time acquisition and monitoring of biomarker data receives similar support to that traditionally reserved for clinical outcome data and far more patients contribute to the testing of personalized medicine hypotheses. Copyright © 2012 Elsevier B.V. All rights reserved.

The effect of post traumatic stress disorders on rehabilitation among combat-wounded veterans.

PubMed

Siddharthan, Kris

2012-01-01

In June 2008 the Congressionally Directed Medical Research Program provided a grant to the Research Foundation at the James A Haley Veterans Hospital in Tampa, Florida to provide care for wounded veterans from Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (OEF/OIF). The telerehabilitation for OEF/OIF returnees with mild or moderate combat related Traumatic Brain Injury (TBI) has as its objectives 1) care coordination for wounded veterans using distance technology via the internet and 2) monitoring of physical and mental health outcomes using a variety of instruments. A total of 75 veterans were enrolled in the study. Our initial findings indicate that 1) Functional capabilities measured by locomotion and mobility appear to have stabilized among our cohort of veterans while deficiencies in cognition (memory, problem solving), psychosocial adjustment (anger, emotional status) and problems in integrating into society pose challenges 2) Those with comorbid PTSD appear to linger in employability and ultimate integration into society as compared to those without the diagnosis 3) Individualized treatment pathways are needed for rehabilitation and ultimate integration into society.

Subpopulation Treatment Effect Pattern Plot (STEPP) analysis for continuous, binary, and count outcomes.

PubMed

Yip, Wai-Ki; Bonetti, Marco; Cole, Bernard F; Barcella, William; Wang, Xin Victoria; Lazar, Ann; Gelber, Richard D

2016-08-01

For the past few decades, randomized clinical trials have provided evidence for effective treatments by comparing several competing therapies. Their successes have led to numerous new therapies to combat many diseases. However, since their conclusions are based on the entire cohort in the trial, the treatment recommendation is for everyone, and may not be the best option for an individual. Medical research is now focusing more on providing personalized care for patients, which requires investigating how patient characteristics, including novel biomarkers, modify the effect of current treatment modalities. This is known as heterogeneity of treatment effects. A better understanding of the interaction between treatment and patient-specific prognostic factors will enable practitioners to expand the availability of tailored therapies, with the ultimate goal of improving patient outcomes. The Subpopulation Treatment Effect Pattern Plot (STEPP) approach was developed to allow researchers to investigate the heterogeneity of treatment effects on survival outcomes across values of a (continuously measured) covariate, such as a biomarker measurement. Here, we extend the Subpopulation Treatment Effect Pattern Plot approach to continuous, binary, and count outcomes, which can be easily modeled using generalized linear models. With this extension of Subpopulation Treatment Effect Pattern Plot, these additional types of treatment effects within subpopulations defined with respect to a covariate of interest can be estimated, and the statistical significance of any observed heterogeneity of treatment effect can be assessed using permutation tests. The desirable feature that commonly used models are applied to well-defined patient subgroups to estimate treatment effects is retained in this extension. We describe a simulation study to confirm that the proper Type I error rate is maintained when there is no treatment heterogeneity, and a power study to show that the statistics have power to detect treatment heterogeneity under alternative scenarios. As an illustration, we apply the methods to data from the Aspirin/Folate Polyp Prevention Study, a clinical trial evaluating the effect of oral aspirin, folic acid, or both as a chemoprevention agent against colorectal adenomas. The pre-existing R software package stepp has been extended to handle continuous, binary, and count data using Gaussian, Bernoulli, and Poisson models, and it is available on the Comprehensive R Archive Network. The extension of the method and the availability of new software now permit STEPP to be applied to the full range of clinical trial end points. © The Author(s) 2016.

An Examination of Incentive Strategies to Increase Participation in Outcomes Research for an Adolescent Inpatient Unit.

PubMed

Ha, Carolyn; Madan, Alok; Long, Tessa A; Sharp, Carla

2016-05-01

Tracking adolescent outcomes after inpatient hospitalization is important in informing clinical care for this age group, as inpatient care is one of the most expensive treatment modalities. This study examined 4 incentive strategies used to maintain adolescent participation in follow-up research (at 6, 12, and 18 mo) after their discharge from the hospital (N=267). A generalized estimation equation approach was taken to investigate whether different incentive strategies predicted adolescent completion of the follow-up assessments at each time point. Findings demonstrate that implementation of social worker contact significantly differed from other incentive strategies in increasing adolescent completion of follow-up assessments (Z=2.51, P=0.012) over the 3 time points, even when controlling for age and sex. Although these findings ultimately need to be confirmed through a randomized controlled study of incentive strategies, they provide preliminary support for the notion that relational incentives, such as maintaining contact with a member of the clinical team at the hospital, may be particularly important in promoting adolescent participation in outcomes research.

Mechanisms of Resistance in Multiple Myeloma.

PubMed

Papadas, Athanasios; Asimakopoulos, Fotis

2017-03-18

Multiple myeloma (MM) is an incurable hematopoietic cancer that is characterized by malignant plasma cell infiltration of the bone marrow and/or extramedullary sites. Multi-modality approaches including "novel agents," traditional chemotherapy, and/or stem cell transplantation are used in MM therapy. Drug resistance, however, ultimately develops and the disease remains incurable for the vast majority of patients. In this chapter, we review both tumor cell-autonomous and non-autonomous (microenvironment-dependent) mechanisms of drug resistance. MM provides an attractive paradigm highlighting a number of current concepts and challenges in oncology. Firstly, identification of MM cancer stem cells and their unique drug resistance attributes may provide rational avenues towards MM eradication and cure. Secondly, the oligoclonal evolution of MM and alternation of "clonal tides" upon therapy challenge our current understanding of treatment responses. Thirdly, the success of MM "novel agents" provides exemplary evidence for the impact of therapies that target the immune and non-immune microenvironment. Fourthly, the rapid pace of drug approvals for MM creates an impetus for development of precision medicine strategies and biomarkers that promote efficacy and mitigate toxicity and cost. While routine cure of the disease remains the ultimate and yet unattainable prize, MM advances in the last 10-15 years have provided an astounding paradigm for the treatment of blood cancers in the modern era and have radically transformed patient outcomes.

Reproductive and oncologic outcomes after progestin therapy for endometrial complex atypical hyperplasia or carcinoma.

PubMed

Kudesia, Rashmi; Singer, Tomer; Caputo, Thomas A; Holcomb, Kevin Michael; Kligman, Isaac; Rosenwaks, Zev; Gupta, Divya

2014-03-01

This study evaluated fertility and oncological outcomes in women with complex atypical hyperplasia (CAH) or nonmyoinvasive grade 1 endometrioid endometrial carcinoma (EM) who desired fertility-sparing therapy. The retrospective cohort study included women younger than 45 years with CAH or EM who desired fertility-sparing treatment at our institution. Only patients for whom both oncological treatment and pregnancy outcomes were available were included. Statistical analyses were performed using a Fisher exact test, Pearson χ(2) test, and Spearman rank correlation test, as appropriate. Seventy-five patients were identified, and 23 (13 CAH, 10 EM) met the inclusion criteria. All 23 patients had at least 1 prior pregnancy. Treatment was split between oral progesterone only (38.5% CAH, 40% EM), levonorgestrel intrauterine device only (30.8% CAH, 20% EM), and both (30.8% CAH, 40% EM). After a median follow-up of 13 months (range, 3-74 months), 9 patients (46.2% CAH, 30% EM, P = .39) had persistent/progressive disease. Eight patients (30.8% CAH, 40% EM, P = .69) ultimately had a hysterectomy, and 3 of these (13.0%) were found to have persistent/progressive disease. Median time from diagnosis to hysterectomy was 13 months (range, 4-56 months). Fourteen of the 23 patients utilized assisted reproductive techniques (60.9%); 12 underwent IVF and 2 chose a gestation carrier. Seven clinical intrauterine pregnancies (30.4%) resulting in 6 live births (26.1%) were found in the entire cohort. Fertility-sparing treatment for CAH and grade 1 endometrial cancer is feasible with progestin therapy and leads to clinically meaningful rates of pregnancy in young women who desire fertility. Copyright © 2014 Mosby, Inc. All rights reserved.

Haemodialysis or haemodiafiltration: that is the question.

PubMed

Locatelli, Francesco; Carfagna, Fabio; Del Vecchio, Lucia; La Milia, Vincenzo

2018-04-24

Despite the technological and pharmacological advancements in the last 30 years, morbidity and mortality of dialysis patients are still astonishingly high. Today, convective treatments, such as high-flux haemodialysis (hf-HD) and haemodiafiltration (HDF), are established techniques; the online production of fresh pure dialysate has provided clinical and economic advantages. Nevertheless, the actual benefits of HDF, even with high-convective-volume treatments, are still debatable. Three recent, randomized controlled trials compared survival outcomes in prevalent patients receiving conventional HD or post-dilution HDF and reported conflicting results. The meta-analyses of the published trials were ultimately incapable of providing a clear and definitive answer on the possible beneficial effects of choosing one treatment over the other. All-cause mortality, anaemia, phosphate control and clearance of small molecules seemed to be unaffected by the treatment modality. On the other hand, cardiovascular mortality, intradialytic vascular stability and the clearance of protein-bound molecules fared better in patients treated with HDF. These results were not consistent between the studies. Thus, there is still no conclusive answer to the question that nephrologists would like to have answered: 'Which is the best treatment for my patient?' In the age of evidence-based medicine, we need strong data to support the superiority of a treatment in comparison with another, although theoretically plausible. There is the need for a well-designed clinical trial comparing outcomes for patients randomly assigned to high- or moderate-convection-volume HDF versus hf-HD to clearly prove the clinical superiority of HDF, including the effect of different infusion volumes.

Laparoscopic esophagomyotomy for achalasia in children: A review

PubMed Central

Pandian, T Kumar; Naik, Nimesh D; Fahy, Aodhnait S; Arghami, Arman; Farley, David R; Ishitani, Michael B; Moir, Christopher R

2016-01-01

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care. PMID:26839646

A FOUR-PHASE PHYSICAL THERAPY REGIMEN FOR RETURNING ATHLETES TO SPORT FOLLOWING HIP ARTHROSCOPY FOR FEMOROACETABULAR IMPINGEMENT WITH ROUTINE CAPSULAR CLOSURE

PubMed Central

Weber, Alexander E.; Batko, Brian; Nho, Shane J.; Stegemann, Catherine

2017-01-01

Hip preservation surgery has become more common over the past decade and is now a preferred treatment modality for an increasingly diverse array of pathology in the young, active patient with hip pain. In particular, hip arthroscopy has become an increasingly popular treatment choice for active patients diagnosed with femoroacetabular impingement (FAI). Appropriate postoperative rehabilitation is critical for overall patient success and optimal long-term outcome. As surgical techniques continue to evolve, rehabilitation protocols must adapt to accommodate changes in the surgical procedure and ultimately provide the safest and fastest recovery of function for the patient. One such surgical modification has been the incorporation of routine capsular closure as part of the treatment of FAI in the young, active patient. The purpose of this clinical commentary is to present a four-phase rehabilitation protocol for returning to sport following arthroscopic correction of FAI with routine capsular closure. Level of Evidence 5 PMID:28900574

Neuropsychological impairments predict the clinical course in schizophrenia.

PubMed

Wölwer, Wolfgang; Brinkmeyer, Jürgen; Riesbeck, Mathias; Freimüller, Lena; Klimke, Ansgar; Wagner, Michael; Möller, Hans-Jürgen; Klingberg, Stefan; Gaebel, Wolfgang

2008-11-01

To add to the open question whether cognitive impairments predict clinical outcome in schizophrenia, a sample of 125 first episode patients was assessed at the onset and over one year of controlled long-term treatment within a study of the German Research Network on Schizophrenia. No relapse according to predefined criteria occurred within the first year, but a total of 29 patients fulfilled post-hoc criteria of "clinical deterioration". Impairments in cognitive functioning assessed by the Trail-Making Test B at the onset of long-term treatment differentiated between patients with vs. without later clinical deterioration and proved to be a significant predictor of the clinical course in a regression analysis outperforming initial clinical status as predictor. However, low sensitivity (72%) and specificity (51%) limit possibilities of a transfer to individual predictions. As a linear combination of neuropsychological and psychopathological variables obtained highest predictive validity, such a combination may improve the prediction of the course of schizophrenic disorders and may ultimately lead to a more efficient and comprehensive treatment planning.

Developing a Theoretical Framework to Illustrate Associations Among Patient Satisfaction, Body Image and Quality of Life for Women Undergoing Breast Reconstruction

PubMed Central

Fingeret, Michelle Cororve; Nipomnick, Summer; Crosby, Melissa A.; Reece, Gregory P.

2013-01-01

Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient. PMID:23380309

Rheumatoid arthritis patient perceptions on the value of predictive testing for treatments: a qualitative study.

PubMed

Kumar, Kanta; Peters, Sarah; Barton, Anne

2016-11-08

Rheumatoid arthritis (RA) is a long term condition that requires early treatment to control symptoms and improve long-term outcomes. Lack of response to RA treatments is not only a waste of healthcare resources, but also causes disability and distress to patients. Identifying biomarkers predictive of treatment response offers an opportunity to improve clinical decisions about which treatment to recommend in patients and could ultimately lead to better patient outcomes. The aim of this study was to explore the understanding of and factors affecting Rheumatoid Arthritis (RA) patients' decisions around predictive treatment testing. A qualitative study was conducted with a purposive sample of 16 patients with RA from three major UK cities. Four focus groups explored patient perceptions of the use of biomarker tests to predict response to treatments. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis by three researchers. Data were organised within three interlinking themes: [1] Perceptions of predictive tests and patient preference of tests; [2] Utility of the test to manage expectations; [3] The influence of the disease duration on take up of predictive testing. During consultations for predictive testing, patients felt they would need, first, careful explanations detailing the consequences of untreated RA and delayed treatment response and, second, support to balance the risks of tests, which might be invasive and/or only moderately accurate, with the potential benefits of better management of symptoms. This study provides important insights into predictive testing. Besides supporting clinical decision making, the development of predictive testing in RA is largely supported by patients. Developing strategies which communicate risk information about predictive testing effectively while reducing the psychological burden associated with this information will be essential to maximise uptake.

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

PubMed

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

2013-06-01

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

Current advances in esophageal cancer proteomics.

PubMed

Uemura, Norihisa; Kondo, Tadashi

2015-06-01

We review the current status of proteomics for esophageal cancer (EC) from a clinician's viewpoint. The ultimate goal of cancer proteomics is the improvement of clinical outcome. The proteome as a functional translation of the genome is a straightforward representation of genomic mechanisms that trigger carcinogenesis. Cancer proteomics has identified the mechanisms of carcinogenesis and tumor progression, detected biomarker candidates for early diagnosis, and provided novel therapeutic targets for personalized treatments. Our review focuses on three major topics in EC proteomics: diagnostics, treatment, and molecular mechanisms. We discuss the major histological differences between EC types, i.e., esophageal squamous cell carcinoma and adenocarcinoma, and evaluate the clinical significance of published proteomics studies, including promising diagnostic biomarkers and novel therapeutic targets, which should be further validated prior to launching clinical trials. Multi-disciplinary collaborations between basic scientists, clinicians, and pathologists should be established for inter-institutional validation. In conclusion, EC proteomics has provided significant results, which after thorough validation, should lead to the development of novel clinical tools and improvement of the clinical outcome for esophageal cancer patients. This article is part of a Special Issue entitled: Medical Proteomics. Copyright © 2014 Elsevier B.V. All rights reserved.

Update on the Treatment of Early-Stage Triple-Negative Breast Cancer.

PubMed

Sharma, Priyanka

2018-04-14

Triple-negative breast cancer (TNBC) accounts for 15% of all breast cancers and is associated with poor long-term outcomes compared to other breast cancer subtypes. Currently, chemotherapy remains the main modality of treatment for early-stage TNBC, as there is no approved targeted therapy for this subtype. The biologic heterogeneity of TNBC has hindered the development and evaluation of novel agents, but recent advancements in subclassifying TNBC have paved the way for further investigation of more effective systemic therapies, including cytotoxic and targeted agents. TNBC is enriched for germline BRCA mutation and for somatic deficiencies in homologous recombination DNA repair, the so-called "BRCAness" phenotype. Together, germline BRCA mutations and BRCAness are promising biomarkers of susceptibility to DNA-damaging therapy. Various investigational approaches are consequently being investigated in early-stage TNBC, including immune checkpoint inhibitors, platinum compounds, PI3K pathway inhibitors, and androgen receptor inhibitors. Due to the biological diversity found within TNBC, patient selection based on molecular biomarkers could aid the design of early-phase clinical trials, ultimately accelerating the clinical application of effective new agents. TNBC is an aggressive breast cancer subtype, for which multiple targeted approaches will likely be required for patient outcomes to be substantially improved.

Project ECHO: A Telementoring Program for Cervical Cancer Prevention and Treatment in Low-Resource Settings.

PubMed

Lopez, Melissa S; Baker, Ellen S; Milbourne, Andrea M; Gowen, Rose M; Rodriguez, Ana M; Lorenzoni, Cesaltina; Mwaba, Catherine; Msadabwe, Susan Citonje; Tavares, José Humberto; Fontes-Cintra, Georgia; Zucca-Matthes, Gustavo; Callegaro-Filho, Donato; Ramos-Martin, Danielle; Thiago de Carvalho, Icaro; Coelho, Robson; Marques, Renato Moretti; Chulam, Thiago; Pontremoli-Salcedo, Mila; Nozar, Fernanda; Fiol, Veronica; Maza, Mauricio; Arora, Sanjeev; Hawk, Ernest T; Schmeler, Kathleen M

2017-10-01

Cervical cancer incidence and mortality rates are significantly higher in low- and middle-income countries compared with the United States and other developed countries. This disparity is caused by decreased access to screening, often coupled with low numbers of trained providers offering cancer prevention and treatment services. However, similar disparities are also found in underserved areas of the United States, such as the Texas-Mexico border, where cervical cancer mortality rates are 30% higher than in the rest of Texas. To address these issues, we have adopted the Project ECHO (Extension for Community Healthcare Outcomes) program, a low-cost telementoring model previously proven to be successful in increasing local capacity, improving patient management skills, and ultimately improving patient outcomes in rural and underserved areas. We use the Project ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and have adapted it to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa. This innovative approach, using ECHO, is part of a larger strategy to enhance clinical skills and develop collaborative projects between academic centers and partners in low-resource regions.

Chimeric Antigen Receptor T-Cells (CAR T-Cells) for Cancer Immunotherapy - Moving Target for Industry?

PubMed

Salmikangas, Paula; Kinsella, Niamh; Chamberlain, Paul

2018-05-31

The first CD19 CAR T-cell products, Kymriah and Yescarta, are entering the US market and also being evaluated for marketing authorization in the EU. This breakthrough has expanded the interest and also investments towards novel chimeric antigen receptor (CAR) designs, both for hematological malignancies and solid tumors. At the same time, there is active development in moving from autologous products to allogeneic, off-the-shelf -products. New manufacturing technologies are also emerging for production of these complex genetically-modified cells and even decentralized manufacturing in hospitals is under consideration. However, the high potency of CAR T-cells is associated with toxicity and not all patients respond to the treatment. In addition, the number of patient and product variables impacting the clinical outcome is high. The race towards novel CAR T treatment options for cancer patients has begun, but without careful design of the constructs and overall understanding of the factors that impact the ultimate outcome in each case, the road towards commercial success may be long and winding. This review discusses the product- and patient-related variables that may pose challenges for the industry and developers both from the scientific and regulatory perspective.

Surgical Updates in the Treatment of Pelvic Organ Prolapse.

PubMed

Geynisman-Tan, Julia; Kenton, Kimberly

2017-04-28

Pelvic organ prolapse affects approximately 8% of women, and the demand for pelvic organ prolapse surgery is expected to increase by nearly 50% over the next 40 years. The surgical techniques used to correct pelvic organ prolapse have evolved over the last 10 years, with multiple well-designed studies addressing the risks, outcomes, reoperation rates, and optimal surgical approaches. Here we review the most recent evidence on the route of access, concomitant procedures, and synthetic materials for augmenting the repair. Ultimately, this review highlights that there is no optimal method for correcting pelvic organ prolapse and that the risks, benefits, and approaches should be discussed in a patient-centered, goal-oriented approach to decision-making.

MECHANISMS OF HYPNOSIS:

PubMed Central

Jensen, Mark P.; Adachi, Tomonori; Tomé-Pires, Catarina; Lee, Jikwan; Osman, Zubaidah Jamil; Miró, Jordi

2014-01-01

Evidence supports the efficacy of hypnotic treatments, but there remain many unresolved questions regarding how hypnosis produces its beneficial effects. Most theoretical models focus more or less on biological, psychological, and social factors. This scoping review summarizes the empirical findings regarding the associations between specific factors in each of these domains and response to hypnosis. The findings indicate that: (1) no single factor appears primary; (2) different factors may contribute more or less to outcomes in different subsets of individuals or for different conditions; and (3) comprehensive models of hypnosis that incorporate factors from all 3 domains may ultimately prove to be more useful than more restrictive models that focus on 1 or a very few factors. PMID:25365127

Increasing infertility in myotonia dystrophica Curschmann-Steinert. A case report.

PubMed

Hauser, W; Aulitzky, W; Baltaci, S; Frick, J

1991-01-01

A 26-year-old male came to our andrologic out-patient clinic because of his desire to have children. Preliminary examinations revealed a varicocele left and a subclinical varicocele right. Testicular volume was smaller than normal, and spermiogram values were already poor (vitality, motility and morphology). Basic hormones were normal. The anamnesis gave no information on hereditary disorders. Surgical treatment of the varicocele did not bring the desired outcome. A testicular biopsy showed Leydig cell hyperplasia with strongly reduced spermiohistogenesis. In a renewed and extensive anamnesis, the patient revealed that he suffers from myotonia dystrophica Curschmann-Steinert. This disorder causes sclerosis of the tubuli seminiferi contorti, which can ultimately lead to azoospermia.

Training professionals' communication and motivation skills to improve spinal cord injury patients' satisfaction and clinical outcomes: Study protocol of the ESPELMA trial.

PubMed

Lusilla-Palacios, Pilar; Castellano-Tejedor, Carmina; Lucrecia-Ramírez-Garcerán; Navarro-Sanchís, José A; Rodríguez-Urrutia, Amanda; Parramon-Puig, Gemma; Valero-Ventura, Sergi; Cuxart-Fina, Ampar

2015-10-01

Acute spinal cord injury leaves patients severely impaired and generates high levels of psychological distress among them and their families, which can cause a less active role in rehabilitation, worse functional recovery, and less perceived satisfaction with the results. Additionally, rehabilitation professionals who deal with this psychological distress could ultimately experience higher stress and more risk of burnout. This article presents the study protocol of the ESPELMA project, aimed to train rehabilitation professionals in the clinical management of acute spinal cord injury-associated psychological distress, and to measure the impact of this training on the patients' perceived satisfaction with treatment. © The Author(s) 2013.

Diabetes and periodontal diseases.

PubMed

1996-02-01

This position paper on diabetes mellitus was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology. It is intended to: 1) update members of the dental profession on the diagnosis and medical management of patients with diabetes mellitus; 2) summarize current knowledge on the relation between diabetes mellitus and periodontal diseases; 3) provide an overview of factors in diabetic patients relevant to understanding the pathogenesis of periodontal diseases in these subjects; 4) outline special considerations associated with treatment of periodontal diseases in diabetic patients; and 5) discuss possible approaches to the management of diabetic emergencies in the dental office. Reliance on this position paper in patient management will not guarantee a successful outcome. Periodontal diseases often involve numerous and complex causes and symptoms. Ultimately, decisions regarding the diagnosis and treatment of disease in an individual patient must be made by the treating practitioner in light of the specific facts presented by that patient.

Immune tolerance: a synopsis of the international experience.

PubMed

Di Michele, D M

1998-07-01

Because of the increased morbidity and cost of care associated with inhibitor development, immune tolerance therapy (ITT) is of crucial value in the care of haemophilia. The 24-year experience with this modality, primarily in the treatment of factor VIII inhibitors, has included the use of both high and low doses of clotting factor, with and without immune modulation. Overall success rates for ITT in haemophilia A have been similar (63-83%), while median time to IT has been variable (1.2-24 months). The role of type and purity of clotting factor used remains unclear. Three immune tolerance registries have suggested the potential importance of treatment parameters such as pre-induction inhibitor titer and daily factor dose in the prediction of successful outcome. Ultimately, prospective randomized studies of ITT are required to definitively compare therapeutic regimens with respect to efficacy, safety, and cost effectiveness.

Cerebellar ataxia and epilepsy with anti-GAD antibodies: treatment with IVIG and plasmapheresis

PubMed Central

Georgieva, Zoya; Parton, Matthew

2014-01-01

Glutamic acid decarboxylase autoantibody (GAD-65) catalyses glutamate conversion into γ-aminobutyric acid (GABA) in the central nervous system and in the pancreatic β cells. Antibodies targeting GAD-65 are of uncertain pathogenic significance and occur in stiff person syndrome, cerebellar ataxia, epilepsy, limbic encephalitis and combinations thereof and diabetes mellitus. A 45-year-old man with a cerebellar gait ataxia, dysmetria, nystagmus and mild cerebellar dysarthria was diagnosed with insulin-dependent diabetes mellitus a year after the onset of neurological symptoms. He also developed complex and tonic-clonic seizures, resistant to anticonvulsant medication and deteriorated cognitively. Blood and cerebrospinal fluid serology, and imaging supported the diagnosis of GAD-65 cerebellar ataxia and epilepsy. He was treated with intravenous immunoglobulin and subsequently plasmapheresis. We report the outcome of 3 years of treatment, which resulted in the improvement of cerebellar signs (particularly gait), with some ultimate decline of efficacy. PMID:24419643

Objective support for subjective reports of successful inner speech in two people with aphasia.

PubMed

Hayward, William; Snider, Sarah F; Luta, George; Friedman, Rhonda B; Turkeltaub, Peter E

2016-01-01

People with aphasia frequently report being able to say a word correctly in their heads, even if they are unable to say that word aloud. It is difficult to know what is meant by these reports of "successful inner speech". We probe the experience of successful inner speech in two people with aphasia. We show that these reports are associated with correct overt speech and phonologically related nonword errors, that they relate to word characteristics associated with ease of lexical access but not ease of production, and that they predict whether or not individual words are relearned during anomia treatment. These findings suggest that reports of successful inner speech are meaningful and may be useful to study self-monitoring in aphasia, to better understand anomia, and to predict treatment outcomes. Ultimately, the study of inner speech in people with aphasia could provide critical insights that inform our understanding of normal language.

History, instrumentation, and techniques of flexible endoscopic laser surgery in horses.

PubMed

Blikslager, A T; Tate, L P

2000-08-01

There are clearly a number of applications for which flexible endoscopic laser surgery has become the state of the art in equine surgery, and the Nd:YAG laser seems to be the most versatile instrument for this type of surgery. Nevertheless, it is critical to understand the advantages and disadvantages of each laser technique. For example, the Nd:YAG laser used in a noncontact fashion seems to be superior when ablation of tissue is required such as treatment of upper airway masses. Conversely, contact Nd:YAG laser techniques have proven themselves to be superior when more precise cutting is advantageous such as treatment of epiglottic entrapment. Ultimately, it seems that a range of lasers is necessary to ensure selection of the most appropriate technique, adding significantly to the expense of equipment but improving the outcome for a range of equine diseases.

Long-term follow-up after cervical cancer treatment and subsequent successful surrogate pregnancy.

PubMed

Agorastos, T; Zafrakas, M; Mastrominas, M

2009-08-01

Preservation of fertility is a major concern for premenopausal women after diagnosis of cervical cancer. Successful surrogate pregnancy after treatment for cervical cancer has very rarely been reported. In the present report, a case of successful surrogate pregnancy after radical hysterectomy, lymphadenectomy and ovarian transposition for cervical cancer, followed by radiation therapy, is presented. After stimulation of the transposed ovaries using the short gonadotrophin-releasing hormone (GnRH) analogue protocol, four oocytes were retrieved transabdominally from the genetic mother. IVF followed and two embryos were transferred to the surrogate mother, leading to an uneventful singleton pregnancy, and ultimately normal vaginal delivery of a healthy female infant at term. The unique aspect in this case is the long-lasting favourable outcome for both genetic mother and child, observed during 8.5 years of follow-up, the longest follow-up period reported to date in such cases.

Unravelling signal escape through maintained EGFR activation in advanced non-small cell lung cancer (NSCLC): new treatment options

PubMed Central

Remon, Jordi; Besse, Benjamin

2016-01-01

The discovery of activating epidermal growth factor receptor (EGFR) mutations has opened up a new era in the development of more effective treatments for patients with non-small cell lung cancer (NSCLC). However, patients with EGFR-activating mutated NSCLC treated with EGFR tyrosine kinase inhibitors (TKIs) ultimately develop acquired resistance (AR). Among known cases of patients with AR, 70% of the mechanisms involved in the development of AR to EGFR TKI have been identified and may be categorised as either secondary EGFR mutations such as the T790M mutation, activation of bypass track signalling pathways such as MET amplification, or histologic transformation. EGFR-mutant NSCLC tumours maintain oncogenic addiction to the EGFR pathway beyond progression with EGFR TKI. Clinical strategies that can be implemented in daily clinical practice to potentially overcome this resistance and prolong the outcome in this subgroup of patients are presented. PMID:27843631

Ultrasound as visual feedback in speech habilitation: exploring consultative use in rural British Columbia, Canada.

PubMed

Bernhardt, May B; Bacsfalvi, Penelope; Adler-Bock, Marcy; Shimizu, Reiko; Cheney, Audrey; Giesbrecht, Nathan; O'connell, Maureen; Sirianni, Jason; Radanov, Bosko

2008-02-01

Ultrasound has shown promise as a visual feedback tool in speech therapy. Rural clients, however, often have minimal access to new technologies. The purpose of the current study was to evaluate consultative treatment using ultrasound in rural communities. Two speech-language pathologists (SLPs) trained in ultrasound use provided consultation with ultrasound in rural British Columbia to 13 school-aged children with residual speech impairments. Local SLPs provided treatment without ultrasound before and after the consultation. Speech samples were transcribed phonetically by independent trained listeners. Eleven children showed greater gains in production of the principal target /[image omitted]/ after the ultrasound consultation. Four of the seven participants who received more consultation time with ultrasound showed greatest improvement. Individual client factors also affected outcomes. The current study was a quasi-experimental clinic-based study. Larger, controlled experimental studies are needed to provide ultimate evaluation of the consultative use of ultrasound in speech therapy.

A Pilot Study Evaluating "Dojo," a Videogame Intervention for Youths with Externalizing and Anxiety Problems.

PubMed

Schuurmans, Angela A T; Nijhof, Karin S; Vermaes, Ignace P R; Engels, Rutger C M E; Granic, Isabela

2015-10-01

Externalizing problems, which are the main reason for youth referrals to mental health agencies, are highly persistent and predict a range of negative outcomes. Youths with externalizing problems are also frequently comorbid with anxiety. Among the most widely recognized evidence-based treatments is cognitive behavioral therapy (CBT). Although CBT principles seem to be sound, effect sizes remain moderate, suggesting improvements could be made to this conventional treatment approach. The main premise of the current pilot study is to investigate the feasibility of implementing a videogame intervention ("Dojo" [Gamedesk, Los Angeles, CA]) that incorporates CBT principles and aims to address the limitations of conventional CBT delivery models, with the ultimate goal of improving outcomes for this difficult-to-treat population. "Dojo" is an emotion management game that helps youths to recognize and control their physiological and emotional arousal. We explored the implementation and user experience of "Dojo" in a sample of eight adolescents in residential treatment for both externalizing and anxiety problems. Participants attended all sessions without complaints. They evaluated "Dojo" very positively and exhibited high compliance during the training sessions. We encountered some problems with session scheduling and obtaining mentor reports. Quantitative data show the predicted decrease in three out of four measurements. The smooth implementation, high user satisfaction, high self-reported compliance during training sessions, and initial outcome results all indicate the high potential "Dojo" holds as an innovative intervention. If additional rigorously designed randomized controlled trials prove to be successful, "Dojo" can be a cost-effective way to engage high-risk youths in effective intervention.

Call for action: how to improve use of patient-reported outcomes to guide clinical decision making in rheumatoid arthritis.

PubMed

Fautrel, Bruno; Alten, Rieke; Kirkham, Bruce; de la Torre, Inmaculada; Durand, Frederick; Barry, Jane; Holzkaemper, Thorsten; Fakhouri, Walid; Taylor, Peter C

2018-06-01

Current guidelines for the management of rheumatoid arthritis (RA) recommend early treatment and a treat-to-target goal of remission or low disease activity. Over the past decade, this approach has been extremely successful in reducing disease activity and joint damage in patients with RA. At the same time, however, overall patient perception of well-being appears to have decreased with respect to outcome measures considered important by patients themselves, such as pain, fatigue, physical function and quality of life. The timely and effective use of patient-reported outcomes (PROs) could encourage physicians to focus more on the impact of RA on patients and how patients are feeling. This in turn would facilitate shared decision making between patients and physicians, ultimately leading to a more patient-centered approach and improved patient care. Indeed, PROs provide information about individual patients that complements information provided by physical assessment and composite scores, and can also be used to guide patient care, such as determining whether a clinic visit is needed or whether treatment modifications are necessary. This is particularly important for patients who do not achieve the aspirational target of remission or low disease activity with pharmacological treatment. A number of validated PRO questionnaires are available, but how and which PROs should be incorporated into rheumatology clinical practice as part of the decision-making process is still controversial. Combining PROs with technology, such as computer adaptive tests, electronic PRO systems, web-based platforms and patient dashboards, could further aid PRO integration into daily rheumatology clinical practice.

Determinants of health information-seeking behavior: implications for post-treatment cancer patients.

PubMed

Jung, Minsoo

2014-01-01

Health information-seeking behavior (HISB) is active need-fulfillment behavior whereby health information is obtained from diverse sources, such as the media, and has emerged as an important issue within the transforming medical environment and the rise of medical consumers. However, little is known about the factors that affect HISB and its associations, and the health outcome of HISB. The aim of this study was to examine individual and social contextual factors associated with HISB and to systematically review their effects on health status among post- treatment cancer patients. Individual determinants of HISB included demographic factors, psychosocial factors, perceived efficacy and norms, and health beliefs. Contextual determinants of HISB encompassed community characteristics, neighborhood social capital, and media advocacy. Improving through factors on these two levels, HISB raised individuals' self-care management skills and medical treatment compliance, and enhanced shared decision-making and medical treatment satisfaction. Moreover, because HISB can differ according to individuals' social contextual conditions, it can give rise to communication inequalities. Because these can ultimately lead to health disparities between groups, social interest in HISB and balanced HISB promotion strategies are necessary.

Operational research in malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV

PubMed Central

2011-01-01

Background In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. Discussion District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. Summary Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not. PMID:21794154

Screening for Cardiovascular Disease Risk With Electrocardiography: US Preventive Services Task Force Recommendation Statement.

PubMed

Curry, Susan J; Krist, Alex H; Owens, Douglas K; Barry, Michael J; Caughey, Aaron B; Davidson, Karina W; Doubeni, Chyke A; Epling, John W; Kemper, Alex R; Kubik, Martha; Landefeld, C Seth; Mangione, Carol M; Silverstein, Michael; Simon, Melissa A; Tseng, Chien-Wen; Wong, John B

2018-06-12

Cardiovascular disease (CVD), which encompasses atherosclerotic conditions such as coronary heart disease, cerebrovascular disease, and peripheral arterial disease, is the most common cause of death among adults in the United States. Treatment to prevent CVD events by modifying risk factors is currently informed by CVD risk assessment with tools such as the Framingham Risk Score or the Pooled Cohort Equations, which stratify individual risk to inform treatment decisions. To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on screening for coronary heart disease with electrocardiography (ECG). The USPSTF reviewed the evidence on whether screening with resting or exercise ECG improves health outcomes compared with the use of traditional CVD risk assessment alone in asymptomatic adults. For asymptomatic adults at low risk of CVD events (individuals with a 10-year CVD event risk less than 10%), it is very unlikely that the information from resting or exercise ECG (beyond that obtained with conventional CVD risk factors) will result in a change in the patient's risk category as assessed by the Framingham Risk Score or Pooled Cohort Equations that would lead to a change in treatment and ultimately improve health outcomes. Possible harms are associated with screening with resting or exercise ECG, specifically the potential adverse effects of subsequent invasive testing. For asymptomatic adults at intermediate or high risk of CVD events, there is insufficient evidence to determine the extent to which information from resting or exercise ECG adds to current CVD risk assessment models and whether information from the ECG results in a change in risk management and ultimately reduces CVD events. As with low-risk adults, possible harms are associated with screening with resting or exercise ECG in asymptomatic adults at intermediate or high risk of CVD events. The USPSTF recommends against screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at low risk of CVD events. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events. (I statement).

Interventions for Hip Pain in the Maturing Athlete

PubMed Central

Gomberawalla, M. Mustafa; Kelly, Bryan T.; Bedi, Asheesh

2014-01-01

Context: Femoroacetabular impingement (FAI) alters hip mechanics, results in hip pain, and may lead to secondary osteoarthritis (OA) in the maturing athlete. Hip impingement can be caused by osseous abnormalities in the proximal femur or acetabulum. These impingement lesions may cause altered loads within the hip joint, which result in repetitive collision damage or sheer forces to the chondral surfaces and acetabular labrum. These anatomic lesions and resultant abnormal mechanics may lead to early osteoarthritic changes. Evidence Acquisition: Relevant articles from the years 1995 to 2013 were identified using MEDLINE, EMBASE, and the bibliographies of reviewed publications. Level of Evidence: Level 4. Results: Improvements in hip arthroscopy have allowed FAI to be addressed utilizing the arthroscope. Adequately resecting the underlying osseous abnormalities is essential to improving hip symptomatology and preventing further chondral damage. Additionally, preserving the labrum by repairing the damaged tissue and restoring the suction seal may theoretically help normalize hip mechanics and prevent further arthritic changes. The outcomes of joint-preserving treatment options may be varied in the maturing athlete due to the degree of underlying OA. Irreversible damage to the hip joint may have already occurred in patients with moderate to advanced OA. In the presence of preexisting arthritis, these patients may only experience fair or even poor results after hip arthroscopy, with early conversion to hip replacement. For patients with advanced hip arthritis, total hip arthroplasty remains a treatment option to reliably improve symptoms with good to excellent outcomes and return to low-impact activities. Conclusion: Advances in the knowledge base and treatment techniques of intra-articular hip pain have allowed surgeons to address this complex clinical problem with promising outcomes. Traditionally, open surgical dislocations for hip preservation surgery have shown good long-term results. Improvements in hip arthroscopy have led to outcomes equivalent to open surgery while utilizing significantly less invasive techniques. However, outcomes may ultimately depend on the degree of underlying OA. When counseling the mature athlete with hip pain, an understanding of the underlying anatomy, degree of arthritis, and expectations will help guide the treating surgeon in offering appropriate treatment options. PMID:24427445

Alterations in regional shape on ipsilateral and contralateral cortex contrast in children with unilateral cerebral palsy and are predictive of multiple outcomes.

PubMed

Pagnozzi, Alex M; Dowson, Nicholas; Fiori, Simona; Doecke, James; Bradley, Andrew P; Boyd, Roslyn N; Rose, Stephen

2016-10-01

Congenital brain lesions result in a wide range of cerebral tissue alterations observed in children with cerebral palsy (CP) that are associated with a range of functional impairments. The relationship between injury severity and functional outcomes, however, remains poorly understood. This research investigates the differences in cortical shape between children with congenital brain lesions and typically developing children (TDC) and investigates the correlations between cortical shape and functional outcome in a large cohort of patients diagnosed with unilateral CP. Using 139 structural magnetic resonance images, including 95 patients with clinically diagnosed CP and 44 TDC, cortical segmentations were obtained using a modified expectation maximization algorithm. Three shape characteristics (cortical thickness, curvature, and sulcal depth) were computed within a number of cortical regions. Significant differences in these shape measures compared to the TDC were observed on both the injured hemisphere of children with CP (P < 0.004), as well as on the apparently uninjured hemisphere, illustrating potential compensatory mechanisms in these children. Furthermore, these shape measures were significantly correlated with several functional outcomes, including motor, cognition, vision, and communication (P < 0.012), with three out of these four models performing well on test set validation. This study highlights that cortical neuroplastic effects may be quantified using MR imaging, allowing morphological changes to be studied longitudinally, including any influence of treatment. Ultimately, such approaches could be used for the long term prediction of outcomes and the tailoring of treatment to individuals. Hum Brain Mapp 37:3588-3603, 2016. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Targeting epidermal growth factor receptor in the treatment of non-small-cell lung cancer.

PubMed

Kotsakis, Athanasios; Georgoulias, Vassilis

2010-10-01

The management of non-small-cell lung cancer (NSCLC) has undergone a paradigm shift in the last decade, with the survival advantage demonstrated by the incorporation of anti-epidermal growth factor receptor (EGFR) agents to the standard treatment of advanced/metastatic NSCLC. We review the existing data regarding the distinct anti-EGFR agents in the NSCLC treatment and the potential role of the investigated biomarkers in the clinical outcome. Tyrosine kinase inhibitors have been used in first-line, second-line and more settings with extremely good results in a subgroup of patients. Cetuximab remains the only anti-EGFR monoclonal antibody to show survival benefit when combined with a cytotoxic agent in the front-line setting. Anti-EGFR treatment is associated with a dramatic clinical benefit in a subgroup of patients, emphasizing the importance of customizing treatment. Several biomarkers have been investigated for their predictive or prognostic value. Validation of identification of biomarkers remains a focus of intense research that may ultimately guide therapeutic decision making, as none of these is considered ideal to discriminate responding from non-responding patients. However, the current evidence of the EGFR mutation analysis from a recent randomised trial suggests that EGFR mutation analysis is quite a good predictive marker for responsiveness to anti-EGFR TKIs. Moreover, the identification of surrogate markers to indicate optimal activity of the anti-EGFR agent is also needed. This review article provides data from large clinical trials using anti-EGFR agents and correlates these results with the tested biomarkers. EGFR inhibition has shown very encouraging results and has improved the outcome of the NSCLC treatment. However, a plateau of significant clinical benefit seems to have been reached and we believe that the time to move away from the traditional treatment approach to more individualizing therapies has come.

Modeling a molecular initiating event to population effects: A case study of aromatase inhibition in fathead minnows

EPA Science Inventory

An adverse outcome pathway (AOP) conceptually links a molecular initiating event with measureable key events at higher levels of biological organization that ultimately result in an adverse outcome. Development of an AOP requires experimental data and scientific expertise to ide...

Service Provisions for Youth with Emotional and Behavioral Disorders

ERIC Educational Resources Information Center

Dean, Latoya Lavan

2012-01-01

Youth with emotional or behavioral disorders (EBD) have poorer outcomes compared to their peers with and without disabilities. As a result, the federal government has mandated transition services to improve supports and ultimately student outcomes. Using data from the National Longitudinal Transition Study-2 (NLTS-2), this secondary analysis…

Increasing scientific confidence in adverse outcome pathways: Application of tailored Bradford-Hill considerations for evaluating weight of evidence

EPA Science Inventory

Systematic consideration of scientific support is a critical element in developing and, ultimately, using adverse outcome pathways (AOPs) for various regulatory applications. Though weight of evidence (WoE) analysis has been proposed as a basis for assessment of the maturity and...

The Development of Trust in Residential Environmental Education Programs

ERIC Educational Resources Information Center

Ardoin, Nicole M.; DiGiano, Maria L.; O'Connor, Kathleen; Podkul, Timothy E.

2017-01-01

Trust, a relational phenomenon that is an important building block of interpersonal relationships and within society, can also be an intermediary outcome of field-based environmental education programs. Trust creates a foundation for collaboration and decision-making, which are core to many ultimate outcomes of environmental education. Yet,…

Management of cervical esophageal and hypopharyngeal perforations.

PubMed

Zenga, Joseph; Kreisel, Daniel; Kushnir, Vladimir M; Rich, Jason T

2015-01-01

Evidence is limited for outcomes of surgical versus conservative management for patients with cervical esophageal or hypopharyngeal perforations. Patients with cervical esophageal or hypopharyngeal perforations treated between 1994 and 2014 were identified using an institutional database. Outcomes were compared between patients who underwent operative drainage and those who had conservative management with broad-spectrum antibiotics and withholding oral intake. Twenty-eight patients were identified with hypopharyngeal or cervical esophageal perforations, mostly due to iatrogenic (nasogastric tube placement, endoscopy, endotracheal intubation) injuries (68%). Fourteen were treated initially with conservative management and 14 with initial surgery. Six patients failed conservative treatment and two patients failed surgical treatment. Patients managed conservatively who had eaten between injury and diagnosis (p=0.003), those who had 24 hours or more between the time of injury and diagnosis (p=0.026), and those who showed signs of systemic toxicity (p=0.001) were significantly more likely to fail conservative treatment and require surgery. No variables were significant for treatment failure in the surgical group. Of the 20 patients who ultimately underwent a surgical procedure, two required a second procedure. Patients who have eaten between the time of perforation and diagnosis, have 24 hours or more between injury and diagnosis, and those that show signs of systemic toxicity are at higher risk of failing conservative management and surgical drainage should be considered. For patients without these risk factors, a trial of conservative management can be attempted. Copyright © 2015 Elsevier Inc. All rights reserved.

Clinical importance of achieving biochemical control with medical therapy in adult patients with acromegaly

PubMed Central

Christofides, Elena A

2016-01-01

In acromegaly, achieving biochemical control (growth hormone [GH] level <1.0 ng/mL and age- and sex-normalized levels of insulin-like growth factor 1 [IGF-1]) through timely diagnosis and appropriate treatment provides an opportunity to improve patient outcomes. Diagnosis of acromegaly is challenging because it is rooted in observing subtle clinical manifestations, and it is typical for acromegaly to evolve for up to 10 years before it is recognized. This results in chronic exposure to elevated levels of GH and IGF-1 and delay in patients receiving appropriate treatment, which consequently increases mortality risk. In this review, the clinical impact of elevated GH and IGF-1 levels, the effectiveness of current therapies, and the potential role of novel treatments for acromegaly will be discussed. Clinical burden of acromegaly and benefits associated with management of GH and IGF-1 levels will be reviewed. Major treatment paradigms in acromegaly include surgery, medical therapy, and radiotherapy. With medical therapies, such as somatostatin analogs, dopamine agonists, and GH receptor antagonists, a substantial proportion of patients achieve reduced GH and normalized IGF-1 levels. In addition, signs and symptoms, quality of life, and comorbidities have also been reported to improve to varying degrees in patients who achieve biochemical control. Currently, there are several innovative therapies in development to improve patient outcomes, patient use, and access. Timely biochemical control of acromegaly ensures that the patient can ultimately improve morbidity and mortality from this disease and its extensive consequences. PMID:27471378

Pituitary gigantism: a retrospective case series.

PubMed

Creo, Ana L; Lteif, Aida N

2016-05-01

Pituitary gigantism (PG) is a rare pediatric disease with poorly defined long-term outcomes. Our aim is to describe the longitudinal clinical course in PG patients using a single-center, retrospective cohort study. Patients younger than 19 years diagnosed with PG were identified. Thirteen cases were confirmed based on histopathology of a GH secreting adenoma or hyperplasia and a height >2 SD for age and gender. Laboratory studies, initial pathology, and imaging were abstracted. Average age at diagnosis was 13 years with an average initial tumor size of 7.4×3.8 mm. Initial transsphenoidal surgery was curative in 3/12 patients. Four of the nine patients who failed the initial surgery required a repeat procedure. Octreotide successfully normalized GH levels in 1/6 patients with disease refractory to surgery (1/6). Two out of five patients received pegvisomant after failing octreotide but only one patient responded to treatment. Five patients were ultimately treated with radiosurgery or radiation patients were followed for an average of 10 years. PG is difficult to treat. In most patients, the initial transsphenoidal surgery failed to normalize GH levels. If the initial surgery was unsuccessful, repeat surgery was unlikely to control GH secretion. Treatment with octreotide or pegvisomant was successful in less than half the patients failing surgery. Radiosurgery was curative, but is not an optimal treatment for pediatric patients. Despite the small sample, our study suggests that the treatment outcome of pediatric PG may be different than adults.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.

PubMed

Grubhofer, Florian; Wieser, Karl; Meyer, Dominik C; Catanzaro, Sabrina; Beeler, Silvan; Riede, Ulf; Gerber, Christian

2016-10-01

Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome. Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Poster - Thur Eve - 55: Monte Carlo simulations of variations in planned dose distributions in a prostate patient population.

PubMed

Balderson, M J; Brown, D W; Quirk, S; Ghasroddashti, E; Kirkby, C

2012-07-01

Clinical outcome studies with clear and objective endpoints are necessary to make informed radiotherapy treatment decisions. Commonly, clinical outcomes are established after lengthy and costly clinical trials are performed and the data are analyzed and published. One the challenges with obtaining meaningful data from clinical trials is that by the time the information gets to the medical profession the results may be less clinically relevant than when the trial began, An alternative approach is to estimate clinical outcomes through patient population modeling. We are developing a mathematical tool that uses Monte Carlo techniques to simulate variations in planned and delivered dose distributions of prostate patients receiving radiotherapy. Ultimately, our simulation will calculate a distribution of Tumor Control Probabilities (TCPs) for a population of patients treated under a given protocol. Such distributions can serve as a metric for comparing different treatment modalities, planning and setup approaches, and machine parameter settings or tolerances with respect to outcomes on broad patient populations. It may also help researchers understand differences one might expect to find before actually doing the clinical trial. As a first step and for the focus of this abstract we wanted to see if we could answer the question: "Can a population of dose distributions of prostate patients be accurately modeled by a set of randomly generated Gaussian functions?" Our results have demonstrated that using a set of randomly generated Gaussian functions can simulate a distribution of prostate patients. © 2012 American Association of Physicists in Medicine.

Ursodeoxycholic acid for cystic fibrosis-related liver disease.

PubMed

Cheng, Katharine; Ashby, Deborah; Smyth, Rosalind L

2014-12-15

Abnormal biliary secretion leads to the thickening of bile and the formation of plugs within the bile ducts; the consequent obstruction and abnormal bile flow ultimately results in the development of cystic fibrosis-related liver disease. This condition peaks in adolescence with up to 20% of adolescents with cystic fibrosis developing chronic liver disease. Early changes in the liver may ultimately result in end-stage liver disease with people needing transplantation. One therapeutic option currently used is ursodeoxycholic acid. To analyse evidence that ursodeoxycholic acid improves indices of liver function, reduces the risk of developing chronic liver disease and improves outcomes in general in cystic fibrosis. We searched the Cochrane CF and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also contacted drug companies.Date of the most recent search of the Group's trials register: 29 May 2014. Randomised controlled trials of the use of ursodeoxycholic acid for at least three months compared with placebo or no additional treatment in people with cystic fibrosis. Two authors independently assessed trial eligibility and quality. Ten trials have been identified, of which three trials involving 118 participants were included; the dose of ursodeoxycholic acid ranged from 10 to 20 mg/kg/day for up to 12 months. The complex design used in two trials meant that data could only be analysed for subsets of participants. There was no significant difference in weight change, mean difference -0.90 kg (95% confidence interval -1.94 to 0.14) based on 30 participants from two trials. Improvement in biliary excretion was reported in only one trial and no significant change after treatment was shown. There were no data available for analysis for long-term outcomes such as death or need for liver transplantation. There are few trials assessing the effectiveness of ursodeoxycholic acid. There is insufficient evidence to justify its routine use in cystic fibrosis.

Neuroimaging mechanisms of change in psychotherapy for addictive behaviors: emerging translational approaches that bridge biology and behavior.

PubMed

Feldstein Ewing, Sarah W; Chung, Tammy

2013-06-01

Research on mechanisms of behavior change provides an innovative method to improve treatment for addictive behaviors. An important extension of mechanisms of change research involves the use of translational approaches, which examine how basic biological (i.e., brain-based mechanisms) and behavioral factors interact in initiating and sustaining positive behavior change as a result of psychotherapy. Articles in this special issue include integrative conceptual reviews and innovative empirical research on brain-based mechanisms that may underlie risk for addictive behaviors and response to psychotherapy from adolescence through adulthood. Review articles discuss hypothesized mechanisms of change for cognitive and behavioral therapies, mindfulness-based interventions, and neuroeconomic approaches. Empirical articles cover a range of addictive behaviors, including use of alcohol, cigarettes, marijuana, cocaine, and pathological gambling and represent a variety of imaging approaches including fMRI, magneto-encephalography, real-time fMRI, and diffusion tensor imaging. Additionally, a few empirical studies directly examine brain-based mechanisms of change, whereas others examine brain-based indicators as predictors of treatment outcome. Finally, two commentaries discuss craving as a core feature of addiction, and the importance of a developmental approach to examining mechanisms of change. Ultimately, translational research on mechanisms of behavior change holds promise for increasing understanding of how psychotherapy may modify brain structure and functioning and facilitate the initiation and maintenance of positive treatment outcomes for addictive behaviors. 2013 APA, all rights reserved

Unilateral fixation for treatment of occipitocervical instability in children with congenital vertebral anomalies of the craniocervical junction.

PubMed

Mazur, Marcus D; Ravindra, Vijay M; Brockmeyer, Douglas L

2015-04-01

OBJECT Patients with occipitocervical (OC) instability from congenital vertebral anomalies (CVAs) of the craniocervical junction (CCJ) often have bony abnormalities that make instrumentation placement difficult. Within this patient population, some bilateral instrumentation constructs either fail or are not feasible, and a unilateral construct must be used. The authors describe the surgical management and outcomes of this disorder in patients in whom unilateral fixation constructs were used to treat OC instability. METHODS From a database of OC fusion procedures, the authors identified patients who underwent unilateral fixation for the management of OC instability. Patient characteristics, surgical details, and radiographic outcomes were reviewed. In each patient, CT scans were performed at least 4 months after surgery to evaluate for fusion. RESULTS Eight patients with CVAs of the CCJ underwent unilateral fixation for the treatment of OC instability. For 4 patients, the procedure occurred after a bilateral OC construct failed or infection forced hardware removal. For the remainder, it was the primary procedure. Two patients required reoperation for hardware revision and 1 developed nonunion requiring revision of the bone graft. Ultimately, 7 patients demonstrated osseous fusion on CT scans and 1 had a stable fibrous union. CONCLUSIONS These findings demonstrate that a unilateral OC fixation is effective for the treatment of OC instability in children with CVAs of the CCJ in whom bilateral screw placement fails or is not feasible.

Neuroimaging mechanisms of change in psychotherapy for addictive behaviors: Emerging translational approaches that bridge biology and behavior

PubMed Central

Feldstein Ewing, Sarah W.; Chung, Tammy

2013-01-01

Research on mechanisms of behavior change provides an innovative method to improve treatment for addictive behaviors. An important extension of mechanisms of change research involves the use of translational approaches, which examine how basic biological (i.e., brain-based mechanisms) and behavioral factors interact in initiating and sustaining positive behavior change as a result of psychotherapy. Articles in this special issue include integrative conceptual reviews and innovative empirical research on brain-based mechanisms that may underlie risk for addictive behaviors and response to psychotherapy from adolescence through adulthood. Review articles discuss hypothesized mechanisms of change for cognitive and behavioral therapies, mindfulness-based interventions, and neuroeconomic approaches. Empirical articles cover a range of addictive behaviors, including use of alcohol, cigarettes, marijuana, cocaine, and pathological gambling and represent a variety of imaging approaches including fMRI, magneto-encephalography, real time fMRI, and diffusion tensor imaging. Additionally, a few empirical studies directly examined brain-based mechanisms of change, whereas others examined brain-based indicators as predictors of treatment outcome. Finally, two commentaries discuss craving as a core feature of addiction, and the importance of a developmental approach to examining mechanisms of change. Ultimately, translational research on mechanisms of behavior change holds promise for increasing understanding of how psychotherapy may modify brain structure and functioning and facilitate the initiation and maintenance of positive treatment outcomes for addictive behaviors. PMID:23815447

Comparison of Clinical Efficacy of Newfactan® versus Surfacten® for the Treatment of Respiratory Distress Syndrome in the Newborn Infants

PubMed Central

Choi, Chang Won; Hwang, Jong Hee; Yoo, Eun Jung; Kim, Kyung Ah; Koh, Sun Young; Lee, Yeon Kyung; Shim, Jae Won; Lee, Eun Kyung; Chang, Wook; Kim, Sung Shin; Chang, Yun Sil; Shin, Son Moon

2005-01-01

Newfactan® is a domestically developed, bovine lung-derived, semi-synthetic surfactant. The aim of this study was to compare the clinical efficacy of Newfactan® with that of Surfacten® in the treatment of respiratory distress syndrome (RDS). Newfactan® or Surfacten® was randomly allocated to 492 newborn infants who were diagnosed as RDS and required surfactant instillation in four participating hospitals. The comparisons were made individually in two subsets of infants by birth weight (<1,500 g group [n=253] and ≥1,500 g group [n=239]). Short-term responses to surfactant and acute complications, such as the total doses of surfactant instilled, response type, extubation rate, ventilator settings, changes in respiratory parameters, air leak, patent ductus arteriosus, pulmonary hemorrhage, and intraventricular hemorrhage, and mortality during the 96 hr after surfactant instillation were measured. Long-term outcome and complications, such as total duration of intubation, bronchopulmonary dysplasia and periventricular leukomalacia, and ultimate mortality were measured. There were no significant differences in demographic and perinatal variables, short-term responses to surfactant and acute complications, and long-term outcome and complications between Newfactan® and Surfacten® in both birth weight groups. We concluded that Newfactan® was comparable to Surfacten® in the clinical efficacy in the treatment of RDS in both birth weight groups. PMID:16100449

Wound Closure and Outcome in Extensively Burned Patients Treated with Cultured Autologous Keratinocytes,

DTIC Science & Technology

1993-05-01

long-term joint consequently has exerted no demonstrable effect on the contractures could be expected. Was any increase noted in this outcome of...ELECTE . , AD-A268 707 THE JOURNAL or TRAUMA so AU 3 019934 N Copyright 1993 by Wils & Printed in U.S.A. WOUND CLOSLRE AND OUTCOME IN EXTENSIVELY...Ultimate patient outcome remains dependent upon ocytes has prompted many investigators to assess the early, timely closure of the burn wound, typically

Cost-effectiveness of hepatitis C treatment using generic direct-acting antivirals available in India

PubMed Central

Aggarwal, Rakesh; Chen, Qiushi; Goel, Amit; Seguy, Nicole; Pendse, Razia; Ayer, Turgay

2017-01-01

Background & aims Availability of directly-acting antivirals (DAAs) has changed the treatment landscape of hepatitis C virus (HCV) infection. The high price of DAAs has restricted their use in several countries. However, in some countries such as India, generic DAAs are available at much cheaper price. This study examined whether generic DAAs could be cost-saving and how long it would take for the treatment to become cost-saving/effective. Methods A previously-validated, mathematical model was adapted to the HCV-infected population in India to compare the outcomes of no treatment versus treatment with DAAs. Model parameters were estimated from published studies. Cost-effectiveness of HCV treatment using available DAAs was calculated, using a payer’s perspective. We estimated quality-adjusted life years (QALYs), disability-adjusted life years (DALYs), total costs, and incremental cost-effectiveness ratio of DAAs versus no treatment. One-way and probabilistic sensitivity analyses were conducted. Results Compared with no treatment, the use of generic DAAs in Indian HCV patients would increase the life expectancy by 8.02 years, increase QALYs by 3.89, avert 19.07 DALYs, and reduce the lifetime healthcare costs by $1,309 per-person treated. Treatment became cost-effective within 2 years, and cost-saving within 10 years of its initiation overall and within 5 years in persons with cirrhosis. Treating 10,000 HCV-infected persons could prevent 3400–3850 decompensated cirrhosis, 1800–2500 HCC, and 4000–4550 liver-related deaths. The results were sensitive to the costs of DAAs, pre- and post-treatment diagnostic tests and management of cirrhosis, and quality of life after sustained virologic response. Conclusions Treatment with generic DAAs available in India will improve patient outcomes, provide a good value for money within 2 years, and be ultimately cost-saving. Therefore, in this and similar settings, HCV treatment should be a priority from a public health as well an economic perspective. PMID:28520728

Cost-effectiveness of hepatitis C treatment using generic direct-acting antivirals available in India.

PubMed

Aggarwal, Rakesh; Chen, Qiushi; Goel, Amit; Seguy, Nicole; Pendse, Razia; Ayer, Turgay; Chhatwal, Jagpreet

2017-01-01

Availability of directly-acting antivirals (DAAs) has changed the treatment landscape of hepatitis C virus (HCV) infection. The high price of DAAs has restricted their use in several countries. However, in some countries such as India, generic DAAs are available at much cheaper price. This study examined whether generic DAAs could be cost-saving and how long it would take for the treatment to become cost-saving/effective. A previously-validated, mathematical model was adapted to the HCV-infected population in India to compare the outcomes of no treatment versus treatment with DAAs. Model parameters were estimated from published studies. Cost-effectiveness of HCV treatment using available DAAs was calculated, using a payer's perspective. We estimated quality-adjusted life years (QALYs), disability-adjusted life years (DALYs), total costs, and incremental cost-effectiveness ratio of DAAs versus no treatment. One-way and probabilistic sensitivity analyses were conducted. Compared with no treatment, the use of generic DAAs in Indian HCV patients would increase the life expectancy by 8.02 years, increase QALYs by 3.89, avert 19.07 DALYs, and reduce the lifetime healthcare costs by $1,309 per-person treated. Treatment became cost-effective within 2 years, and cost-saving within 10 years of its initiation overall and within 5 years in persons with cirrhosis. Treating 10,000 HCV-infected persons could prevent 3400-3850 decompensated cirrhosis, 1800-2500 HCC, and 4000-4550 liver-related deaths. The results were sensitive to the costs of DAAs, pre- and post-treatment diagnostic tests and management of cirrhosis, and quality of life after sustained virologic response. Treatment with generic DAAs available in India will improve patient outcomes, provide a good value for money within 2 years, and be ultimately cost-saving. Therefore, in this and similar settings, HCV treatment should be a priority from a public health as well an economic perspective.

Discontinuation of tyrosine kinase inhibitors in chronic myeloid leukemia: Recommendations for clinical practice from the French Chronic Myeloid Leukemia Study Group.

PubMed

Rea, Delphine; Ame, Shanti; Berger, Marc; Cayuela, Jean-Michel; Charbonnier, Aude; Coiteux, Valérie; Cony-Makhoul, Pascale; Dubruille, Viviane; Dulucq, Stéphanie; Etienne, Gabriel; Legros, Laurence; Nicolini, Franck; Roche-Lestienne, Catherine; Escoffre-Barbe, Martine; Gardembas, Martine; Guerci-Bresler, Agnès; Johnson-Ansah, Hyacinthe; Rigal-Huguet, Françoise; Rousselot, Philippe; Mahon, François-Xavier

2018-05-03

The ultimate goal of chronic myeloid leukemia management in the tyrosine kinase inhibitor (TKI) era for patients who obtain deep molecular responses is maintaining a durable off-treatment response after treatment discontinuation; this situation is called treatment-free remission (TFR). Knowledge accumulated during the last 10 years justifies moving TFR strategies from research to clinical practice. Twenty experts from the French Chronic Myeloid Leukemia Study Group (France Intergroupe des Leucémies Myéloïdes Chroniques), including 17 hematologists, 2 molecular biologists, and 1 cytogeneticist, critically reviewed published data with the goal of developing evidence-based recommendations for TKI discontinuation in clinical practice. Clinically relevant questions were addressed, including the selection of candidate patients (with known prognostic factors for outcomes taken into account), detailed monitoring procedures during the treatment-free phase, a definition of relapse requiring therapy resumption, and monitoring after treatment reintroduction. This work presents consensus statements with the aim of guiding physicians and biologists by means of pragmatic recommendations for safe TKI discontinuation in daily practice. Cancer 2018. © 2018 American Cancer Society. © 2018 American Cancer Society.

Molecular pathogenesis of precursor lesions of pancreatic ductal adenocarcinoma.

PubMed

Biankin, Andrew V; Kench, James G; Dijkman, Floriaan P; Biankin, Sandra A; Henshall, Susan M

2003-02-01

Precursor lesions are assuming greater importance in the study of pancreatic ductal adenocarcinoma. As pancreatic cancer is almost universally fatal due to late clinical presentation and biological aggressiveness, characterisation of its precursor lesions may create scope for early diagnosis and improved outcome with conventional therapies as well as the development of novel therapeutic and preventative strategies. Pancreatic intraepithelial neoplasia (PanIN) and intraductal papillary mucinous tumours (IPMTs) are thought to be precursor lesions of ductal adenocarcinoma of the pancreas. Recent work has focused on the molecular aberrations associated with these lesions leading to the formulation of a progression model for pancreatic cancer. Progressive histopathological changes along the progression model are associated with aberrations of cell cycle regulatory and growth factor signalling molecules that occur in pancreatic cancer at high frequency and are common to many cancers. Characterisation of these molecular aberrations provides scope for the development of novel diagnostic and treatment strategies that will ultimately impact on the outcome for people who develop pancreatic cancer.

Characteristics of ballistic and blast injuries.

PubMed

Powers, David B; Delo, Robert I

2013-03-01

Ballistic injury wounds are formed by variable interrelated factors, such as the nature of the tissue, the compositional makeup of the bullet, distance to the target, and the velocity, shape, and mass of the of the projectile. This complex arrangement, with the ultimate outcome dependent on each other, makes the prediction of wounding potential difficult to assess. As the facial features are the component of the body most involved in a patient's personality and interaction with society, preservation of form, cosmesis, and functional outcome should remain the primary goals in the management of ballistic injury. A logical, sequential analysis of the injury patterns to the facial complex is an absolutely necessary component for the treatment of craniomaxillofacial ballistic injuries. Fortunately, these skill sets should be well honed in all craniomaxillofacial surgeons through their exposure to generalized trauma, orthognathic, oncologic, and cosmetic surgery patients. Identification of injured tissues, understanding the functional limitations of these injuries, and preservation of both hard and soft tissues minimizing the need for tissue replacement are paramount.

An overview of animal models of pain: disease models and outcome measures

PubMed Central

Gregory, N; Harris, AL; Robinson, CR; Dougherty, PM; Fuchs, PN; Sluka, KA

2013-01-01

Pain is ultimately a perceptual phenomenon. It is built from information gathered by specialized pain receptors in tissue, modified by spinal and supraspinal mechanisms, and integrated into a discrete sensory experience with an emotional valence in the brain. Because of this, studying intact animals allows the multidimensional nature of pain to be examined. A number of animal models have been developed, reflecting observations that pain phenotypes are mediated by distinct mechanisms. Animal models of pain are designed to mimic distinct clinical diseases to better evaluate underlying mechanisms and potential treatments. Outcome measures are designed to measure multiple parts of the pain experience including reflexive hyperalgesia measures, sensory and affective dimensions of pain and impact of pain on function and quality of life. In this review we discuss the common methods used for inducing each of the pain phenotypes related to clinical pain syndromes, as well as the main behavioral tests for assessing pain in each model. PMID:24035349

Developing a theoretical framework to illustrate associations among patient satisfaction, body image and quality of life for women undergoing breast reconstruction.

PubMed

Fingeret, Michelle Cororve; Nipomnick, Summer W; Crosby, Melissa A; Reece, Gregory P

2013-10-01

Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient. Copyright © 2013 Elsevier Ltd. All rights reserved.

Usability Flaws in Medication Alerting Systems: Impact on Usage and Work System.

PubMed

Marcilly, R; Ammenwerth, E; Roehrer, E; Pelayo, S; Vasseur, F; Beuscart-Zéphir, M-C

2015-08-13

Previous research has shown that medication alerting systems face usability issues. There has been no previous attempt to systematically explore the consequences of usability flaws in such systems on users (i.e. usage problems) and work systems (i.e. negative outcomes). This paper aims at exploring and synthesizing the consequences of usability flaws in terms of usage problems and negative outcomes on the work system. A secondary analysis of 26 papers included in a prior systematic review of the usability flaws in medication alerting was performed. Usage problems and negative outcomes were extracted and sorted. Links between usability flaws, usage problems, and negative outcomes were also analyzed. Poor usability generates a large variety of consequences. It impacts the user from a cognitive, behavioral, emotional, and attitudinal perspective. Ultimately, usability flaws have negative consequences on the workflow, the effectiveness of the technology, the medication management process, and, more importantly, patient safety. Only few complete pathways leading from usability flaws to negative outcomes were identified. Usability flaws in medication alerting systems impede users, and ultimately their work system, and negatively impact patient safety. Therefore, the usability dimension may act as a hidden explanatory variable that could explain, at least partly, the (absence of) intended outcomes of new technology.

Usability Flaws in Medication Alerting Systems: Impact on Usage and Work System

PubMed Central

Ammenwerth, E.; Roehrer, E.; Pelayo, S.; Vasseur, F.; Beuscart-Zéphir, M.-C.

2015-01-01

Summary Objectives Previous research has shown that medication alerting systems face usability issues. There has been no previous attempt to systematically explore the consequences of usability flaws in such systems on users (i.e. usage problems) and work systems (i.e. negative outcomes). This paper aims at exploring and synthesizing the consequences of usability flaws in terms of usage problems and negative outcomes on the work system. Methods A secondary analysis of 26 papers included in a prior systematic review of the usability flaws in medication alerting was performed. Usage problems and negative outcomes were extracted and sorted. Links between usability flaws, usage problems, and negative outcomes were also analyzed. Results Poor usability generates a large variety of consequences. It impacts the user from a cognitive, behavioral, emotional, and attitudinal perspective. Ultimately, usability flaws have negative consequences on the workflow, the effectiveness of the technology, the medication management process, and, more importantly, patient safety. Only few complete pathways leading from usability flaws to negative outcomes were identified. Conclusion Usability flaws in medication alerting systems impede users, and ultimately their work system, and negatively impact patient safety. Therefore, the usability dimension may act as a hidden explanatory variable that could explain, at least partly, the (absence of) intended outcomes of new technology. PMID:26123906

Chronic Exposure to Methamphetamine Disrupts Reinforcement-Based Decision Making in Rats.

PubMed

Groman, Stephanie M; Rich, Katherine M; Smith, Nathaniel J; Lee, Daeyeol; Taylor, Jane R

2018-03-01

The persistent use of psychostimulant drugs, despite the detrimental outcomes associated with continued drug use, may be because of disruptions in reinforcement-learning processes that enable behavior to remain flexible and goal directed in dynamic environments. To identify the reinforcement-learning processes that are affected by chronic exposure to the psychostimulant methamphetamine (MA), the current study sought to use computational and biochemical analyses to characterize decision-making processes, assessed by probabilistic reversal learning, in rats before and after they were exposed to an escalating dose regimen of MA (or saline control). The ability of rats to use flexible and adaptive decision-making strategies following changes in stimulus-reward contingencies was significantly impaired following exposure to MA. Computational analyses of parameters that track choice and outcome behavior indicated that exposure to MA significantly impaired the ability of rats to use negative outcomes effectively. These MA-induced changes in decision making were similar to those observed in rats following administration of a dopamine D2/3 receptor antagonist. These data use computational models to provide insight into drug-induced maladaptive decision making that may ultimately identify novel targets for the treatment of psychostimulant addiction. We suggest that the disruption in utilization of negative outcomes to adaptively guide dynamic decision making is a new behavioral mechanism by which MA rigidly biases choice behavior.

Management of pediatric patients with refractory constipation who fail cecostomy.

PubMed

Bonilla, Silvana F; Flores, Alejandro; Jackson, Carl-Christian A; Chwals, Walter J; Orkin, Bruce A

2013-09-01

Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking. To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients. Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed. 76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up. Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues. Copyright © 2013 Elsevier Inc. All rights reserved.

Leadership in Nigerian health system for cancer prevention and control.

PubMed

Ogbimi, R I

2009-06-01

Unacceptable health system outcomes are often related to problems with leadership because the ultimate responsibility for assigned work rests on leadership. In this paper, proper leadership at micro and macro-levels can have positive impact on the health and well being of citizens. While this may be readily obvious in other spheres, it has not been addressed adequately in the context of health care systems and its impact on health outcomes. In this paper, I discuss types of work and leadership systems in order to highlight the importance of leadership and leadership training in collaborative training and research for cancer management. The complexity of health systems highlight the expanded role of leadership in terms of capacity and capability to control the environmental risk factors for cancer, deploy adequate resources for the management of cancers, and ensure fruitful and productive post treatment life for citizens. Improved community awareness, better training of health care workers, improved working environment based on better interpersonal relationships between all cadres of health care workers, environmental health and safety initiatives and research on cancer are some of the areas where improved leadership can lead to better health outcomes. Effective leadership requires a set of skills that can be acquired with requisite operating environment, political will and adequate funding in order to generate the expected improvements in outcome.

A value framework in head and neck cancer care.

PubMed

de Souza, Jonas A; Seiwert, Tanguy Y

2014-01-01

The care of head and neck squamous cell carcinoma has greatly evolved over the past 30 years. From single modality to a multidisciplinary care, there has also been a concurrent increase in treatment intensity, resulting, at many times, in more zealous regimens that patients must endure. In this article, we apply Porter's value model as a framework to balance survival, toxicities, cost, and trade-offs from a patient's perspective in head and neck cancer. This model defines value as the health outcome per dollar achieved. Domains and outcomes that are important to patients, including not only survival or short-term quality of life, but also functional outcomes, recovery, sustainability of recovery, and the lasting consequences of therapy are included in this framework. Other outcomes that are seldom measured in head and neck cancer, such as work disability and financial toxicities, are also included and further discussed. Within this value model and based on evidence, we further discuss de-escalation of care, intensity-modulated radiation therapy, newer surgical methods, and enhancements in the process of care as potential approaches to add value for patients. Finally, we argue that knowing the patient's preferences is essential in the value discussion, as the attribute that will ultimately provide the most value to the individual patient with head and neck cancer.

Combination treatment of pediatric coats' disease: a bicenter study in Taiwan.

PubMed

Lin, Chun-Ju; Chen, San-Ni; Hwang, Jiunn-Feng; Yang, Chung-May

2013-01-01

To present the clinical outcome of different combination treatment modalities in pediatric Coats' disease in two Taiwan medical centers. A retrospective review of clinical records was done of pediatric patients with Coats' disease treated at National Taiwan University Hospital and Changhua Christian Hospital. Data regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications were recorded. Changes in vision and retinal status with the different methods of treatment were specifically evaluated. From 2005 through 2011, 10 eyes of 9 patients were treated under the diagnosis of Coats' disease. The clinical manifestations varied from localized vascular abnormalities with subretinal fluid and hard exudates to extensive detachment with massive exudates and retinal hemorrhage. The main treatment modalities include argon laser photocoagulation, micropulse laser, and cryotherapy. The adjunctive therapies included intravitreal triamcinolone, bevacizumab, and ranibizumab. The mean follow-up was 40.50 ± 20.52 months (range: 14 to 72 months). Best corrected visual acuity at last follow-up was light perception to 1.0 (20/20 Snellen). Anatomic improvement was achieved in 9 eyes (90%). Visual improvement was noted in 7 eyes (70%), visual stabilization in 2 eyes (20%), and visual deterioration in 1 eye (10%). Vitreous fibrosis evolving into tractional retinal detachment occurred in 1 patient receiving cryotherapy combined with intravitreal bevacizumab injections. No enucleation was ultimately necessary. Pediatric Coats' disease varies greatly in severity. Carefully selected treatment modalities can improve most eyes with different conditions. Intravitreal anti-vascular endothelial growth factor agents may act as useful adjuncts to improve anatomic and functional outcome. Cryotherapy combined with the intravitreal bevacizumab injection in severe cases of exudative retinal detachment may carry the risk of vitreoretinal traction and tractional retinal detachment.

Measuring what matters to rare disease patients - reflections on the work by the IRDiRC taskforce on patient-centered outcome measures.

PubMed

Morel, Thomas; Cano, Stefan J

2017-11-02

Our ability to evaluate outcomes which genuinely reflect patients' unmet needs, hopes and concerns is of pivotal importance. However, much current clinical research and practice falls short of this objective by selecting outcome measures which do not capture patient value to the fullest. In this Opinion, we discuss Patient-Centered Outcomes Measures (PCOMs), which have the potential to systematically incorporate patient perspectives to measure those outcomes that matter most to patients. We argue for greater multi-stakeholder collaboration to develop PCOMs, with rare disease patients and families at the center. Beyond advancing the science of patient input, PCOMs are powerful tools to translate care or observed treatment benefit into an 'interpretable' measure of patient benefit, and thereby help demonstrate clinical effectiveness. We propose mixed methods psychometric research as the best route to deliver fit-for-purpose PCOMs in rare diseases, as this methodology brings together qualitative and quantitative research methods in tandem with the explicit aim to efficiently utilise data from small samples. And, whether one opts to develop a brand-new PCOM or to select or adapt an existing outcome measure for use in a rare disease, the anchors remain the same: patients, their daily experience of the rare disease, their preferences, core concepts and values. Ultimately, existing value frameworks, registries, and outcomes-based contracts largely fall short of consistently measuring the full range of outcomes that matter to patients. We argue that greater use of PCOMs in rare diseases would enable a fast track to Patient-Centered Care.

Distinguishing between Unipolar Depression and Bipolar Depression: Current and Future Clinical and Neuroimaging Perspectives

PubMed Central

de Almeida, Jorge Renner Cardoso; Phillips, Mary Louise

2012-01-01

Differentiating bipolar disorder (BD) from recurrent unipolar depression (UD) is a major clinical challenge. Main reasons for this include the higher prevalence of depressive relative to hypo/manic symptoms during the course of BD illness and the high prevalence of subthreshold manic symptoms in both BD and UD depression. Identifying objective markers of BD might help improve accuracy in differentiating between BD and UD depression, to ultimately optimize clinical and functional outcome for all depressed individuals. Yet, only eight neuroimaging studies to date directly compared UD and BD depressed individuals. Findings from these studies suggest more widespread abnormalities in white matter connectivity and white matter hyperintensities in BD than UD depression, habenula volume reductions in BD but not UD depression, and differential patterns of functional abnormalities in emotion regulation and attentional control neural circuitry in the two depression types. These findings suggest different pathophysiologic processes, especially in emotion regulation, reward and attentional control neural circuitry in BD versus UD depression. This review thereby serves as a “call to action” to highlight the pressing need for more neuroimaging studies, using larger samples sizes, comparing BD and UD depressed individuals. These future studies should also include dimensional approaches, studies of at risk individuals, and more novel neuroimaging approaches, such as, connectivity analysis and machine learning. Ultimately, these approaches might provide biomarkers to identify individuals at future risk for BD versus UD, and biological targets for more personalized treatment and new treatment developments for BD and UD depression. PMID:22784485

A trauma outreach program provided by a level I trauma center is an effective way to initiate peer review at referring hospitals and foster process improvements.

PubMed

Byrnes, Matthew C; Irwin, Eric; Becker, Leslie; Thorson, Melissa; Beilman, Greg; Horst, Patrick; Croston, Kevin

2010-04-01

The initial care of critically injured patients has profound effects on ultimate outcomes. The "golden hour" of trauma care is often provided by rural hospitals before definitive transfer. There are, however, no standardized methods for providing educational feedback to these hospitals for the purposes of performance improvement. We hypothesized that an outreach program would stimulate peer review and identify systematic deficiencies in the care of patients with injuries. We developed a quality improvement program aimed at providing educational feedback to hospitals that referred patients to our American College of Surgeons-verified level I trauma center. We traveled to each referral center to provide feedback on the initial treatment and ultimate outcome of patients that were transferred to us. These feedback sessions were presented in the format of case presentations and case discussions. The outreach program was presented at each hospital every 3 months to 6 months. Nine hospitals were included in our program. We received 334 patients in transfer from these hospitals during the study period. Formal peer review that focused on trauma patients increased from 14% of hospitals to 100% of hospitals after institution of the program. Eighty-five percent of hospitals thought that the care of patients with injuries was improved as a result of the program. Eighty-five percent of hospitals developed process improvement initiatives as a result of the program. A formal outreach program can stimulate peer review at rural hospitals, provide continuing education in the care of patients with injuries, and foster process improvements at referring hospitals.

Bonding Effectiveness of Luting Composites to Different CAD/CAM Materials.

PubMed

Peumans, Marleen; Valjakova, Emilija Bajraktarova; De Munck, Jan; Mishevska, Cece Bajraktarova; Van Meerbeek, Bart

To evaluate the influence of different surface treatments of six novel CAD/CAM materials on the bonding effectiveness of two luting composites. Six different CAD/CAM materials were tested: four ceramics - Vita Mark II; IPS Empress CAD and IPS e.max CAD; Celtra Duo - one hybrid ceramic, Vita Enamic, and one composite CAD/CAM block, Lava Ultimate. A total of 60 blocks (10 per material) received various mechanical surface treatments: 1. 600-grit SiC paper; 2. sandblasting with 30-μm Al2O3; 3. tribochemical silica coating (CoJet). Subsequent chemical surface treatments involved either no further treatment (control), HF acid etching (HF), silanization (S, or HF acid etching followed by silanization (HF+S). Two specimens with the same surface treatment were bonded together using two dual-curing luting composites: Clearfil Esthetic Cement (self-etching) or Panavia SA Cement (self-adhesive). After 1 week of water storage, the microtensile bond strength of the sectioned microspecimens was measured and the failure mode was evaluated. The bonding performance of the six CAD/CAM materials was significantly influenced by surface treatment (linear mixed models, p < 0.05). The luting cement had a significant influence on bond strength for Celtra Duo and Lava Ultimate (linear mixed models, p < 0.05). Mechanical surface treatment significantly influenced the bond strength for Celtra Duo (p = 0.0117), IPS e.max CAD (p = 0.0115), and Lava Ultimate (p < 0.0001). Different chemical surface treatments resulted in the highest bond strengths for the six CAD/CAM materials: Vita Mark II and IPS Empress CAD: S, HF+S; Celtra Duo: HF, HF+S; IPS e.max CAD: HF+S; Vita Enamic: HF+S, S. For Lava Ultimate, the highest bond strengths were obtained with HF, S, HF+S. Failure analysis showed a relation between bond strength and failure type: more mixed failures were observed with higher bond strengths. Mainly adhesive failures were noticed if no further surface treatment was done. The percentage of adhesive failures was higher for CAD/CAM materials with higher flexural strength (Celtra Duo, IPS e.max CAD, and Lava Ultimate). The bond strength of luting composites to novel CAD/CAM materials is influenced by surface treatment. For each luting composite, an adhesive cementation protocol can be specified in order to obtain the highest bond to the individual CAD/CAM materials.

Clinical, histopathological and immunohistochemical characterization of a novel equine ocular disorder: heterochromic iridocyclitis with secondary keratitis in adult horses.

PubMed

Pinto, Nelson I; McMullen, Richard J; Linder, Keith E; Cullen, John M; Gilger, Brian C

2015-11-01

To describe the clinical, histopathologic and immunohistochemical characteristics of an equine ocular inflammatory disease resulting in anterior uveitis and corneal endothelial inflammation associated with iris pigment dispersion and retrocorneal fibrous membrane (RFM) formation. Retrospective study. Sixteen horses with evidence of pigmented keratic precipitates (KPs), corneal edema, and/or iris depigmentation. Information collected from the medical records included signalment, clinical signs, prereferral treatment duration and response to therapy, ophthalmic examination findings, postreferral treatment, response to therapy, and outcome. Twenty-one eyes from 16 horses were affected. Age ranged between 9 and 25 years (Average 16.1 years). Blepharospasm, epiphora, and/or corneal opacification were the first clinical signs noted. At the time of referral pigmented KPs, corneal edema, iridal depigmentation, and retrocorneal membranes were commonly seen. Treatment included topical and/or systemic anti-inflammatories and antibiotics with variable response. Reduction or cessation of anti-inflammatory therapy resulted in worsening of clinical signs and disease progression. Eight eyes ultimately required enucleation. Histopathology changes include iridal pigment loss and dispersion, RFM formation, and keratitis. Variable degrees of lymphoplasmacytic inflammation were dominated by T-cells within the corneal stroma, RFM, iris, and ciliary body with occasional multinucleated giant cells. Heterochromic iridocyclitis with secondary keratitis (HIK) is characterized by uveal inflammation with pigment dispersion and suspected corneal endothelial dysfunction. Horses being treated for HIK require diligent and frequent follow-up examinations in combination with aggressive local immune suppression to control the disease. However, HIK may not respond to therapy and enucleation may ultimately be required to ensure the horse's comfort. © 2014 American College of Veterinary Ophthalmologists.

Characterization of the Asian Phenotype - An Emerging Paradigm with Clinicopathological and Human Research Implications.

PubMed

Leow, Melvin Khee-Shing

2017-01-01

Background : Modern medicine recognizes that salient, inherent variations between Caucasians and Asians exist. Radical changes are occurring in the health scene with increasing emphasis centered on the recognition of inter-individual variations unique to Asians that impact on medical management and outcomes. Aim : This review analyzes distinct features or outcomes in terms of epidemiology, disease thresholds, diagnostic cutoffs and treatment responses of Asian people compared with non-Asians. Methods : This review is based on a literature search via PubMed and MEDLINE for relevant articles related to the Asian phenotype and its impact on health and disease. Results : An 'Asian phenotype' could be characterized across the spectrum of biomedical disciplines and underscores the major challenges clinicians must face in their daily management of a cosmopolitan population and their extrapolation of research outcomes. Conclusion : Interventions for various ailments that have traditionally ignored population differences have now entered the age of personalized, stratified or precision medicine requiring an individualized approach being adopted as a new standard of care. Factoring in Asian phenotypes is essential for the medical research community and the development of improved clinical practice guidelines across a continuum of disciplines that will ultimately translate to better human health round the world.

Schizophrenia and Physical Comorbidity.

PubMed

Šimunović Filipčić, Ivona; Filipčić, Igor

2018-06-01

Schizophrenia is a severe psychiatric disorder increasingly recognized as a systemic disorder. In addition to the burden and suffering caused by the mental illness itself, individuals with schizophrenia have a high risk for physical illnesses. The life expectancy gap remains 13 to 30 years wider in people with schizophrenia compared to the general population. This premature mortality is caused largely by deaths due to cardiovascular disease, cancer, diabetes mellitus, and other natural causes, poor diagnosis and treatment, and insufficient prevention of modifiable risk factors. Although the links between schizophrenia and physical illnesses are well established, in clinical practice, physical illnesses in patients with schizophrenia are often overlooked, and the mortality gap between general population and people with schizophrenia continues to widen. The physical health of people with schizophrenia is commonly self-neglected but also ignored by people around them and by health systems, resulting in significant physical health disparities and limited access to health services. The root of the problem of insufficient healthcare appear to lie in interrelated contributory factors from illness, patients, and medical and mental healthcare system. Furthermore, a growing body of literature has been indicating the effect of the chronic physical illness on the treatment outcome of psychosis. Premature mortality and disability could be reduced if there was a greater focus on the implementation of strategies that effectively prevent modifiable risk factors from the first psychotic episode and enhance early recognition of physical illnesses, reduce the burden of physical comorbidity and lead to improved health outcomes. Ultimately, to improve treatment outcome and to reduce the suffering of people with schizophrenia, it is crucial to treat physical comorbidity promptly and assertively from the appearance of the first symptoms of the psychotic disorder. The integrative approach and collaborative care within all levels of healthcare providers should be the imperative in clinical practice.

Assessing the population health impact of market interventions to improve access to antiretroviral treatment

PubMed Central

Bärnighausen, Till; Kyle, Margaret; Salomon, Joshua A; Waning, Brenda

2012-01-01

Despite extraordinary global progress in increasing coverage of antiretroviral treatment (ART), the majority of people needing ART currently are not receiving treatment. Both the number of people needing ART and the average ART price per patient-year are expected to increase in coming years, which will dramatically raise funding needs for ART. Several international organizations are using interventions in ART markets to decrease ART price or to improve ART quality, delivery and innovation, with the ultimate goal of improving population health. These organizations need to select those market interventions that are most likely to substantially affect population health outcomes (ex ante assessment) and to evaluate whether implemented interventions have improved health outcomes (ex post assessment). We develop a framework to structure ex ante and ex post assessment of the population health impact of market interventions, which is transmitted through effects in markets and health systems. Ex ante assessment should include evaluation of the safety and efficacy of the ART products whose markets will be affected by the intervention; theoretical consideration of the mechanisms through which the intervention will affect population health; and predictive modelling to estimate the potential population health impact of the intervention. For ex post assessment, analysts need to consider which outcomes to estimate empirically and which to model based on empirical findings and understanding of the economic and biological mechanisms along the causal pathway from market intervention to population health. We discuss methods for ex post assessment and analyse assessment issues (unintended intervention effects, interaction effects between different interventions, and assessment impartiality and cost). We offer seven recommendations for ex ante and ex post assessment of population health impact of market interventions. PMID:21914713

Retrograde type a dissection in a 24th gestational week pregnant patient - the importance of interdisciplinary interaction to a successful outcome.

PubMed

Easo, Jerry; Horst, Michael; Schmuck, Bernhard; Thomas, Rohit Philip; Saupe, Steffen; Book, Malte; Weymann, Alexander

2018-05-02

Type A Dissection in pregnancy is a devastating medical condition with 2 lives at stake and unclear strategy at early gestational stages. We describe a successful outcome, clearly dependent on the coordination of all involved disciplines. This case history describes a 28 year old female with a 24th week pregnancy gravida 2 para 0 with a DeBakey Type I aortic dissection, diagnosed via ultrasound. Surgery was perfomed on the day of diagnosis. After conferral with the mother, caesarean section was performed and a 690 g fetus could be delivered and was immediately transferred to the neonatal unit. Subsequent aortic repair was performed after hysterectomy, with replacement of the ascending aorta and hemiarch treatment. Intraoperatively no entry in the ascending aorta or transverse arch could be demonstrated, so that a retrograde Type A with entry distal to the left subclavian had to be postulated. We decided to perform subsequent computer tomography, demonstrating multiple entry sites in the descending aorta distal to the left subclavian artery. Successful endovascular treatment could be performed with a Medtronic Valiant Stent via a transfemoral approach. The further hospital stay was uneventful and the patient could be discharged on the 18th postoperative day. The baby demonstrated fighter qualities and could be discharged home after a 3 month hospital stay to be reunited with his mother. Prompt diagnosis, precise coordination between all involved subspecialties and ultimately, as in this case, definitive treatment in consensus with operative and interventional departments have led to a successful outcome and encourages us in our daily struggle in this often demanding surgery.

Pediatric Return to Sports After Spinal Surgery.

PubMed

Christman, Tyler; Li, Ying

2016-07-01

Pediatric patients who undergo spinal surgery are frequently involved in sporting activities. Return to play is often an important postoperative concern for the patient and family. A PubMed search was conducted for articles in the English language on return to play after treatment of pediatric acute disc herniation, degenerative disc disease, spondylolysis, spondylolisthesis, and scoliosis from 1980 to 2015. Reference lists were reviewed for additional pertinent articles. We included articles that focused on return to sports after surgical treatment of these conditions in this review. Clinical review. Level 4. There are no published guidelines, and most of the literature in this area has focused on return to play after spinal injury rather than after spinal surgery. Most children and adolescents have excellent outcomes with minimal pain at 1 year after lumbar discectomy. The majority of surgeons allow return to full activity once pain-free range of motion and strength are regained, typically at 8 to 12 weeks postoperatively. Pediatric patients with spondylolysis have good outcomes after direct pars repair. Satisfactory outcomes have been demonstrated after fusion for low- and high-grade spondylolisthesis. Most surgeons allow return to noncontact sports by 6 months after surgical treatment of spondylolysis and spondylolisthesis. Return to contact and collision sports is controversial. After posterior spinal fusion for scoliosis, most surgeons allow return to noncontact sports by 3 months and return to contact sports between 6 months and 1 year. Return to collision sports is controversial. There is little evidence to guide practitioners on return to sports after pediatric spinal surgery. Ultimately, the decision to allow any young athlete to resume sports participation after spinal injury or surgery must be individualized. © 2016 The Author(s).

Pediatric Return to Sports After Spinal Surgery

PubMed Central

Christman, Tyler; Li, Ying

2016-01-01

Context: Pediatric patients who undergo spinal surgery are frequently involved in sporting activities. Return to play is often an important postoperative concern for the patient and family. Evidence Acquisition: A PubMed search was conducted for articles in the English language on return to play after treatment of pediatric acute disc herniation, degenerative disc disease, spondylolysis, spondylolisthesis, and scoliosis from 1980 to 2015. Reference lists were reviewed for additional pertinent articles. We included articles that focused on return to sports after surgical treatment of these conditions in this review. Study Design: Clinical review. Level of Evidence: Level 4. Results: There are no published guidelines, and most of the literature in this area has focused on return to play after spinal injury rather than after spinal surgery. Most children and adolescents have excellent outcomes with minimal pain at 1 year after lumbar discectomy. The majority of surgeons allow return to full activity once pain-free range of motion and strength are regained, typically at 8 to 12 weeks postoperatively. Pediatric patients with spondylolysis have good outcomes after direct pars repair. Satisfactory outcomes have been demonstrated after fusion for low- and high-grade spondylolisthesis. Most surgeons allow return to noncontact sports by 6 months after surgical treatment of spondylolysis and spondylolisthesis. Return to contact and collision sports is controversial. After posterior spinal fusion for scoliosis, most surgeons allow return to noncontact sports by 3 months and return to contact sports between 6 months and 1 year. Return to collision sports is controversial. Conclusion: There is little evidence to guide practitioners on return to sports after pediatric spinal surgery. Ultimately, the decision to allow any young athlete to resume sports participation after spinal injury or surgery must be individualized. PMID:26920125

Is nonoperative management of partial distal biceps tears really successful?

PubMed

Bauer, Tyler M; Wong, Justin C; Lazarus, Mark D

2018-04-01

The current treatment of partial distal biceps tears is a period of nonoperative management, followed by surgery, if symptoms persist. Little is known about the success rate and outcomes of nonoperative management of this illness. We identified 132 patients with partial distal biceps tears through an International Classification of Diseases, Ninth Revision code query of our institution's database. Patient records were reviewed to abstract demographic information and confirm partial tears of the distal biceps tendon based on clinical examination findings and confirmatory magnetic resonance imaging (MRI). Seventy-four patients completed an outcome survey. In our study, 55.7% of the contacted patients who tried a nonoperative course (34 of 61 patients) ultimately underwent surgery, and 13 patients underwent immediate surgery. High-need patients, as defined by occupation, were more likely to report that they recovered ideally if they underwent surgery, as compared with those who did not undergo surgery (odds ratio, 11.58; P = .0138). For low-need patients, the same analysis was not statistically significant (P = .139). There was no difference in satisfaction scores between patients who tried a nonoperative course before surgery and those who underwent immediate surgery (P = .854). An MRI-diagnosed tear of greater than 50% was a predictor of needing surgery (odds ratio, 3.0; P = .006). This study has identified clinically relevant information for the treatment of partial distal biceps tears, including the following: the failure rate of nonoperative treatment, the establishment of MRI percent tear as a predictor of failing nonoperative management, the benefit of surgery for the high-need occupational group, and the finding that nonoperative management does not negatively affect outcome if subsequent surgery is necessary. Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Impact and Effectiveness of a Stand-Alone NRT Starter Kit in a Statewide Tobacco Cessation Program.

PubMed

Kerr, Amy N; Schillo, Barbara A; Keller, Paula A; Lachter, Randi B; Lien, Rebecca K; Zook, Heather G

2018-01-01

To examine 2-week nicotine replacement therapy (NRT) starter kit quit outcomes and predictors and the impact of adding this new service on treatment reach. Observational study of a 1-year cohort of QUITPLAN Services enrollees using registration and utilization data and follow-up outcome survey data of a subset of enrollees who received NRT starter kits. ClearWay Minnesota's QUITPLAN Services provides a quit line that is available to uninsured and underinsured Minnesotans and NRT starter kits (a free 2-week supply of patches, gum, or lozenges) that are available to all Minnesota tobacco users. A total of 15 536 adult QUITPLAN Services enrollees and 818 seven-month follow-up survey NRT starter kit respondents. Treatment reach for all services and tobacco quit outcomes and predictors for starter kit recipients. Descriptive analyses, χ 2 analyses, and logistic regression. Treatment reach increased 3-fold after adding the 2-week NRT starter kit service option to QUITPLAN Services compared to the prior year (1.86% vs 0.59%). Among all participants enrolling in QUITPLAN services during a 1-year period, 83.8% (13 026/15 536) registered for a starter kit. Among starter kit respondents, 25.6% reported being quit for 30 days at the 7-month follow-up. After controlling for other factors, using all NRT and selecting more cessation services predicted quitting. An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.

Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT

PubMed Central

Radcliff, Kris; Kepler, Christopher; Hilibrand, Alan; Rihn, Jeffrey; Zhao, Wenyan; Lurie, Jon; Tosteson, Tor; Vaccaro, Alexander; Albert, Todd; Weinstein, James

2013-01-01

Summary of Background Data Lumbar spinal stenosis is a common incidental finding among adults over the age of 60, The use of ESI in these patients is common, although there is little evidence in the literature to demonstrate the long-term benefit of ESI in the treatment of lumbar stenosis. Objective The hypothesis of this study was that patients who received epidural steroid injections (ESI) during initial treatment as part of the Spine Patient Outcomes Research Trial (SPORT) would have improved clinical outcomes and a lower rate of crossover to surgery compared to patients who did not receive ESI. Methods Patients with lumbar spinal stenosis who received epidural steroid injections within the first three months of enrollment in SPORT (ESI) were compared to patients who did not receive epidural injections during the first three months of the study (No ESI). Results There were 69 ESI patients and 207 No-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (62% vs. 33%, p <0.001). There was an average 26 minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over four years, there was significantly less improvement in SF36 PF among surgically treated ESI patients (ESI 14.8 vs. No-ESI 22.5, p=0.025). In addition, there was also significantly less improvement among the nonsurgically treated patients in SF36 BP (ESI 7.3 vs. No-ESI 16.7, p=0.007) and SF36 PF (ESI 5.5 vs. No-ESI 15.2, p=0.009). Of the patients assigned to surgical treatment, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. No ESI 11%, p=0.012). Of the patients assigned to non-operative treatment, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. No ESI 32%, p=0.003). Conclusion Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT. Furthermore, ESI were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically. PMID:23238485

Atherosclerotic renovascular disease – epidemiology, treatment and current challenges

PubMed Central

Vassallo, Diana

2017-01-01

The neutral results of recent large randomized controlled trials comparing renal revascularization with optimal medical therapy in patients with atherosclerotic renovascular disease (ARVD) have cast doubt on the role of revascularization in the management of unselected patients with this condition. However, these studies have strengthened the evidence base for the role of contemporary intensive medical vascular protection therapy and aggressive risk factor control in improving clinical outcomes in ARVD. Patients presenting with ‘high-risk’ clinical features such as uncontrolled hypertension, rapidly declining renal function or flash pulmonary oedema are underrepresented in these studies; hence these results may not be applicable to all patients with ARVD. In this ‘high-risk’ subgroup, conservative management may not be sufficient in preventing adverse events, and indeed, observational evidence suggests that this specific patient subgroup may gain benefit from timely renal revascularization. Current challenges include the development of novel diagnostic techniques to establish haemodynamic significance of a stenosis, patient risk stratification and prediction of post-revascularization outcomes to ultimately facilitate patient selection for revascularization. In this paper we describe the epidemiology of this condition and discuss treatment recommendations for this condition in light of the results of recent randomized controlled trials while highlighting important clinical unmet needs and challenges faced by clinicians managing this condition. PMID:29056991

A novel rapid access testicular cancer clinic: prospective evaluation after one year.

PubMed

Carey, K; Davis, N F; Elamin, S; Ahern, P; Brady, C M; Sweeney, P

2016-02-01

Our institution has recently developed a rapid access outpatient clinic to investigate men with testicular lumps and/or pain suspicious for testicular cancer (TCa). To present our experience after 12 months. All referrals to the rapid access testicular clinic (RATC) clinic were prospectively analysed from 01/01/2013 to 01/01/2014. The primary outcome variable was incidence of TCa in the referred patient cohort. Secondary outcome variables were waiting times prior to clinical review and waiting times prior to radical orchidectomy in patients diagnosed with TCa. Seventy-four new patients were referred to the RATC during the 1-year period and the mean age was 34 (range 15-81 years). TCa was the most common diagnosis and was found in 18 (25 %) patients. Patients diagnosed with TCa underwent radical orchidectomy, a median of 3 (range 1-5) days after their initial GP referral. Patients requiring surgical intervention for benign scrotal pathology underwent their procedure a median of 32 (range 3-61) days after their initial referral. Of the 18 patients diagnosed with TCa, 9 (50 %) were diagnosed with a seminomatous germ cell tumour on histopathology. The RATC is a new initiative in Ireland that provides expedient and definitive treatment of patients with newly diagnosed TCa. Early treatment will ultimately improve long-term prognosis in this patient cohort.

Minimal Brain Dysfunction in Childhood: 1. Outcome in Late Adolescence and Early Adult Years. Final Version.

ERIC Educational Resources Information Center

Milman, Doris H.

Seventy-three patients, diagnosed in childhood as having either maturational lag or organic brain syndrome, were followed for an average of 12 years into late adolescence and early adult life for the purpose of discovering the outcome with respect to ultimate psychiatric status, educational attainment, social adjustment, and global adjustment. At…

The Impact of Emotional Labor on Work-Family Outcomes

ERIC Educational Resources Information Center

Yanchus, Nancy J.; Eby, Lilian T.; Lance, Charles E.; Drollinger, Sabrina

2010-01-01

Theory and research on emotional labor at work is applied to the study of the work-family interface to explore how emotional experiences in both the work and the family domain relate to the experience of work-family conflict and work-family enrichment, and ultimately attitudinal and health outcomes. Emotional intelligence is also examined as a…

Improving Child Outcomes with Data-Based Decision Making: Interpreting and Using Data

ERIC Educational Resources Information Center

Gischlar, Karen L.; Hojnoski, Robin L.; Missall, Kristen N.

2009-01-01

This article is the third in a series describing the steps in using data-based decision making to inform intervention and, ultimately, improve outcomes for children. Whereas the first two articles describe identifying and measuring important behaviors to target for intervention, the purpose of this article is to describe basic considerations in…

Assessing and improving organizational readiness to implement substance use disorder treatment in primary care: findings from the SUMMIT study.

PubMed

Ober, Allison J; Watkins, Katherine E; Hunter, Sarah B; Ewing, Brett; Lamp, Karen; Lind, Mimi; Becker, Kirsten; Heinzerling, Keith; Osilla, Karen C; Diamant, Allison L; Setodji, Claude M

2017-12-21

Millions of people with substance use disorders (SUDs) need, but do not receive, treatment. Delivering SUD treatment in primary care settings could increase access to treatment because most people visit their primary care doctors at least once a year, but evidence-based SUD treatments are underutilized in primary care settings. We used an organizational readiness intervention comprised of a cluster of implementation strategies to prepare a federally qualified health center to deliver SUD screening and evidence-based treatments (extended-release injectable naltrexone (XR-NTX) for alcohol use disorders, buprenorphine/naloxone (BUP/NX) for opioid use disorders and a brief motivational interviewing/cognitive behavioral -based psychotherapy for both disorders). This article reports the effects of the intervention on key implementation outcomes. To assess changes in organizational readiness we conducted pre- and post-intervention surveys with prescribing medical providers, behavioral health providers and general clinic staff (N = 69). We report on changes in implementation outcomes: acceptability, perceptions of appropriateness and feasibility, and intention to adopt the evidence-based treatments. We used Wilcoxon signed rank tests to analyze pre- to post-intervention changes. After 18 months, prescribing medical providers agreed more that XR-NTX was easier to use for patients with alcohol use disorders than before the intervention, but their opinions about the effectiveness and ease of use of BUP/NX for patients with opioid use disorders did not improve. Prescribing medical providers also felt more strongly after the intervention that XR-NTX for alcohol use disorders was compatible with current practices. Opinions of general clinic staff about the appropriateness of SUD treatment in primary care improved significantly. Consistent with implementation theory, we found that an organizational readiness implementation intervention enhanced perceptions in some domains of practice acceptability and appropriateness. Further research will assess whether these factors, which focus on individual staff readiness, change over time and ultimately predict adoption of SUD treatments in primary care.

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis

PubMed Central

Perl, Jeffrey; Davies, Simon J.; Lambie, Mark; Pisoni, Ronald L.; McCullough, Keith; Johnson, David W.; Sloand, James A.; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M.

2016-01-01

♦ Background: Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ Methods: The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ Results: A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ Conclusion: The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. PMID:26526049

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis.

PubMed

Perl, Jeffrey; Davies, Simon J; Lambie, Mark; Pisoni, Ronald L; McCullough, Keith; Johnson, David W; Sloand, James A; Prichard, Sarah; Kawanishi, Hideki; Tentori, Francesca; Robinson, Bruce M

2016-01-01

♦ Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD. ♦ The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes. ♦ A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation. ♦ The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients. Copyright © 2016 International Society for Peritoneal Dialysis.

Rho Inhibitor VX-210 in Acute Traumatic Subaxial Cervical Spinal Cord Injury: Design of the SPinal Cord Injury Rho INhibition InvestiGation (SPRING) Clinical Trial.

PubMed

Fehlings, Michael G; Kim, Kee D; Aarabi, Bizhan; Rizzo, Marco; Bond, Lisa M; McKerracher, Lisa; Vaccaro, Alexander R; Okonkwo, David O

2018-05-01

Traumatic spinal cord injury (SCI) is associated with a lifetime of disability stemming from loss of motor, sensory, and autonomic functions; these losses, along with increased comorbid sequelae, negatively impact health outcomes and quality of life. Early decompression surgery post-SCI can enhance patient outcomes, but does not directly facilitate neural repair and regeneration. Currently, there are no U.S. Food and Drug Administration-approved pharmacological therapies to augment motor function and functional recovery in individuals with traumatic SCI. After an SCI, the enzyme, Rho, is activated by growth-inhibitory factors and regulates events that culminate in collapse of the neuronal growth cone, failure of axonal regeneration, and, ultimately, failure of motor and functional recovery. Inhibition of Rho activation is a potential treatment for injuries such as traumatic SCI. VX-210, an investigational agent, inhibits Rho. When administered extradurally after decompression (corpectomy or laminectomy) and stabilization surgery in a phase 1/2a study, VX-210 was well tolerated. Here, we describe the design of the SPRING trial, a multicenter, phase 2b/3, randomized, double-blind, placebo-controlled clinical trial to evaluate the efficacy and safety of VX-210 (NCT02669849). A subset of patients with acute traumatic cervical SCI is currently being enrolled in the United States and Canada. Medical, neurological, and functional changes are evaluated at 6 weeks and at 3, 6, and 12 months after VX-210 administration. Efficacy will be assessed by the primary outcome measure, change in upper extremity motor score at 6 months post-treatment, and by secondary outcomes that include question-based and task-based evaluations of functional recovery.

How Ocular Surface Disease Impacts the Glaucoma Treatment Outcome

PubMed Central

Kaštelan, Snježana; Tomić, Martina; Metež Soldo, Kata; Salopek-Rabatić, Jasminka

2013-01-01

The treatment goals for glaucoma are lowering the intraocular pressure and preservation of vision. Topical hypotensive drops are the standard form of therapy which is often associated with some symptoms of toxicity, ocular inflammation, allergy, or ocular surface disease (OSD). OSD is a common comorbidity in glaucoma patients, and its prevalence with glaucoma increases with age. Use of topical treatment could additionally increase symptoms of OSD mostly due to preservatives added to multidose medication bottles used to reduce the risk of microbial contamination. This toxicity has been particularly associated with BAK, the most commonly used preservative which damages conjunctival and corneal epithelial cells and significantly aggravates OSD symptoms. OSD adversely affects patients' quality of life causing discomfort and problems with vision which in turn may result in noncompliance, lack of adherence, and eventually visual impairment. In the management of glaucoma patients OSD symptoms should not be overlooked. If they are present, topical glaucoma treatment should be adapted by decreasing the amount of drops instilled daily, using BAK-free or preservative-free medication and lubricants if necessary. Awareness of the presence and importance of OSD will in turn improve patients' adherence and compliance and thus ultimately the preservation of long-term vision. PMID:24224176

Beyond interferon: rationale and prospects for newer treatment paradigms for chronic hepatitis C

PubMed Central

Cortez, Karoll J.

2015-01-01

Hepatitis C virus (HCV) infection results in a chronic carrier state in 80% of individuals infected with the virus and presently affects over 170 million people worldwide. Approximately 20% of those chronically infected will ultimately progress to develop cirrhosis and death due to end-stage liver disease or hepatocellular carcinoma (HCC). Unlike many other chronic viral infections, effective treatments for HCV are available. Cure from the infection is known as a sustained virologic response (SVR). SVR is associated with reversal of the long-term outcomes of chronic liver disease, decrease in incidence of HCC, and decrease HCV attributable mortality. The current FDA approved therapies for hepatitis C virus genotype 1 (GT-1) include pegylated interferon (PEG-IFN) and ribavirin (RBV) in combination with a directly acting antiviral agent (DAA). New therapeutic advances are being made aiming to simplify management, improve the tolerability of treatment, and shorten the duration of therapy. Moreover, treatment regimens that will effectively eradicate hepatitis C without the use of interferon formulations (IFN) are being developed. In this review, we report the transition of HCV therapeutics from an interferon-α based combination therapy to an all-oral, directly acting antiviral therapy. PMID:25553238

PI3K/AKT/mTOR Pathway in Ovarian Cancer Treatment: Are We on the Right Track?

PubMed Central

Gasparri, Maria Luisa; Bardhi, Erlisa; Ruscito, Ilary; Papadia, Andrea; Farooqi, Ammad Ahmad; Marchetti, Claudia; Bogani, Giorgio; Ceccacci, Irene; Mueller, Michael D.; Benedetti Panici, Pierluigi

2017-01-01

The high recurrence rate and the low overall survival in ovarian cancer suggest that a more specific therapeutic approach in addition to conventional treatment is required. Translational and clinical research is investigating new molecular targets in order to find an alternative way to affect tumor growth and to minimize the overlap of toxicity of antiblastic agents. Given its implication in many cellular activities including regulation of cell growth, motility, survival, proliferation, protein synthesis, autophagy, transcription, as well as angiogenesis, PI3K/AKT/mTOR is one of the most investigated intracellular signaling pathways. A dis-regulation of this pathway has been shown in several tumors, including ovarian cancer. In this setting, mTor proteins represent a potential target for inhibitors, which could ultimately play a pivotal role in counteracting cellular proliferation. Recently, mTor inhibitors have been approved in the treatment of pancreatic neuroendocrine tumors, mantle cell lymphoma and renal cancer. Clinical trials have assessed the safety of these drugs in ovarian cancer patients. Ongoing phase I and II studies are evaluating the oncologic outcome of mTor inhibitor treatment and its effect in combination with conventional chemotherapy and target agents. PMID:29093603

PI3K/AKT/mTOR Pathway in Ovarian Cancer Treatment: Are We on the Right Track?

PubMed

Gasparri, Maria Luisa; Bardhi, Erlisa; Ruscito, Ilary; Papadia, Andrea; Farooqi, Ammad Ahmad; Marchetti, Claudia; Bogani, Giorgio; Ceccacci, Irene; Mueller, Michael D; Benedetti Panici, Pierluigi

2017-10-01

The high recurrence rate and the low overall survival in ovarian cancer suggest that a more specific therapeutic approach in addition to conventional treatment is required. Translational and clinical research is investigating new molecular targets in order to find an alternative way to affect tumor growth and to minimize the overlap of toxicity of antiblastic agents. Given its implication in many cellular activities including regulation of cell growth, motility, survival, proliferation, protein synthesis, autophagy, transcription, as well as angiogenesis, PI3K/AKT/mTOR is one of the most investigated intracellular signaling pathways. A dis-regulation of this pathway has been shown in several tumors, including ovarian cancer. In this setting, mTor proteins represent a potential target for inhibitors, which could ultimately play a pivotal role in counteracting cellular proliferation. Recently, mTor inhibitors have been approved in the treatment of pancreatic neuroendocrine tumors, mantle cell lymphoma and renal cancer. Clinical trials have assessed the safety of these drugs in ovarian cancer patients. Ongoing phase I and II studies are evaluating the oncologic outcome of mTor inhibitor treatment and its effect in combination with conventional chemotherapy and target agents.

Education attainment is associated with patient-reported outcomes: findings from the Swedish Hip Arthroplasty Register.

PubMed

Greene, Meridith E; Rolfson, Ola; Nemes, Szilard; Gordon, Max; Malchau, Henrik; Garellick, Göran

2014-06-01

Age, sex, and medical comorbidities may be associated with differences in patient-reported outcome scores after THA. Highest level of education may be a surrogate for socioeconomic status, but the degree to which this is associated with patient-reported outcomes after THA is not known. We investigated the national Swedish Hip Arthroplasty Register for the association of education attainment on patient-reported outcomes 1 year after THA; specifically, we evaluated level of education attainment against health-related quality of life (HRQoL), pain reduction, and satisfaction with treatment 1 year after THA. All THAs for osteoarthritis performed from 2005 through 2007 with complete patient-reported outcome measures (representing 49% of the THAs performed for this diagnosis) were selected from the Swedish Hip Arthroplasty Register. These cases were merged with national databases containing education attainment, marital status, and comorbidities (n = 11,464; mean age of patients, 64 years). The patient-reported outcome measure protocol included the HRQoL measure EuroQol five-dimension scale (EQ-5D), a VAS for pain, the Charnley classification survey, and a VAS addressing THA satisfaction. Linear regression analyses determined the association of preoperative patient factors with patient-reported outcomes. High education attainment was associated with higher HRQoL (EQ-5D index ß(high) = 0.03 ± 0.01; EQ VAS ß(high) = 2.6 ± 0.5) after THA, whereas those with low and medium education were at risk for lower HRQoL. High education was associated with less pain after treatment (ß(high) = -3.3 ± 0.05). Individuals with low or medium education were at risk for less satisfaction with THA (p < 0.001). Our results suggest clinicians should support patients with low and medium education to a greater extent. Identification of patients who will benefit most from THA and educating those at risk for poorer outcomes, like patients with low and medium education, ultimately may improve patient satisfaction, HRQoL, pain, and the cost utility of THA. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Photodynamic therapy potentiates the paracrine endothelial stimulation by colorectal cancer

NASA Astrophysics Data System (ADS)

Lamberti, María Julia; Florencia Pansa, María; Emanuel Vera, Renzo; Belén Rumie Vittar, Natalia; Rivarola, Viviana Alicia

2014-11-01

Colorectal cancer (CRC) is the third most common cancer and the third leading cause of cancer death worldwide. Recurrence is a major problem and is often the ultimate cause of death. In this context, the tumor microenvironment influences tumor progression and is considered as a new essential feature that clearly impacts on treatment outcome, and must therefore be taken into consideration. Photodynamic therapy (PDT), oxygen, light and drug-dependent, is a novel treatment modality when CRC patients are inoperable. Tumor vasculature and parenchyma cells are both potential targets of PDT damage modulating tumor-stroma interactions. In biological activity assessment in photodynamic research, three-dimensional (3D) cultures are essential to integrate biomechanical, biochemical, and biophysical properties that better predict the outcome of oxygen- and drug-dependent medical therapies. Therefore, the objective of this study was to investigate the antitumor effect of methyl 5-aminolevulinic acid-PDT using a light emitting diode for the treatment of CRC cells in a scenario that mimics targeted tissue complexity, providing a potential bridge for the gap between 2D cultures and animal models. Since photodynamic intervention of the tumor microenvironment can effectively modulate the tumor-stroma interaction, it was proposed to characterize the endothelial response to CRC paracrine communication, if one of these two populations is photosensitized. In conclusion, we demonstrated that the dialogue between endothelial and tumor populations when subjected to lethal PDT conditions induces an increase in angiogenic phenotype, and we think that it should be carefully considered for the development of PDT therapeutic protocols.

Percutaneous Tumor Ablation Tools: Microwave, Radiofrequency, or Cryoablation—What Should You Use and Why?

PubMed Central

Lubner, Meghan G.; Ziemlewicz, Timothy J.; Lee, Fred T.; Brace, Christopher L.

2014-01-01

Image-guided thermal ablation is an evolving and growing treatment option for patients with malignant disease of multiple organ systems. Treatment indications have been expanding to include benign tumors as well. Specifically, the most prevalent indications to date have been in the liver (primary and metastatic disease, as well as benign tumors such as hemangiomas and adenomas), kidney (primarily renal cell carcinoma, but also benign tumors such as angiomyolipomas and oncocytomas), lung (primary and metastatic disease), and soft tissue and/or bone (primarily metastatic disease and osteoid osteomas). Each organ system has different underlying tissue characteristics, which can have profound effects on the resulting thermal changes and ablation zone. Understanding these issues is important for optimizing clinical results. In addition, thermal ablation technology has evolved rapidly during the past several decades, with substantial technical and procedural improvements that can help improve clinical outcomes and safety profiles. Staying up to date on these developments is challenging but critical because the physical properties underlying the different ablation modalities and the appropriate use of adjuncts will have a tremendous effect on treatment results. Ultimately, combining an understanding of the physical properties of the ablation modalities with an understanding of the thermal kinetics in tissue and using the most appropriate ablation modality for each patient are key to optimizing clinical outcomes. Suggested algorithms are described that will help physicians choose among the various ablation modalities for individual patients. ©RSNA, 2014 PMID:25208284

Study protocol: a randomised controlled trial of cognitive remediation for a national cohort of forensic mental health patients with schizophrenia or schizoaffective disorder.

PubMed

O'Reilly, Ken; Donohoe, Gary; O'Sullivan, Danny; Coyle, Ciaran; Mullaney, Ronan; O'Connell, Paul; Maddock, Catherine; Nulty, Andrea; O'Flynn, Padraic; O'Connell, Carina; Kennedy, Harry G

2016-01-13

Evidence is accumulating that cognitive remediation therapy (CRT) is an effective intervention for patients with schizophrenia or schizoaffective disorder. To date there has been no randomised controlled trial (RCT) cohort study of cognitive remediation within a forensic hospital. The goal of this study is to examine the effectiveness of a trial of cognitive remediation for forensic mental health patients with schizophrenia or schizoaffective disorder. An estimated sixty patients will be enrolled in the study. Participants will be randomised to one of two conditions: CRT with treatment as usual (TAU), or TAU. CRT will consist of 42 individual sessions and 14 group sessions. The primary outcome measure for this study is change in cognitive functioning using the MATRICS Consensus Cognitive Battery (MCCB). Secondary outcomes include change in social and occupational functioning, disorganised symptoms, negative symptoms, violence, participation in psychosocial treatment and recovery. In addition to these effectiveness measures, we will examine patient satisfaction. Cognitive difficulties experienced by schizophrenia spectrum patients are associated with general functioning, ability to benefit from psychosocial interventions and quality of life. Research into the treatment of cognitive difficulties within a forensic setting is therefore an important priority. The results of the proposed study will help answer the question whether cognitive remediation improves functional outcomes in forensic mental health patients with schizophrenia or schizoaffective disorder. Forensic mental health patients are detained for the dual purpose of receiving treatment and for public protection. There can be conflict between these two roles perhaps causing forensic services to have an increased length of stay compared to general psychiatric admissions. Ultimately a focus on emphasising cognition and general functioning over symptoms may decrease tension between the core responsibilities of forensic mental health services. ClinicalTrials.gov Identifier: NCT02360813. Trial registered Feb 4th 2015 and last updated May 1(st) 2015.

WE-B-304-03: Biological Treatment Planning

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

Orton, C.

The ultimate goal of radiotherapy treatment planning is to find a treatment that will yield a high tumor control probability (TCP) with an acceptable normal tissue complication probability (NTCP). Yet most treatment planning today is not based upon optimization of TCPs and NTCPs, but rather upon meeting physical dose and volume constraints defined by the planner. It has been suggested that treatment planning evaluation and optimization would be more effective if they were biologically and not dose/volume based, and this is the claim debated in this month’s Point/Counterpoint. After a brief overview of biologically and DVH based treatment planning bymore » the Moderator Colin Orton, Joseph Deasy (for biological planning) and Charles Mayo (against biological planning) will begin the debate. Some of the arguments in support of biological planning include: this will result in more effective dose distributions for many patients DVH-based measures of plan quality are known to have little predictive value there is little evidence that either D95 or D98 of the PTV is a good predictor of tumor control sufficient validated outcome prediction models are now becoming available and should be used to drive planning and optimization Some of the arguments against biological planning include: several decades of experience with DVH-based planning should not be discarded we do not know enough about the reliability and errors associated with biological models the radiotherapy community in general has little direct experience with side by side comparisons of DVH vs biological metrics and outcomes it is unlikely that a clinician would accept extremely cold regions in a CTV or hot regions in a PTV, despite having acceptable TCP values Learning Objectives: To understand dose/volume based treatment planning and its potential limitations To understand biological metrics such as EUD, TCP, and NTCP To understand biologically based treatment planning and its potential limitations.« less

WE-B-304-02: Treatment Planning Evaluation and Optimization Should Be Biologically and Not Dose/volume Based

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

Deasy, J.

The ultimate goal of radiotherapy treatment planning is to find a treatment that will yield a high tumor control probability (TCP) with an acceptable normal tissue complication probability (NTCP). Yet most treatment planning today is not based upon optimization of TCPs and NTCPs, but rather upon meeting physical dose and volume constraints defined by the planner. It has been suggested that treatment planning evaluation and optimization would be more effective if they were biologically and not dose/volume based, and this is the claim debated in this month’s Point/Counterpoint. After a brief overview of biologically and DVH based treatment planning bymore » the Moderator Colin Orton, Joseph Deasy (for biological planning) and Charles Mayo (against biological planning) will begin the debate. Some of the arguments in support of biological planning include: this will result in more effective dose distributions for many patients DVH-based measures of plan quality are known to have little predictive value there is little evidence that either D95 or D98 of the PTV is a good predictor of tumor control sufficient validated outcome prediction models are now becoming available and should be used to drive planning and optimization Some of the arguments against biological planning include: several decades of experience with DVH-based planning should not be discarded we do not know enough about the reliability and errors associated with biological models the radiotherapy community in general has little direct experience with side by side comparisons of DVH vs biological metrics and outcomes it is unlikely that a clinician would accept extremely cold regions in a CTV or hot regions in a PTV, despite having acceptable TCP values Learning Objectives: To understand dose/volume based treatment planning and its potential limitations To understand biological metrics such as EUD, TCP, and NTCP To understand biologically based treatment planning and its potential limitations.« less

WE-B-304-01: Treatment Planning Evaluation and Optimization Should Be Dose/volume and Not Biologically Based

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

Mayo, C.

The ultimate goal of radiotherapy treatment planning is to find a treatment that will yield a high tumor control probability (TCP) with an acceptable normal tissue complication probability (NTCP). Yet most treatment planning today is not based upon optimization of TCPs and NTCPs, but rather upon meeting physical dose and volume constraints defined by the planner. It has been suggested that treatment planning evaluation and optimization would be more effective if they were biologically and not dose/volume based, and this is the claim debated in this month’s Point/Counterpoint. After a brief overview of biologically and DVH based treatment planning bymore » the Moderator Colin Orton, Joseph Deasy (for biological planning) and Charles Mayo (against biological planning) will begin the debate. Some of the arguments in support of biological planning include: this will result in more effective dose distributions for many patients DVH-based measures of plan quality are known to have little predictive value there is little evidence that either D95 or D98 of the PTV is a good predictor of tumor control sufficient validated outcome prediction models are now becoming available and should be used to drive planning and optimization Some of the arguments against biological planning include: several decades of experience with DVH-based planning should not be discarded we do not know enough about the reliability and errors associated with biological models the radiotherapy community in general has little direct experience with side by side comparisons of DVH vs biological metrics and outcomes it is unlikely that a clinician would accept extremely cold regions in a CTV or hot regions in a PTV, despite having acceptable TCP values Learning Objectives: To understand dose/volume based treatment planning and its potential limitations To understand biological metrics such as EUD, TCP, and NTCP To understand biologically based treatment planning and its potential limitations.« less

Money matters: exploiting the data from outcomes research for quality improvement initiatives.

PubMed

Impellizzeri, Franco M; Bizzini, Mario; Leunig, Michael; Maffiuletti, Nicola A; Mannion, Anne F

2009-08-01

In recent years, there has been an increase in studies that have sought to identify predictors of treatment outcome and to examine the efficacy of surgical and non-surgical treatments. In addition to the scientific advancement associated with these studies per se, the hospitals and clinics where the studies are conducted may gain indirect financial benefit from participating in such projects as a result of the prestige derived from corporate social responsibility, a reputational lever used to reward such institutions. It is known that there is a positive association between corporate social performance and corporate financial performance. However, in addition to this, the research findings and the research staff can constitute resources from which the provider can reap a more direct benefit, by means of their contribution to quality control and improvement. Poor quality is costly. Patient satisfaction increases the chances that the patient will be a promoter of the provider to friends and colleagues. As such, involvement of the research staff in the improvement of the quality of care can ultimately result in economic revenue for the provider. The most advanced methodologies for continuous quality improvement (e.g., six-sigma) are data-driven and use statistical tools similar to those utilized in the traditional research setting. Given that these methods rely on the application of the scientific process to quality improvement, researchers have the adequate skills and mind-set to embrace them and thereby contribute effectively to the quality team. The aim of this article is to demonstrate by means of real-life examples how to utilize the findings of outcome studies for quality management in a manner similar to that used in the business community. It also aims to stimulate research groups to better understand that, by adopting a different perspective, their studies can be an additional resource for the healthcare provider. The change in perspective should stimulate researchers to go beyond the traditional studies examining predictors of treatment outcome and to see things instead in terms of the "bigger picture", i.e., the improvement of the process outcome, the quality of the service.

Money matters: exploiting the data from outcomes research for quality improvement initiatives

PubMed Central

Bizzini, Mario; Leunig, Michael; Maffiuletti, Nicola A.; Mannion, Anne F.

2009-01-01

In recent years, there has been an increase in studies that have sought to identify predictors of treatment outcome and to examine the efficacy of surgical and non-surgical treatments. In addition to the scientific advancement associated with these studies per se, the hospitals and clinics where the studies are conducted may gain indirect financial benefit from participating in such projects as a result of the prestige derived from corporate social responsibility, a reputational lever used to reward such institutions. It is known that there is a positive association between corporate social performance and corporate financial performance. However, in addition to this, the research findings and the research staff can constitute resources from which the provider can reap a more direct benefit, by means of their contribution to quality control and improvement. Poor quality is costly. Patient satisfaction increases the chances that the patient will be a promoter of the provider to friends and colleagues. As such, involvement of the research staff in the improvement of the quality of care can ultimately result in economic revenue for the provider. The most advanced methodologies for continuous quality improvement (e.g., six-sigma) are data-driven and use statistical tools similar to those utilized in the traditional research setting. Given that these methods rely on the application of the scientific process to quality improvement, researchers have the adequate skills and mind-set to embrace them and thereby contribute effectively to the quality team. The aim of this article is to demonstrate by means of real-life examples how to utilize the findings of outcome studies for quality management in a manner similar to that used in the business community. It also aims to stimulate research groups to better understand that, by adopting a different perspective, their studies can be an additional resource for the healthcare provider. The change in perspective should stimulate researchers to go beyond the traditional studies examining predictors of treatment outcome and to see things instead in terms of the “bigger picture”, i.e., the improvement of the process outcome, the quality of the service. PMID:19294433

An overview of treatments for obesity in a population with mental illness.

PubMed

Taylor, Valerie H; Stonehocker, Brian; Steele, Margot; Sharma, Arya M

2012-01-01

Obesity is associated with early mortality and has overtaken smoking as the health problem with the greatest impact on quality of life, mortality, and morbidity. Despite public health initiatives and numerous commercial enterprises focusing on weight loss, obesity rates continue to rise. In part, this is because obesity is a multifaceted, complex illness, impacted by numerous social, psychological, and behavioural factors that are unrecognized in most current initiatives. One significant factor associated with obesity is mental illness. While having a psychiatric illness does not make weight gain inevitable, it does often require that additional tools be added to lifestyle recommendations around diet and exercise. The following article reviews the common approaches to obesity management and addresses how these strategies can be implemented in psychiatric care. It is important that health professionals involved in the care of people with a mental illness become familiar with the interventions available to control and treat the obesity epidemic, as this will improve treatment compliance and ultimately lead to improved physical and psychological outcomes.

Objective support for subjective reports of successful inner speech in two people with aphasia

PubMed Central

Hayward, William; Snider, Sarah F.; Luta, George; Friedman, Rhonda B.; Turkeltaub, Peter E.

2016-01-01

People with aphasia frequently report being able to say a word correctly in their heads, even if they are unable to say that word aloud. It is difficult to know what is meant by these reports of “successful inner speech”. We probe the experience of successful inner speech in two people with aphasia. We show that these reports are associated with correct overt speech and phonologically related nonwords errors, that they relate to word characteristics associated with ease of lexical access but not ease of production, and that they predict whether or not individual words are relearned during anomia treatment. These findings suggest that reports of successful inner speech are meaningful and may be useful to study self-monitoring in aphasia, to better understand anomia, and to predict treatment outcomes. Ultimately, the study of inner speech in people with aphasia could provide critical insights that inform our understanding of normal language. PMID:27469037

Scar Management of the Burned Hand

PubMed Central

Sorkin, Michael; Cholok, David; Levi, Benjamin

2017-01-01

Unimpaired hand function is critical in almost all activities of daily living. Burn injury can result in hypertrophic scar formation that can lead to debilitating functional deficits and poor aesthetic outcomes. Initial algorithms of acute burn management involve early debridement and skin grafting and early mobilization to prevent formation of hypertrophic scarring and ultimately digit contractures. While non-operative modalities in the early phase of scar maturation are critical to minimize hypertrophic scar formation, surgical management is often indicated in order to restore hand function. The essential tenant of operative scar management is release of tension, which can often be achieved through local tissue rearrangement. Laser therapy has emerged as a central pillar of subsequent scar rehabilitation with several modalities that address scar texture, color, pruritis and thickness. These can be utilized in conjunction with local corticosteroid treatment and other emerging modalities to modulate the scar and achieve optimal hand function. These treatment tools provide an effective resource for the reconstructive surgeon to treat hypertrophic hand scars. PMID:28363297

Successful management of severe neuroinvasive eastern equine encephalitis.

PubMed

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

2013-08-01

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

Evaluating Symptom Expression as a Function of a Posttraumatic Stress Disorder Severity

PubMed Central

Palm, Kathleen M.; Strong, David R.; MacPherson, Laura

2009-01-01

Little is known about the relative severity or typical sequence of Diagnostic and Statistical Manual (DSM-IV) symptoms of posttraumatic stress disorder (PTSD). Using data from the National Comorbidity Study – Replication (Kessler et al., 2004), the current study used a logistic item response model to assess the degree to which DSM-IV symptoms combine to define a primary construct underlying PTSD, to identify which symptoms are associated with greater severity of PTSD, and to determine whether the symptoms and symptom patterns are influenced by gender. Results suggested that PTSD symptoms can be combined to assess a single dimension of PTSD severity, providing support for a continuum of symptom severity. However, several DSM-IV symptoms provided overlapping information, potentially reducing the effectiveness of these symptoms in describing a broad range of PTSD. More precise assessment of PTSD severity may help improve the descriptive value of PTSD measures relationship to continuous measures of treatment outcomes, and ultimately inform more effective treatments. PMID:18434083

Atlantoaxial Chordoma in Two Patients with Occipital Neuralgia and Cervicalgia.

PubMed

Kim, Won Seop; Park, Jong Taek; Lee, Young Bok; Park, Woo Young

2014-09-01

Chordoma arises from cellular remnants of the notochord. It is the most common primary malignancy of the spine in adults. Approximately 50% of chordomas arise from the sacrococcygeal area with other areas of the spine giving rise to another 15% of chordomas. Following complete resection, patients can expect a 5-year survival rate of 85%. Chordoma has a recurrence rate of 40%, which leads to a less favorable prognosis. Here, we report two cases of chordoma presenting with occipital neuralgia and cervicalgia. The first patient presented with a C1-C2 chordoma. He rejected surgical intervention and ultimately died of respiratory failure. The second patient had an atlantoaxial chordoma and underwent surgery because of continued occipital neuralgia and cervicalgia despite nerve block. This patient has remained symptom-free since his operation. The presented cases show that the patients' willingness to participate in treatment can lead to appropriate and aggressive management of cancer pain, resulting in better outcomes in cancer treatment.

Atlantoaxial Chordoma in Two Patients with Occipital Neuralgia and Cervicalgia

PubMed Central

Kim, Won Seop; Park, Jong Taek; Lee, Young Bok; Park, Woo Young

2014-01-01

Chordoma arises from cellular remnants of the notochord. It is the most common primary malignancy of the spine in adults. Approximately 50% of chordomas arise from the sacrococcygeal area with other areas of the spine giving rise to another 15% of chordomas. Following complete resection, patients can expect a 5-year survival rate of 85%. Chordoma has a recurrence rate of 40%, which leads to a less favorable prognosis. Here, we report two cases of chordoma presenting with occipital neuralgia and cervicalgia. The first patient presented with a C1–C2 chordoma. He rejected surgical intervention and ultimately died of respiratory failure. The second patient had an atlantoaxial chordoma and underwent surgery because of continued occipital neuralgia and cervicalgia despite nerve block. This patient has remained symptom-free since his operation. The presented cases show that the patients’ willingness to participate in treatment can lead to appropriate and aggressive management of cancer pain, resulting in better outcomes in cancer treatment. PMID:26064862

Outcome Measurement Using Naturalistic Language Samples: A Feasibility Pilot Study Using Language Transcription Software and Speech and Language Therapy Assistants

ERIC Educational Resources Information Center

Overton, Sarah; Wren, Yvonne

2014-01-01

The ultimate aim of intervention for children with language impairment is an improvement in their functional language skills. Baseline and outcome measurement of this is often problematic however and practitioners commonly resort to using formal assessments that may not adequately reflect the child's competence. Language sampling,…

The cytokine storm of severe influenza and development of immunomodulatory therapy.

PubMed

Liu, Qiang; Zhou, Yuan-hong; Yang, Zhan-qiu

2016-01-01

Severe influenza remains unusual in its virulence for humans. Complications or ultimately death arising from these infections are often associated with hyperinduction of proinflammatory cytokine production, which is also known as 'cytokine storm'. For this disease, it has been proposed that immunomodulatory therapy may improve the outcome, with or without the combination of antiviral agents. Here, we review the current literature on how various effectors of the immune system initiate the cytokine storm and exacerbate pathological damage in hosts. We also review some of the current immunomodulatory strategies for the treatment of cytokine storms in severe influenza, including corticosteroids, peroxisome proliferator-activated receptor agonists, sphingosine-1-phosphate receptor 1 agonists, cyclooxygenase-2 inhibitors, antioxidants, anti-tumour-necrosis factor therapy, intravenous immunoglobulin therapy, statins, arbidol, herbs, and other potential therapeutic strategies.

Ischemia-Reperfusion Injury in Stroke

PubMed Central

Nour, May; Scalzo, Fabien; Liebeskind, David S.

2013-01-01

Despite ongoing advances in stroke imaging and treatment, ischemic and hemorrhagic stroke continue to debilitate patients with devastating outcomes at both the personal and societal levels. While the ultimate goal of therapy in ischemic stroke is geared towards restoration of blood flow, even when mitigation of initial tissue hypoxia is successful, exacerbation of tissue injury may occur in the form of cell death, or alternatively, hemorrhagic transformation of reperfused tissue. Animal models have extensively demonstrated the concept of reperfusion injury at the molecular and cellular levels, yet no study has quantified this effect in stroke patients. These preclinical models have also demonstrated the success of a wide array of neuroprotective strategies at lessening the deleterious effects of reperfusion injury. Serial multimodal imaging may provide a framework for developing therapies for reperfusion injury. PMID:25187778

Host-dependent variables: The missing link to personalized medicine.

PubMed

Demlova, Regina; Zdrazilova-Dubska, Lenka; Sterba, Jaroslav; Stanta, Giorgio; Valik, Dalibor

2018-04-26

Individualized medicine has the potential to tailor anticancer therapy with the best response and highest safety margin to provide better patient care. However, modern targeted therapies are still being tested through clinical trials comparing preselected patient cohorts and assessed upon behaviour of group averages. Clinically manifesting malignant disease requires identification of host- and tumour-dependent variables such as biological characteristics of the tumour and its microenvironment including immune response features, and overall capacity of the host to receive, tolerate and efficiently utilize treatment. Contemporary medical oncology including clinical trial design need to refocus from assessing group averages to individuality taking into consideration time dependent host-associated characteristics and reinventing outliers to be appreciated as naturally occurring variables collectively determining the ultimate outcome of malignant disease. Copyright © 2018. Published by Elsevier Ltd.

Injection of Unicameral Bone Cysts with Bone Marrow Aspirate and Demineralized Bone Matrix Avoids Open Curettage and Bone Grafting in a Retrospective Cohort.

PubMed

Gundle, Kenneth R; Bhatt, Etasha M; Punt, Stephanie E; Bompadre, Viviana; Conrad, Ernest U

2017-01-01

Many treatment options exist for unicameral bone cysts (UBC), without clear evidence of superiority. Meta-analyses have been limited by small numbers of patients in specific anatomic and treatment subgroups. The purpose of this study was to report the outcomes of injecting bone marrow aspirate and demineralized bone matrix (BMA/DBM) for the treatment of proximal humerus UBC. Fifty-one patients with proximal humerus lesions treated by BMA/DBM injection were retrospectively reviewed from a single academic medical center. The mean number of injections performed per patient was 2.14 (range 1-5). Eleven patients underwent only one injection (22%), an additional 19 patients completed treatment after two injections (37%), four patients healed after three injections (8%), and one patient healed after four injections (2%). The cumulative success rate of serial BMA/DBM injections was 22% (11/51), 58% (30/51), 67% (34/51), and 69% (35/51). Eleven patients (22%) ultimately underwent open curettage and bone grafting, and five patients (10%) were treated with injection of calcium phosphate bone substitute. A BMA/DBM injection strategy avoided an open procedure in 78% of patients with a proximal humerus UBC. The majority of patients underwent at least 2 injection treatments. Level IV retrospective cohort study.

Depression in type 2 diabetes mellitus: prevalence, impact, and treatment.

PubMed

Semenkovich, Katherine; Brown, Miriam E; Svrakic, Dragan M; Lustman, Patrick J

2015-04-01

Clinically significant depression is present in one of every four people with type 2 diabetes mellitus (T2DM). Depression increases the risk of the development of T2DM and the subsequent risks of hyperglycemia, insulin resistance, and micro- and macrovascular complications. Conversely, a diagnosis of T2DM increases the risk of incident depression and can contribute to a more severe course of depression. This linkage reflects a shared etiology consisting of complex bidirectional interactions among multiple variables, a process that may include autonomic and neurohormonal dysregulation, weight gain, inflammation, and hippocampal structural alterations. Two recent meta-analyses of randomized controlled depression treatment trials in patients with T2DM concluded that psychotherapy and antidepressant medication (ADM) were each moderately effective for depression and that cognitive behavior therapy (CBT) had beneficial effects on glycemic control. However, the number of studies (and patients exposed to randomized treatment) included in these analyses is extremely small and limits the certainty of conclusions that can be drawn from the data. Ultimately, there is no escaping the paucity of the evidence base and the need for additional controlled trials that specifically address depression management in T2DM. Future trials should determine both the effects of treatment and the change in depression during treatment on measures of mood, glycemic control, and medical outcome.

Pedophilia.

PubMed

Fagan, Peter J; Wise, Thomas N; Schmidt, Chester W; Berlin, Fred S

2002-11-20

This article addresses the risk factors associated with the psychiatric disorder pedophilia, its treatment, and treatment outcomes. It addresses physician responsibilities associated with case identification of victims and possible roles in the medical management of pedophilia. The essential feature of pedophilia is that an individual is sexually attracted exclusively or in part to prepubescent children. While pedophilia may be limited to fantasies and impulses, pedophilic behaviors are the primary concern of both the mental health and criminal justice systems. Remote risk factors for development of pedophilia often include the individual having been sexually abused as a child. Proximate risk factors for its behavioral expression are prevalence of comorbid psychiatric disorders and substance abuse disorders. Current treatment goals focus on stopping the behavior and achieving long-term behavioral control in the community. Common treatment methods are cognitive-behavioral, group therapy, and, when appropriate, medications such as androgen-lowering agents that can act as sexual appetite suppressants. Meta-analyses have established that treatment is more effective than nontreatment in preventing recidivism of sexual offenders in general, a finding that has a high probability of application to individuals with pedophilia. Pedophilia is a chronic psychiatric disorder, but it is treatable in terms of developing strategies for preventing behavioral expression. Ultimately, reducing the prevalence of pedophilic behavior requires further collaboration between the criminal justice system and the health care communities.

Head and Neck Cancer: An Overview

PubMed Central

Stepnick, David; Gilpin, David

2010-01-01

Ablative surgery for malignancies of the upper aerodigestive tract is the most common reason why the reconstructive surgeon is called upon to reconstruct adult head and neck defects. An understanding of the pathophysiology and treatment of head and neck malignancy is vital to the reconstructive surgeon so that restoration of both form and function can be achieved. It is important to understand the behavior of cancers of each head and neck subsite, as staging and ultimately the treatment of tumors from each subsite is different. Historically, the standard treatment of head and neck cancer was surgery and/or primary radiation therapy with surgical salvage for failure. Beginning in the 1980s, advances in chemotherapy and concurrent delivery with radiation offered new options to standard surgical therapy. Over the past two decades, the concept of organ preservation using chemotherapy together with radiation therapy has been definitively established. Yet, even with the strides made over these two decades with chemoradiation, surgical treatment of head and neck cancer and reconstruction thereof will be an important treatment option for the foreseeable future. Therefore, the relationship between the extirpative and reconstructive surgeon is vital, and a clear understanding of the biology and behavior of head and neck malignancy is crucial to successful patient outcomes. PMID:22550431

Patient's perceptions of chronic kidney disease and their association with psychosocial and clinical outcomes: a narrative review

PubMed Central

Clarke, Amy L.; Yates, Thomas; Smith, Alice C.; Chilcot, Joseph

2016-01-01

Patients with chronic kidney disease (CKD) form organized beliefs regarding their illness and treatment. These perceptions influence the coping strategies employed by an individual to manage his/her illness and may act as a predictor for his/her willingness to engage in self-management behaviours. While illness perceptions have been identified as predictors of non-adherence, depression and mortality in dialysis patients, there is a paucity of research in CKD patients not requiring renal replacement therapy. This narrative review synthesizes the existing literature regarding the role of illness perceptions and associated clinical and psychosocial outcomes in non-dialysis CKD patients. Studies were identified following database searches of AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsycINFO and Google Scholar in January 2016. Despite the small evidence base, existing studies indicate that negative illness perceptions are associated with disease progression and a number of psychosocial outcomes in non-dialysis CKD patients. Evidence from other clinical populations suggests that illness perceptions are modifiable through psychological intervention, which may be most effective if delivered early before beliefs have the chance to become more established. Therefore, targeting illness perceptions in the earlier stages of CKD may be optimal. Further studies are now required to ascertain the mechanisms through which illness perceptions predict psychosocial and clinical outcomes in CKD patients and to ultimately test the efficacy of illness perception–based interventions. PMID:27274839

Patient's perceptions of chronic kidney disease and their association with psychosocial and clinical outcomes: a narrative review.

PubMed

Clarke, Amy L; Yates, Thomas; Smith, Alice C; Chilcot, Joseph

2016-06-01

Patients with chronic kidney disease (CKD) form organized beliefs regarding their illness and treatment. These perceptions influence the coping strategies employed by an individual to manage his/her illness and may act as a predictor for his/her willingness to engage in self-management behaviours. While illness perceptions have been identified as predictors of non-adherence, depression and mortality in dialysis patients, there is a paucity of research in CKD patients not requiring renal replacement therapy. This narrative review synthesizes the existing literature regarding the role of illness perceptions and associated clinical and psychosocial outcomes in non-dialysis CKD patients. Studies were identified following database searches of AMED, BNI, CINAHL, EMBASE, Health Business Elite, HMIC, Medline, PsycINFO and Google Scholar in January 2016. Despite the small evidence base, existing studies indicate that negative illness perceptions are associated with disease progression and a number of psychosocial outcomes in non-dialysis CKD patients. Evidence from other clinical populations suggests that illness perceptions are modifiable through psychological intervention, which may be most effective if delivered early before beliefs have the chance to become more established. Therefore, targeting illness perceptions in the earlier stages of CKD may be optimal. Further studies are now required to ascertain the mechanisms through which illness perceptions predict psychosocial and clinical outcomes in CKD patients and to ultimately test the efficacy of illness perception-based interventions.

Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke.

PubMed

Campbell, Bruce C V; Donnan, Geoffrey A; Lees, Kennedy R; Hacke, Werner; Khatri, Pooja; Hill, Michael D; Goyal, Mayank; Mitchell, Peter J; Saver, Jeffrey L; Diener, Hans-Christoph; Davis, Stephen M

2015-08-01

Results of initial randomised trials of endovascular treatment for ischaemic stroke, published in 2013, were neutral but limited by the selection criteria used, early-generation devices with modest efficacy, non-consecutive enrollment, and treatment delays. In the past year, six positive trials of endovascular thrombectomy for ischaemic stroke have provided level 1 evidence for improved patient outcome compared with standard care. In most patients, thrombectomy was performed in addition to thrombolysis with intravenous alteplase, but benefits were also reported in patients ineligible for alteplase treatment. Despite differences in the details of eligibility requirements, all these trials required proof of major vessel occlusion on non-invasive imaging and most used some imaging technique to exclude patients with a large area of irreversibly injured brain tissue. The results indicate that modern thrombectomy devices achieve faster and more complete reperfusion than do older devices, leading to improved clinical outcomes compared with intravenous alteplase alone. The number needed to treat to achieve one additional patient with independent functional outcome was in the range of 3·2-7·1 and, in most patients, was in addition to the substantial efficacy of intravenous alteplase. No major safety concerns were noted, with low rates of procedural complications and no increase in symptomatic intracerebral haemorrhage. WHERE NEXT?: Thrombectomy benefits patients across a range of ages and levels of clinical severity. A planned meta-analysis of individual patient data might clarify effects in under-represented subgroups, such as those with mild initial stroke severity or elderly patients. Imaging-based selection, used in some of the recent trials to exclude patients with large areas of irreversible brain injury, probably contributed to the proportion of patients with favourable outcomes. The challenge is how best to implement imaging in clinical practice to maximise benefit for the entire population and to avoid exclusion of patients with smaller yet clinically important potential to benefit. Although favourable imaging identifies patients who might benefit despite long delays from symptom onset to treatment, the proportion of patients with favourable imaging decreases with time. Health systems therefore need to be reorganised to deliver treatment as quickly as possible to maximise benefits. On the basis of available trial data, intravenous alteplase remains the initial treatment for all eligible patients within 4·5 h of stroke symptom onset. Those patients with major vessel occlusion should, in parallel, proceed to endovascular thrombectomy immediately rather than waiting for an assessment of response to alteplase, because minimising time to reperfusion is the ultimate aim of treatment. Copyright © 2015 Elsevier Ltd. All rights reserved.

Strategies for maximizing clinical effectiveness in the treatment of schizophrenia.

PubMed

Tandon, Rajiv; Targum, Steven D; Nasrallah, Henry A; Ross, Ruth

2006-11-01

The ultimate clinical objective in the treatment of schizophrenia is to enable affected individuals to lead maximally productive and personally meaningful lives. As with other chronic diseases that lack a definitive cure, the individual's service/recovery plan must include treatment interventions directed towards decreasing manifestations of the illness, rehabilitative services directed towards enhancing adaptive skills, and social support mobilization aimed at optimizing function and quality of life. In this review, we provide a conceptual framework for considering approaches for maximizing the effectiveness of the array of treatments and other services towards promoting recovery of persons with schizophrenia. We discuss pharmacological, psychological, and social strategies that decrease the burden of the disease of schizophrenia on affected individuals and their families while adding the least possible burden of treatment. In view of the multitude of treatments necessary to optimize outcomes for individuals with schizophrenia, effective coordination of these services is essential. In addition to providing best possible clinical assessment and pharmacological treatment, the psychiatrist must function as an effective leader of the treatment team. To do so, however, the psychiatrist must be knowledgeable about the range of available services, must have skills in clinical-administrative leadership, and must accept the responsibility of coordinating the planning and delivery of this multidimensional array of treatments and services. Finally, the effectiveness of providing optimal individualized treatment/rehabilitation is best gauged by measuring progress on multiple effectiveness domains. Approaches for efficient and reliable assessment are discussed.

The Diagnostic Efficacy of Cone-beam Computed Tomography in Endodontics: A Systematic Review and Analysis by a Hierarchical Model of Efficacy.

PubMed

Rosen, Eyal; Taschieri, Silvio; Del Fabbro, Massimo; Beitlitum, Ilan; Tsesis, Igor

2015-07-01

The aim of this study was to evaluate the diagnostic efficacy of cone-beam computed tomographic (CBCT) imaging in endodontics based on a systematic search and analysis of the literature using an efficacy model. A systematic search of the literature was performed to identify studies evaluating the use of CBCT imaging in endodontics. The identified studies were subjected to strict inclusion criteria followed by an analysis using a hierarchical model of efficacy (model) designed for appraisal of the literature on the levels of efficacy of a diagnostic imaging modality. Initially, 485 possible relevant articles were identified. After title and abstract screening and a full-text evaluation, 58 articles (12%) that met the inclusion criteria were analyzed and allocated to levels of efficacy. Most eligible articles (n = 52, 90%) evaluated technical characteristics or the accuracy of CBCT imaging, which was defined in this model as low levels of efficacy. Only 6 articles (10%) proclaimed to evaluate the efficacy of CBCT imaging to support the practitioner's decision making; treatment planning; and, ultimately, the treatment outcome, which was defined as higher levels of efficacy. The expected ultimate benefit of CBCT imaging to the endodontic patient as evaluated by its level of diagnostic efficacy is unclear and is mainly limited to its technical and diagnostic accuracy efficacies. Even for these low levels of efficacy, current knowledge is limited. Therefore, a cautious and rational approach is advised when considering CBCT imaging for endodontic purposes. Copyright © 2015 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Distinguishing between unipolar depression and bipolar depression: current and future clinical and neuroimaging perspectives.

PubMed

Cardoso de Almeida, Jorge Renner; Phillips, Mary Louise

2013-01-15

Differentiating bipolar disorder (BD) from recurrent unipolar depression (UD) is a major clinical challenge. Main reasons for this include the higher prevalence of depressive relative to hypo/manic symptoms during the course of BD illness and the high prevalence of subthreshold manic symptoms in both BD and UD depression. Identifying objective markers of BD might help improve accuracy in differentiating between BD and UD depression, to ultimately optimize clinical and functional outcome for all depressed individuals. Yet, only eight neuroimaging studies to date have directly compared UD and BD depressed individuals. Findings from these studies suggest more widespread abnormalities in white matter connectivity and white matter hyperintensities in BD than UD depression, habenula volume reductions in BD but not UD depression, and differential patterns of functional abnormalities in emotion regulation and attentional control neural circuitry in the two depression types. These findings suggest different pathophysiologic processes, especially in emotion regulation, reward, and attentional control neural circuitry in BD versus UD depression. This review thereby serves as a call to action to highlight the pressing need for more neuroimaging studies, using larger samples sizes, comparing BD and UD depressed individuals. These future studies should also include dimensional approaches, studies of at-risk individuals, and more novel neuroimaging approaches, such as connectivity analysis and machine learning. Ultimately, these approaches might provide biomarkers to identify individuals at future risk for BD versus UD and biological targets for more personalized treatment and new treatment developments for BD and UD depression. Copyright © 2013 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.

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

NONE

The ultimate goal of radiotherapy treatment planning is to find a treatment that will yield a high tumor control probability (TCP) with an acceptable normal tissue complication probability (NTCP). Yet most treatment planning today is not based upon optimization of TCPs and NTCPs, but rather upon meeting physical dose and volume constraints defined by the planner. It has been suggested that treatment planning evaluation and optimization would be more effective if they were biologically and not dose/volume based, and this is the claim debated in this month’s Point/Counterpoint. After a brief overview of biologically and DVH based treatment planning bymore » the Moderator Colin Orton, Joseph Deasy (for biological planning) and Charles Mayo (against biological planning) will begin the debate. Some of the arguments in support of biological planning include: this will result in more effective dose distributions for many patients DVH-based measures of plan quality are known to have little predictive value there is little evidence that either D95 or D98 of the PTV is a good predictor of tumor control sufficient validated outcome prediction models are now becoming available and should be used to drive planning and optimization Some of the arguments against biological planning include: several decades of experience with DVH-based planning should not be discarded we do not know enough about the reliability and errors associated with biological models the radiotherapy community in general has little direct experience with side by side comparisons of DVH vs biological metrics and outcomes it is unlikely that a clinician would accept extremely cold regions in a CTV or hot regions in a PTV, despite having acceptable TCP values Learning Objectives: To understand dose/volume based treatment planning and its potential limitations To understand biological metrics such as EUD, TCP, and NTCP To understand biologically based treatment planning and its potential limitations.« less

Outcome of 28 open pilon fractures with injury severity-based fixation.

PubMed

Danoff, Jonathan R; Saifi, Comron; Goodspeed, David C; Reid, J Spence

2015-04-01

Open pilon fracture management and treatment poses a significant challenge to orthopedic surgeons. The purpose of this study was to determine patient outcomes for open pilon fractures based on wound complication and infection rates, as well as subjective outcome instruments. This was a retrospective consecutive case series of 28 fractures with Orthopaedic Trauma Association (OTA)-type 43-B and 43-C open pilon fractures. Mean length of follow-up was 36 months and minimum of 1 year. Ten fractures were Gustilo and Anderson grade IIIB, and the remaining fractures were grades I-IIIA. Patients were initially treated with spanning external fixation and staged wound debridement followed by osteosynthesis of the articular surface. Metaphyseal fixation was by either plate fixation or Ilizarov frame. The primary outcome was the incidence of deep tissue infection requiring surgery. Secondary outcomes included the incidence of other complications (nonunion, malunion, amputation) and functional outcomes (Short Musculoskeletal Functional Assessment Questionnaire and AAOS Foot and Ankle Questionnaire). Four patients developed deep tissue infections, three in the internal fixation group and one in the Ilizarov group, and all were treated successfully with staged debridement. There were two delayed unions required bone grafting, and infection-free union was ultimately achieved in all fractures. Two patients underwent arthrodesis secondary to post-traumatic arthritis, while no patients experienced malunions or amputations. The use of staged wound debridement in conjunction with either plate fixation or Ilizarov frame achieves low rates of wound infection and stable fixation after anatomic joint reconstruction for OTA-type 43-B and 43-C open pilon fractures.

Progressive but Previously Untreated CLL Patients with Greater Array CGH Complexity Exhibit a Less Durable Response to Chemoimmunotherapy

PubMed Central

Kay, Neil E.; Eckel-Passow, Jeanette E.; Braggio, Esteban; VanWier, Scott; Shanafelt, Tait D.; Van Dyke, Daniel L.; Jelinek, Diane F.; Tschumper, Renee C.; Kipps, Thomas; Byrd, John C.; Fonseca, Rafael

2010-01-01

To better understand the implications of genomic instability and outcome in B-cell CLL, we sought to address genomic complexity as a predictor of chemosensitivity and ultimately clinical outcome in this disease. We employed array-based comparative genomic hybridization (aCGH), using a one-million probe array and identified gains and losses of genetic material in 48 patients treated on a chemoimmunotherapy (CIT) clinical trial. We identified chromosomal gain or loss in ≥6% of the patients on chromosomes 3, 8, 9, 10, 11, 12, 13, 14 and 17. Higher genomic complexity, as a mechanism favoring clonal selection, was associated with shorter progression-free survival and predicted a poor response to treatment. Of interest, CLL cases with loss of p53 surveillance showed more complex genomic features and were found both in patients with a 17p13.1 deletion and in the more favorable genetic subtype characterized by the presence of 13q14.1 deletion. This aCGH study adds information on the association between inferior trial response and increasing genetic complexity as CLL progresses. PMID:21156228

Peripheral nerve injuries, pain, and neuroplasticity.

PubMed

Osborne, Natalie R; Anastakis, Dimitri J; Davis, Karen D

Peripheral nerve injuries (PNIs) cause both structural and functional brain changes that may be associated with significant sensorimotor abnormalities and pain. The aim of this narrative review is to provide hand therapists an overview of PNI-induced neuroplasticity and to explain how the brain changes following PNI, repair, and during rehabilitation. Toward this goal, we review key aspects of neuroplasticity and neuroimaging and discuss sensory testing techniques used to study neuroplasticity in PNI patients. We describe the specific brain changes that occur during the repair and recovery process of both traumatic (eg, transection) and nontraumatic (eg, compression) nerve injuries. We also explain how these changes contribute to common symptoms including hypoesthesia, hyperalgesia, cold sensitivity, and chronic neurogenic pain. In addition, we describe how maladaptive neuroplasticity as well as psychological and personality characteristics impacts treatment outcome. Greater understanding of the brain's contribution to symptoms in recovering PNI patients could help guide rehabilitation strategies and inform the development of novel techniques to counteract these maladaptive brain changes and ultimately improve outcomes. Copyright © 2018 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

Common social cognitive impairments do not mean common causes: A commentary on Cotter et al. (2018).

PubMed

Dodell-Feder, David; Germine, Laura T

2018-06-06

Many clinical conditions, ranging from psychiatric to neurodegenerative illnesses, are associated with impairments in the processes by which we perceive, interpret, and respond to social information; a suite of abilities known as social cognition. Through a systematic review of meta-analyses, Cotter et al. (2018) present a compelling view of social cognitive deficits as a core phenotype of many clinical conditions. However, we caution against one potential interpretation of their findings, namely, that similar social cognitive outcomes are produced by similar causes. Specifically, we argue that while the outcome may look similar across clinical conditions (i.e., global social cognitive deficits), the cause and nature of those impairments are likely to differ, and, as a consequence, so too will its remediation. We advocate for the development of better methods for assessing social cognition, which may speak to the varying nature of social cognitive impairment across conditions. Ultimately, a better understanding of how social cognition is impaired will facilitate the development of more targeted, more effective treatments, that will improve patient care. Copyright © 2018 Elsevier Ltd. All rights reserved.

Evolution of the concept and practice of mitral valve repair

PubMed Central

Tchantchaleishvili, Vakhtang; Rajab, Taufiek K.

2015-01-01

The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women’s Hospital in 1923. Subsequent evolution in the surgical techniques as well as multi-disciplinary cooperation between cardiac surgeons, cardiologists and cardiac anesthesiologists has resulted in excellent outcomes. In spite of this, the etiology of mitral valve pathology ultimately determines the outcome of mitral valve repair. PMID:26309840

Update on Outcome Measure Development for Large Vessel Vasculitis: Report from OMERACT 12

PubMed Central

Aydin, Sibel Zehra; Direskeneli, Haner; Sreih, Antoine; Alibaz-Oner, Fatma; Gul, Ahmet; Kamali, Sevil; Hatemi, Gulen; Kermani, Tanaz; Mackie, Sarah L.; Mahr, Alfred; Meara, Alexa; Milman, Nataliya; Nugent, Heidi; Robson, Joanna; Tomasson, Gunnar; Merkel, Peter A.

2015-01-01

Objective The rarity of large vessel vasculitis (LVV) is a major factor limiting randomized controlled trials in LVV, resulting in treatment choices in these diseases that are guided mainly by observational studies and expert opinion. Further complicating trials in LVV is the absence of validated and meaningful outcome measures. The Outcome Measures in Rheumatology (OMERACT) vasculitis working group initiated the Large Vessel Vasculitis task force in 2009 to develop data-driven, validated outcome tools for clinical investigation in LVV. This report summarizes the progress that has been made on a disease activity assessment tool and patient-reported outcomes in LVV as well as the group’s research agenda. Methods The OMERACT LVV task force brought an international group of investigators and patient research partners together to work collaboratively on developing outcome tools. The group initially focused on disease activity assessment tools in LVV. Following a systematic literature review, an international Delphi exercise was conducted to obtain expert opinion on principles and domains for disease assessment. The OMERACT vasculitis working group’s LVV task force is also conducting qualitative research with patients, including interviews, focus groups, and engaging patients as research partners, all to ensure that the approach to disease assessment includes measures of patients’ perspectives and that patients have input into the research agenda and process. Results The preliminary results of both the Delphi exercise and the qualitative interviews were discussed at the OMERACT 12 (2014) meeting and the completion of the analyses will produce an initial set of domains and instruments to form the basis of next steps in the research agenda. Conclusion The research agenda continues to evolve, with the ultimate goal of developing an OMERACT-endorsed core set of outcome measures for use in clinical trials of LVV. PMID:26077399

Characterization of the Asian Phenotype - An Emerging Paradigm with Clinicopathological and Human Research Implications

PubMed Central

Leow, Melvin Khee-Shing

2017-01-01

Background: Modern medicine recognizes that salient, inherent variations between Caucasians and Asians exist. Radical changes are occurring in the health scene with increasing emphasis centered on the recognition of inter-individual variations unique to Asians that impact on medical management and outcomes. Aim: This review analyzes distinct features or outcomes in terms of epidemiology, disease thresholds, diagnostic cutoffs and treatment responses of Asian people compared with non-Asians. Methods: This review is based on a literature search via PubMed and MEDLINE for relevant articles related to the Asian phenotype and its impact on health and disease. Results: An 'Asian phenotype' could be characterized across the spectrum of biomedical disciplines and underscores the major challenges clinicians must face in their daily management of a cosmopolitan population and their extrapolation of research outcomes. Conclusion: Interventions for various ailments that have traditionally ignored population differences have now entered the age of personalized, stratified or precision medicine requiring an individualized approach being adopted as a new standard of care. Factoring in Asian phenotypes is essential for the medical research community and the development of improved clinical practice guidelines across a continuum of disciplines that will ultimately translate to better human health round the world. PMID:28824295

The FAST-ED App: A Smartphone Platform for the Field Triage of Patients With Stroke.

PubMed

Nogueira, Raul G; Silva, Gisele S; Lima, Fabricio O; Yeh, Yu-Chih; Fleming, Carol; Branco, Daniel; Yancey, Arthur H; Ratcliff, Jonathan J; Wages, Robert Keith; Doss, Earnest; Bouslama, Mehdi; Grossberg, Jonathan A; Haussen, Diogo C; Sakano, Teppei; Frankel, Michael R

2017-05-01

The Emergency Medical Services field triage to stroke centers has gained considerable complexity with the recent demonstration of clinical benefit of endovascular treatment for acute ischemic stroke. We sought to describe a new smartphone freeware application designed to assist Emergency Medical Services professionals with the field assessment and destination triage of patients with acute ischemic stroke. Review of the application's platform and its development as well as the different variables, assessments, algorithms, and assumptions involved. The FAST-ED (Field Assessment Stroke Triage for Emergency Destination) application is based on a built-in automated decision-making algorithm that relies on (1) a brief series of questions assessing patient's age, anticoagulant usage, time last known normal, motor weakness, gaze deviation, aphasia, and hemineglect; (2) a database of all regional stroke centers according to their capability to provide endovascular treatment; and (3) Global Positioning System technology with real-time traffic information to compute the patient's eligibility for intravenous tissue-type plasminogen activator or endovascular treatment as well as the distances/transportation times to the different neighboring stroke centers in order to assist Emergency Medical Services professionals with the decision about the most suitable destination for any given patient with acute ischemic stroke. The FAST-ED smartphone application has great potential to improve the triage of patients with acute ischemic stroke, as it seems capable to optimize resources, reduce hospital arrivals times, and maximize the use of both intravenous tissue-type plasminogen activator and endovascular treatment ultimately leading to better clinical outcomes. Future field studies are needed to properly evaluate the impact of this tool in stroke outcomes and resource utilization. © 2017 American Heart Association, Inc.

The Global ECT-MRI Research Collaboration (GEMRIC): Establishing a multi-site investigation of the neural mechanisms underlying response to electroconvulsive therapy.

PubMed

Oltedal, Leif; Bartsch, Hauke; Sørhaug, Ole Johan Evjenth; Kessler, Ute; Abbott, Christopher; Dols, Annemieke; Stek, Max L; Ersland, Lars; Emsell, Louise; van Eijndhoven, Philip; Argyelan, Miklos; Tendolkar, Indira; Nordanskog, Pia; Hamilton, Paul; Jorgensen, Martin Balslev; Sommer, Iris E; Heringa, Sophie M; Draganski, Bogdan; Redlich, Ronny; Dannlowski, Udo; Kugel, Harald; Bouckaert, Filip; Sienaert, Pascal; Anand, Amit; Espinoza, Randall; Narr, Katherine L; Holland, Dominic; Dale, Anders M; Oedegaard, Ketil J

2017-01-01

Major depression, currently the world's primary cause of disability, leads to profound personal suffering and increased risk of suicide. Unfortunately, the success of antidepressant treatment varies amongst individuals and can take weeks to months in those who respond. Electroconvulsive therapy (ECT), generally prescribed for the most severely depressed and when standard treatments fail, produces a more rapid response and remains the most effective intervention for severe depression. Exploring the neurobiological effects of ECT is thus an ideal approach to better understand the mechanisms of successful therapeutic response. Though several recent neuroimaging studies show structural and functional changes associated with ECT, not all brain changes associate with clinical outcome. Larger studies that can address individual differences in clinical and treatment parameters may better target biological factors relating to or predictive of ECT-related therapeutic response. We have thus formed the Global ECT-MRI Research Collaboration (GEMRIC) that aims to combine longitudinal neuroimaging as well as clinical, behavioral and other physiological data across multiple independent sites. Here, we summarize the ECT sample characteristics from currently participating sites, and the common data-repository and standardized image analysis pipeline developed for this initiative. This includes data harmonization across sites and MRI platforms, and a method for obtaining unbiased estimates of structural change based on longitudinal measurements with serial MRI scans. The optimized analysis pipeline, together with the large and heterogeneous combined GEMRIC dataset, will provide new opportunities to elucidate the mechanisms of ECT response and the factors mediating and predictive of clinical outcomes, which may ultimately lead to more effective personalized treatment approaches.

U.S. EPA's Ultraviolet Disinfection Technologies Demonstration Study

EPA Science Inventory

This presentation will give a background on USEPA's Disinfection Technologies Demonstration Study. This will include regulatory background, science background, goals of the project, and ultimate expected outcome of the project. This presentation will preceed a panel discussion ...

77 FR 13697 - Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-07

... for Economic and Clinical Health Act HMO--Health Maintenance Organization HOS--Health Outcomes Survey... rule by early 2014. The stages represent an initial graduated approach to arriving at the ultimate goal...

Therapeutic advances in multiple system atrophy and progressive supranuclear palsy.

PubMed

Poewe, Werner; Mahlknecht, Philipp; Krismer, Florian

2015-09-15

Multiple system atrophy (MSA) and progressive supranuclear palsy (PSP) are relentlessly progressive neurodegenerative diseases leading to severe disability and ultimately death within less than 10 y. Despite increasing efforts in basic and clinical research, effective therapies for these atypical parkinsonian disorders are lacking. Although earlier small clinical studies in MSA and PSP mainly focused on symptomatic treatment, advances in the understanding of the molecular underpinnings of these diseases and in the search for biomarkers have paved the way for the first large and well-designed clinical trials aiming at disease modification. Targets of intervention in these trials have included α-synuclein inclusion pathology in the case of MSA and tau-related mechanisms in PSP. Since 2013, four large randomized, placebo-controlled, double-blind disease-modification trials have been completed and published, using rasagiline (MSA), rifampicin (MSA), tideglusib (PSP), or davunetide (PSP). All of these failed to demonstrate signal efficacy with regard to the primary outcome measures. In addition, two randomized, placebo-controlled, double-blind trials have studied the efficacy of droxidopa in the symptomatic treatment of neurogenic orthostatic hypotension, including patients with MSA, with positive results in one trial. This review summarizes the design and the outcomes of these and other smaller trials published since 2013 and attempts to highlight priority areas of future therapeutic research in MSA and PSP. © 2015 International Parkinson and Movement Disorder Society. © 2015 International Parkinson and Movement Disorder Society.

Integral pharmacological management of bone mineral disorders in chronic kidney disease (part II): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification.

PubMed

Bover, J; Ureña-Torres, P; Lloret, M J; Ruiz, C; DaSilva, I; Diaz-Encarnacion, M M; Mercado, C; Mateu, S; Fernández, E; Ballarin, J

2016-07-01

Chronic kidney disease-mineral and bone disorders (CKD-MBD) are associated with costly complications and dismal hard-outcomes. In two comprehensive articles we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (part 1) and hyperparathyroidism (this part 2), taking into account CKD-accelerated cardiovascular calcification (CVC) processes. Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Here, initial guidance to control hyperparathyroidism is provided, taking into account the presence/absence of CVC. We include also measures for patients at risk of adynamic bone disease or suffering from calciphylaxis. Many epidemiological studies (relating to vitamin D) and thorough analyses of recent randomized clinical trials (of cinacalcet) point towards benefits of attempting to improve biochemical parameters while trying to, at least, avoid progression of CVC by more rational use of intestinal P-binders and low-dose vitamin D derivatives and/or calcimimetics. This approach does not seem to be far away from significantly improving hard-outcomes, at least in the dialysis population. The availability of new drugs and the performance of randomized clinical trials should ultimately lead to define earlier, clearer, and more cost-effective patient stratification and biochemical targets with consequent significant clinical improvements.

Evidence-based Guidelines for Precision Risk Stratification-Based Screening (PRSBS) for Colorectal Cancer: Lessons learned from the US Armed Forces: Consensus and Future Directions

PubMed Central

Avital, Itzhak; Langan, Russell C.; Summers, Thomas A.; Steele, Scott R.; Waldman, Scott A.; Backman, Vadim; Yee, Judy; Nissan, Aviram; Young, Patrick; Womeldorph, Craig; Mancusco, Paul; Mueller, Renee; Noto, Khristian; Grundfest, Warren; Bilchik, Anton J.; Protic, Mladjan; Daumer, Martin; Eberhardt, John; Man, Yan Gao; Brücher, Björn LDM; Stojadinovic, Alexander

2013-01-01

Colorectal cancer (CRC) is the third most common cause of cancer-related death in the United States (U.S.), with estimates of 143,460 new cases and 51,690 deaths for the year 2012. Numerous organizations have published guidelines for CRC screening; however, these numerical estimates of incidence and disease-specific mortality have remained stable from years prior. Technological, genetic profiling, molecular and surgical advances in our modern era should allow us to improve risk stratification of patients with CRC and identify those who may benefit from preventive measures, early aggressive treatment, alternative treatment strategies, and/or frequent surveillance for the early detection of disease recurrence. To better negotiate future economic constraints and enhance patient outcomes, ultimately, we propose to apply the principals of personalized and precise cancer care to risk-stratify patients for CRC screening (Precision Risk Stratification-Based Screening, PRSBS). We believe that genetic, molecular, ethnic and socioeconomic disparities impact oncological outcomes in general, those related to CRC, in particular. This document highlights evidence-based screening recommendations and risk stratification methods in response to our CRC working group private-public consensus meeting held in March 2012. Our aim was to address how we could improve CRC risk stratification-based screening, and to provide a vision for the future to achieving superior survival rates for patients diagnosed with CRC. PMID:23459409

Parent-directed approaches to enrich the early language environments of children living in poverty.

PubMed

Leffel, Kristin; Suskind, Dana

2013-11-01

Children's early language environments are critical for their cognitive development, school readiness, and ultimate educational attainment. Significant disparities exist in these environments, with profound and lasting impacts upon children's ultimate outcomes. Children from backgrounds of low socioeconomic status experience diminished language inputs and enter school at a disadvantage, with disparities persisting throughout their educational careers. Parents are positioned as powerful agents of change in their children's lives, however, and evidence indicates that parent-directed intervention is effective in improving child outcomes. This article explores the efficacy of parent-directed interventions and their potential applicability to the wider educational achievement gap seen in typically developing populations of low socioeconomic status and then describes efforts to develop such interventions with the Thirty Million Words Project and Project ASPIRE (Achieving Superior Parental Involvement for Rehabilitative Excellence) curricula. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

MOBILITY AND DEGRADATION OF RESIDUES AT HAZARDOUS WASTE LAND TREATMENT SITES AT CLOSURE

EPA Science Inventory

Soil treatment systems that are designed and managed based on a knowledge of soil-waste interactions may represent a significant technology for simultaneous treatment and ultimate disposal of selected hazardous wastes in an environmentally acceptable manner. hese soil treatment s...

Clinical outcome and evidence of high rate post-surgical anterior hypopituitarism in a cohort of TSH-secreting adenoma patients: Might somatostatin analogs have a role as first-line therapy?

PubMed

Gatto, Federico; Grasso, Ludovica F; Nazzari, Elena; Cuny, Thomas; Anania, Pasquale; Di Somma, Carolina; Colao, Annamaria; Zona, Gianluigi; Weryha, Georges; Pivonello, Rosario; Ferone, Diego

2015-10-01

Thyrotropin-secreting pituitary adenomas (TSHomas) represent a rare subtype of pituitary tumors. Neurosurgery (NCH) is still considered the first-line therapy. In this study we aimed to investigate the outcome of different treatment modalities, including first line somatostatin analogs (SSA) treatment, with a specific focus on neurosurgery-related complications. We retrospectively evaluated thirteen patients diagnosed for TSHomas (9 M; age range 27-61). Ten patients had a magnetic resonance evidence of macroadenoma, three with slight visual field impairment. In the majority of patients, thyroid ultrasonography showed the presence of goiter and/or increased gland vascularization. Median TSH value at diagnosis was 3.29 mU/L (normal ranges 0.2-4.2 mIU/L), with median fT4 2.52 ng/dL (0.9-1.7 ng/dL). Three patients (two microadenoma) were primarily treated with NCH and achieved disease remission, whereas ten patients (nine macroadenomas) were initially treated with SSA. Despite the optimal biochemical response observed during medical treatment in most patients (mean TSH decrease -72%), only two stayed on medical therapy alone, achieving stable biochemical control at the end of the follow-up. The remaining patients (n = 7) underwent NCH later on during their clinical history, followed by radiotherapy or adjuvant SSA treatment in two cases. Noteworthy, five of them developed hypopituitarism. All patients reached a biochemical control, after a multimodal therapeutic approach. Neurosurgery ultimately led to complete disease remission or to biochemical control in majority of patients, whereas resulting in a considerable percentage of post-operative complications (mainly hypopituitarism, 50%). In the light of the optimal results unanimously reported for medical treatment with SSA, our experience suggests that a careful evaluation of risk/benefit ratio should be taken into consideration when directing the treatment approach in patients with TSHoma.

The effectiveness, safety, and economic evaluation of Korean medicine for unexplained infertile women: A multi-center, prospective, observational study protocol.

PubMed

Kim, Su-Hyun; Jo, Junyoung; Kim, Dong-Il

2017-12-01

Infertility is a condition in which a woman has not been pregnant despite having had normal intercourse for 1 year. The number of unexplained infertile females is increasing because of late marriage customs, as well as environmental and lifestyle habits. In Korea, infertile females have been treated with Korean medicine (KM). However, these effects have not been objectively confirmed through clinical trials. Therefore, this study was conducted to demonstrate the effectiveness of herbal medicine treatment in infertile patients and to demonstrate the economic feasibility through economical evaluation with assisted reproductive technology.This study is designed as a multicenter, single-arm clinical trial. All participants included will be from 3 Korean Medicine hospitals in Korea and will voluntarily sign an informed consent agreement. All recruited patients will conduct related surveys and tests, and be provided with treatment according to their menstrual cycle. Patients will take herbal medicines for 4 menstruation cycles and receive acupuncture and moxibustion treatment at 3 times (menstrual cycle day 3, 8, 14) during 4 menstruation cycles. They will also undergo an approximately 4 menstrual cycle treatment period, and 3 menstrual cycle observation period. If pregnant during the study, participants will take the herbal medicine for implantation for about 15 days. In this study, the primary outcome will be the clinical pregnancy rate, whereas the secondary outcome will include the implantation rate, ongoing pregnancy rate, and live birth rate.Ultimately, this study will provide clinical data regarding the effectiveness and safety of KM treatment for females with unexplained infertility and important evidence for establishing standard KM treatments for unexplained infertility. Moreover, we will identify the most cost-effective way to treat unexplained infertility. Korean Clinical Trial Registry (CRIS), Republic of Korea: KCT0002235. Date: February 21, 2017 (retrospectively registered). Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

Gastroenterologists' Perceptions Regarding Ulcerative Colitis and Its Management: Results from a Large-Scale Survey.

PubMed

Lasch, Karen; Liu, Stephen; Ursos, Lyann; Mody, Reema; King-Concialdi, Kristen; DiBonaventura, Marco; Leberman, Julie; Dubinsky, Marla

2016-10-01

Misperceptions about ulcerative colitis (UC) may influence management strategies and limit opportunities for improving patient outcomes. This study assessed physicians' perceptions of UC, concepts of disease severity and remission, and treatment goals. Gastroenterologists who typically treated ≥10 adults with UC per month were recruited for a large-scale, web-based survey. Participants were asked about their perceptions of UC (often vs. Crohn's disease [CD]), treatment goals, and medication use. Response data were evaluated via descriptive statistics and univariate and multivariable analyses. Gastroenterologists (N = 500) with a mean of 16.5 years (standard deviation, 8.7 years) in practice participated. In comparison to CD, survey respondents perceived UC as being easier to diagnose, having better treatment outcomes, and being associated with later prescribing of biologics. Treatment goals commonly considered to have the greatest importance included quality of life improvement (31.2% of respondents), maintenance of clinical remission (17.4%), and mucosal healing (17.4%). When respondents evaluated the performance of medication classes in achieving these goals, biologics were rated significantly higher than all other classes (P < 0.05). However, the most common drivers for the initiation of biologic therapy were the development of steroid refractoriness (66.8%) and steroid dependency (65.8%). Medication class use by UC severity was generally consistent with the traditional step-up approach to UC therapy, with biologics being used most commonly for severe UC. These results suggest a possible disparity between treatment goals and therapeutic management in UC. An increased awareness of general UC perceptions is an important step toward a better overall understanding of the disease and, ultimately, toward improved management aligned with treatment goals. This study was sponsored by the American Gastroenterological Association (AGA), and the design and conduct of the study as well as article processing charges and the open access fee for this publication were funded by Takeda Pharmaceuticals International, Inc. (TPI).

Biomarkers in mood disorders research: developing new and improved therapeutics

PubMed Central

Niciu, Mark J.; Mathews, Daniel C.; Ionescu, Dawn F.; Richards, Erica M.; Furey, Maura L.; Yuan, Peixiong; Nugent, Allison C.; Henter, Ioline D.; Machado-Vieira, Rodrigo; Zarate, Carlos A.

2015-01-01

Background Recently, surrogate neurobiological biomarkers that correlate with target engagement and therapeutic response have been developed and tested in early phase studies of mood disorders. Objective The identification of biomarkers could help develop personalized psychiatric treatments that may impact public health. Methods These biomarkers, which are associated with clinical response post-treatment, can be directly validated using multimodal approaches including genetic tools, proteomics/metabolomics, peripheral measures, neuroimaging, biostatistical predictors, and clinical predictors. Results To date, early phase biomarker studies have sought to identify measures that can serve as “biosignatures”, or biological patterns of clinical response. These studies have also sought to identify clinical predictors and surrogate outcomes associated with pathophysiological domains consistently described in the National Institute of Mental Health’s (NIMH) new Research Domain Criteria (RDoC). Using the N-methyl-D-aspartate (NMDA) antagonist ketamine as an example, we identified changes in several domains (clinical, cognitive, and neurophysiological) that predicted ketamine’s rapid and sustained antidepressant effects in individuals with treatment-resistant major depressive disorder (MDD) or bipolar depression. Discussion These approaches may ultimately provide clues into the neurobiology of psychiatric disorders and may have enormous impact Backon the development of novel therapeutics. PMID:26082563

ESR1 mutations: Moving towards guiding treatment decision-making in metastatic breast cancer patients.

PubMed

Angus, Lindsay; Beije, Nick; Jager, Agnes; Martens, John W M; Sleijfer, Stefan

2017-01-01

Mutations in the gene coding for the estrogen receptor (ER), ESR1, have been associated with acquired endocrine resistance in patients with ER-positive metastatic breast cancer (MBC). Functional studies revealed that these ESR1 mutations lead to constitutive activity of the ER, meaning that the receptor is active in absence of its ligand estrogen, conferring resistance against several endocrine agents. While recent clinical studies reported that the occurrence of ESR1 mutations is rare in primary breast cancer tumors, these mutations are more frequently observed in metastatic tissue and circulating cell-free DNA of MBC patients pretreated with endocrine therapy. Given the assumed impact that the presence of ESR1 mutations has on outcome to endocrine therapy, assessing ESR1 mutations in MBC patients is likely to be of significant interest to further individualize treatment for MBC patients. Here, ESR1 mutation detection methods and the most relevant pre-clinical and clinical studies on ESR1 mutations regarding endocrine resistance are reviewed, with particular interest in the ultimate goal of guiding treatment decision-making based on ESR1 mutations. Copyright © 2016 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Surgical management of obstructive sleep apnea in children with cerebral palsy.

PubMed

Magardino, T M; Tom, L W

1999-10-01

To evaluate the surgical management of obstructive sleep apnea in children with cerebral palsy. Retrospective review of 27 children with cerebral palsy who underwent surgical treatment for obstructive sleep apnea. Charts were reviewed. Data gathered included primary complaint, coexisting illnesses, initial procedure performed, age at initial surgery, number of days the child was monitored postoperatively in the intensive care unit, notation of postoperative respiratory distress and management, and outcome. Nineteen children underwent adenotonsillectomy for initial treatment of obstructive sleep apnea. Three of these children also had a uvulectomy. Six children had an adenoidectomy alone as their initial procedure. Neither uvulopalatopharyngoplasty nor tracheostomy was performed as an initial procedure. Mean follow-up was 34 months. Seventy-six percent of these children have not required any further surgery. Of the six children who have undergone further surgery, one has required a revision adenoidectomy, and another underwent a tonsillectomy and uvulectomy 2 months after the initial adenoidectomy. Four children ultimately required a tracheotomy. Eighty-four percent of these children were successfully managed without a tracheotomy. We recommend tonsillectomy and/or adenoidectomy for initial surgical treatment of obstructive sleep apnea in children with cerebral palsy.

Cachexia and pancreatic cancer: Are there treatment options?

PubMed Central

Mueller, Tara C; Burmeister, Marc A; Bachmann, Jeannine; Martignoni, Marc E

2014-01-01

Cachexia is frequently described in patients with pancreatic ductal adenocarcinoma (PDAC) and is associated with reduced survival and quality of life. Unfortunately, the therapeutic options of this multi-factorial and complex syndrome are limited. This is due to the fact that, despite extensive preclinical and clinical research, the underlying pathological mechanisms leading to PDAC-associated cachexia are still not fully understood. Furthermore, there is still a lack of consensus on the definition of cachexia, which complicates the standardization of diagnosis and treatment as well as the analysis of the current literature. In order to provide an efficient therapy for cachexia, an early and reliable diagnosis and consistent monitoring is required, which can be challenging especially in obese patients. Although many substances have been tested in clinical and preclinical settings, so far none of them have been proven to have a long-term effect in ameliorating cancer-associated cachexia. However, recent studies have demonstrated that multidimensional therapeutic modalities are able to alleviate pancreatic cancer-associated cachexia and ultimately improve patients’ outcome. In this current review, we propose a stepwise and pragmatic approach to facilitate and standardize the treatment of cachexia in pancreatic cancer patients. This strategy consists of nutritional, dietary, pharmacological, physical and psychological methods. PMID:25071331

NETS1HD: study protocol for development of a core outcome set for use in determining the overall success of Hirschsprung's disease treatment.

PubMed

Allin, Benjamin; Bradnock, Timothy; Kenny, Simon; Walker, Gregor; Knight, Marian

2016-12-07

Use of core outcome sets in research has been proposed as a method for countering the problems caused by heterogeneity of outcome measure reporting. Heterogeneity of outcome measure reporting occurs in Hirschsprung's disease (HD) research and is limiting the development of a robust evidence base to support clinical practice. Candidate outcome measures have been identified through a systematic review. These outcome measures will form the starting point for a three-phase online Delphi process to be carried out in parallel by three panels of experts. Panel 1 is a neonatal panel; panel 2 is a non-neonatal panel; and panel 3 is a lay panel. In round 1, experts will be asked to score the previously identified outcome measures from 1 to 9 based on how important they think the measures are in determining the overall success of their/their child's/their patient's HD. In round 2, experts will be presented with the same list of outcome measures and graphical representations of how their panel scored that outcome in round 1. They will be asked to re-score the outcome measure, taking into account how important other members of their panel felt it to be. In round 3, experts will again be asked to re-score each outcome measure, but this time they will receive a graphical representation of the distribution of scores from all three panels, which they should take into account when re-scoring. Following round 3 of the Delphi process, 40 experts will be invited to attend a face-to-face consensus meeting. Participants will be invited in a purposive manner to obtain balance between the different panels. Results of the Delphi process will be discussed, and outcomes will be re-scored. Outcome measures where >70% of participants at the meeting scored it 7-9 and <15% scored it 1-3 will form the core outcome set. Development of a core outcome set will help to reduce heterogeneity of outcome measure reporting in HD. This will increase the quality of research taking place and ultimately improve care provided to infants with HD.

Standardised outcomes in nephrology - Haemodialysis (SONG-HD): study protocol for establishing a core outcome set in haemodialysis.

PubMed

Tong, Allison; Manns, Braden; Hemmelgarn, Brenda; Wheeler, David C; Tugwell, Peter; Winkelmayer, Wolfgang C; van Biesen, Wim; Crowe, Sally; Kerr, Peter G; Polkinghorne, Kevan R; Howard, Kirsten; Pollock, Carol; Hawley, Carmel M; Johnson, David W; McDonald, Stephen P; Gallagher, Martin P; Urquhart-Secord, Rachel; Craig, Jonathan C

2015-08-19

Chronic kidney disease is a significant contributor to mortality and morbidity worldwide, and the number of people who require dialysis or transplantation continues to increase. People on dialysis are 15 times more likely to die than the general population. Dialysis is also costly, intrusive, and time-consuming and imposes an enormous burden on patients and their families. This escalating problem has spurred a proliferation of trials in dialysis, yet health and quality of life remain poor. The reasons for this are complex and varied but are attributable in part to problems in the design and reporting of studies, particularly outcome selection. Problems related to outcomes include use of unvalidated surrogates, outcomes of little or no relevance to patients, highly variable outcome selection limiting comparability across studies, and bias in reporting outcomes. The aim of the Standardised Outcomes in Nephrology-Haemodialysis (SONG-HD) study is to establish a core outcome set for haemodialysis trials, to improve the quality of reporting, and the relevance of trials conducted in people on haemodialysis. SONG-HD is a five-phase project that includes the following: a systematic review to identify outcomes that have been reported in haemodialysis systematic reviews and trials; nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choices; qualitative stakeholder interviews with patients, caregivers, clinicians, researchers, and policy makers to elicit individual values and perspectives on outcomes for haemodialysis trials; a three-round Delphi survey with stakeholder groups to distil and generate a prioritised list of core outcomes; and a consensus workshop to establish a core outcome set for haemodialysis trials. Establishing a core outcome set to be consistently measured and reported in haemodialysis trials will improve the integrity, transparency, usability, and contribution of research relevant to patients requiring haemodialysis; ensure that outcomes of relevance to all stakeholders are consistently reported across trials; and mitigate against outcome reporting bias. Ultimately, patients will be more protected from potential harm, patients and clinicians will be better able to make informed decisions about treatment, and researchers and policy makers will be more able to maximise the value of research to the public.

Decision making in pediatric oncology: Views of parents and physicians in two European countries.

PubMed

Badarau, Domnita O; Ruhe, Katharina; Kühne, Thomas; De Clercq, Eva; Colita, Anca; Elger, Bernice S; Wangmo, Tenzin

2017-01-01

Decision making is a highly complex task when providing care for seriously ill children. Physicians, parents, and children face many challenges when identifying and selecting from available treatment options. This qualitative interview study explored decision-making processes for children with cancer at different stages in their treatment in Switzerland and Romania. Thematic analysis of interviews conducted with parents and oncologists identified decision making as a heterogeneous process in both countries. Various decisions were made based on availability and reasonableness of care options. In most cases, at the time of diagnosis, parents were confronted with a "choiceless choice"-that is, there was only one viable option (a standard protocol), and physicians took the lead in making decisions significant for health outcomes. Parents' and sometimes children's role increased during treatment when they had to make decisions regarding research participation and aggressive therapy or palliative care. Framing these results within the previously described Decisional Priority in Pediatric Oncology Model (DPM) highlights family's more prominent position when making elective decisions regarding quality-of-life or medical procedures, which had little effect on health outcomes. The interdependency between oncologists, parents, and children is always present. Communication, sharing of information, and engaging in discussions about preferences, values, and ultimately care goals should be decision making's foundation. Patient participation in these processes was reported as sometimes limited, but parents and oncologists should continue to probe patients' abilities and desire to be involved in decision making. Future research should expand the DPM and explore how decisional priority and authority can be shared by oncologists with parents and even patients.

Unattractive consequences: litigation from facial dermabrasion and chemical peels.

PubMed

Svider, Peter F; Jiron, Jose; Zuliani, Giancarlo; Shkoukani, Mahdi A; Folbe, Adam J; Carron, Michael

2014-11-01

Facial dermabrasion and chemical peel are common cosmetic procedures that are generally safe yet do possess inherent risks. The patient's expectations, formed well in advance of treatment, strongly correlate with overall satisfaction. The authors reviewed and analyzed litigation related to the performance of facial dermabrasion and chemical peel. The authors searched the WestlawNext legal database for relevant litigation and examined factors such as allegations raised, patient demographics, defendant specialties, final outcomes, and payments. Proceedings from 25 cases were analyzed, involving 22 female and 2 male plaintiffs; in 1 case, sex was not specified. Sixteen cases (64%) resulted in a decision for the defendant and 9 (36%) were resolved with payments. The median difference between out-of-court settlements (median, $940 000) and jury-awarded damages (median, $535 000) was not statistically significant. Factors raised in litigation included poor cosmetic outcome (80%), alleged intratreatment negligence (68%), permanent injury (64%), informed-consent deficits (60%), emotional/psychological injury (44%), posttreatment negligence (32%), and the need for additional treatment/surgery (32%). Out-of-court settlements and jury-awarded damages were considerable in cases where physicians practicing various (or multiple) specialties were named as defendants. These findings emphasize the need for physicians to thoroughly document potential complications prior to treatment, during the informed-consent process. Additionally, general considerations should be taken into account, such as patient expectations and the potential need for other procedures, which may enhance pretreatment communication and ultimately minimize liability. Finally, it is important to stress that physicians may be held liable for procedures performed by nonphysician ancillary staff. © 2014 The American Society for Aesthetic Plastic Surgery, Inc.

The role of narrative medicine in the management of joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type.

PubMed

Knight, Isobel

2015-03-01

Joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT) is a hereditary connective tissue disorder affecting every bodily system. It is largely underdiagnosed by many practitioners, with the result of a considerable delay in diagnosis and, consequently, in the onset of adequate management schedule and treatment. Patients may also experience to be misbelieved, erroneously considered affected by a psychiatric or psychosomatic disorders, and rejected by the medical profession, which can lead to feelings of anger and resentment. Patient journeys are often long and complicated, but if doctors allowed the patient time to tell the full story, and were more prepared to think holistically, there may be a far more positive outcome. Here, the patients' perspective is presented with a narrative medicine approach, illustrating the tri-dimensional experience of a JHS/EDS-HT patient, who is also a Bowen Practitioner and a medical writer/educator. Narrative medicine would be invaluable in working with JHS/EDS-HT so that the patient can tell the story, and offer the practitioner a whole picture of her/his suffering and, often, the key for understanding the cause(s). Once this has been achieved, it might be possible to build upon a more positive and therapeutic dialogue which would result in better treatment and more effective management. It is also important for doctors to communicate with JHS/EDS-HT experts who will ultimately improve the patient journey and treatment outcomes of such a complex connective tissue disorder. © 2015 Wiley Periodicals, Inc.

Future delivery of the Drug Interventions Programme: do the benefits justify the costs?

PubMed

Osborne, Andrew

2013-10-01

The Drug Interventions Programme is an initiative employed by the Home Office in 2003 to integrate the Criminal Justice System with drug treatment services with the ultimate goal of reducing acquisitive crime. Drug Action Teams employ this scheme on a local level by providing a broad range of services for misusers in the community. Although much attention has been placed on societal gains, there is an added benefit in improving the health outcomes of those referred. Opioid replacement therapy decreases illicit heroin use, reduces mortality and maintains contact with misusers allowing for psychosocial intervention. The Drug Interventions Programme provides direct access to such treatment in an otherwise high-risk and disengaged population. Anecdotal evidence of the programme is positive; with improved mental and physical health in offenders and a reduction in hospital admissions. However, monitoring health outcomes in offenders is challenging as long-term follow-up is difficult, poor compliance is an issue and coercive referrals may introduce a reporting bias. Drug Action Team services are cost-effective due a lower consumption of health and social care and reduced offending levels. The Drug Interventions Programme has been successful in maintaining offenders in treatment and the Home Office claim its role in reducing crime is cost-saving. Future delivery of the initiative is at risk due to spending reductions, competing interests and a focus towards payment by results. Opposition to future implementation of the Drug Interventions Programme must be met with evidence for its effectiveness in order to ensure its continued investment. Copyright © 2013 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

The Traumatic Brain Injury Endpoints Development (TED) Initiative: Progress on a Public-Private Regulatory Collaboration to Accelerate Diagnosis and Treatment of Traumatic Brain Injury.

PubMed

Manley, Geoffrey T; MacDonald, Christine L; Markowitz, Amy; Stephenson, Diane; Robbins, Ann; Gardner, Raquel C; Winkler, Ethan A; Bodien, Yelena; Taylor, Sabrina; Yue, John K; Kannan, Lakshmi; Kumar, Allison; McCrea, Michael; Wang, Kevin K W

2017-03-31

The Traumatic Brain Injury Endpoints Development (TED) Initiative is a 5-year, Department of Defense (DoD) funded project that is working toward the ultimate goal of developing better designed clinical trials, leading to more precise diagnosis, and effective treatments for traumatic brain injury (TBI). TED is comprised of leading academic clinician-scientists, along with innovative industry leaders in biotechnology and imaging technology, patient advocacy organizations, and philanthropists, working collaboratively with regulatory authorities, specifically the US Food and Drug Administration (FDA). The goals of the TED Initiative are to gain consensus and validation of TBI clinical outcome assessment measures and biomarkers for endorsement by global regulatory agencies for use in drug and device development processes. This manuscript summarizes the Initiative's Stage 1 progress over the first 18 months, including intensive engagement with a number of FDA divisions responsible for review and validation of biomarkers and clinical outcome assessments, progression into the prequalification phase of FDA's Medical Device Development Tool program for a candidate set of neuroimaging biomarkers, and receipt of FDA's Recognition of Research Importance Letter regarding TBI. Other signal achievements relate to the creation of the TED Metadataset, harmonizing study measures across eight major TBI studies, and the leadership role played by TED investigators in the conversion of the NINDS TBI Common Data Elements (CDEs) to Clinical Data Interchange Standards Consortium (CDISC) standards. This paper frames both the near-term expectations and the Initiative's long-term vision to accelerate approval of treatments for patients affected by TBI in urgent need of effective therapies.

Degenerative meniscus: Pathogenesis, diagnosis, and treatment options

PubMed Central

Howell, Richard; Kumar, Neil S; Patel, Nimit; Tom, James

2014-01-01

The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well. PMID:25405088

Secondary Analysis and Integration of Existing Data to Elucidate the Genetic Architecture of Cancer Risk and Related Outcomes, R21 | Informatics Technology for Cancer Research (ITCR)

Cancer.gov

This funding opportunity announcement (FOA) encourages applications that propose to conduct secondary data analysis and integration of existing datasets and database resources, with the ultimate aim to elucidate the genetic architecture of cancer risk and related outcomes. The goal of this initiative is to address key scientific questions relevant to cancer epidemiology by supporting the analysis of existing genetic or genomic datasets, possibly in combination with environmental, outcomes, behavioral, lifestyle, and molecular profiles data.

Secondary Analysis and Integration of Existing Data to Elucidate the Genetic Architecture of Cancer Risk and Related Outcomes, R01 | Informatics Technology for Cancer Research (ITCR)

Cancer.gov

This funding opportunity announcement (FOA) encourages applications that propose to conduct secondary data analysis and integration of existing datasets and database resources, with the ultimate aim to elucidate the genetic architecture of cancer risk and related outcomes. The goal of this initiative is to address key scientific questions relevant to cancer epidemiology by supporting the analysis of existing genetic or genomic datasets, possibly in combination with environmental, outcomes, behavioral, lifestyle, and molecular profiles data.

Virtual reality in radiology: virtual intervention

NASA Astrophysics Data System (ADS)

Harreld, Michael R.; Valentino, Daniel J.; Duckwiler, Gary R.; Lufkin, Robert B.; Karplus, Walter J.

1995-04-01

Intracranial aneurysms are the primary cause of non-traumatic subarachnoid hemorrhage. Morbidity and mortality remain high even with current endovascular intervention techniques. It is presently impossible to identify which aneurysms will grow and rupture, however hemodynamics are thought to play an important role in aneurysm development. With this in mind, we have simulated blood flow in laboratory animals using three dimensional computational fluid dynamics software. The data output from these simulations is three dimensional, complex and transient. Visualization of 3D flow structures with standard 2D display is cumbersome, and may be better performed using a virtual reality system. We are developing a VR-based system for visualization of the computed blood flow and stress fields. This paper presents the progress to date and future plans for our clinical VR-based intervention simulator. The ultimate goal is to develop a software system that will be able to accurately model an aneurysm detected on clinical angiography, visualize this model in virtual reality, predict its future behavior, and give insight into the type of treatment necessary. An associated database will give historical and outcome information on prior aneurysms (including dynamic, structural, and categorical data) that will be matched to any current case, and assist in treatment planning (e.g., natural history vs. treatment risk, surgical vs. endovascular treatment risks, cure prediction, complication rates).

The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner.

PubMed

Nadler, Scott F; Weingand, Kurt; Kruse, Roger J

2004-07-01

Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries. Clinicians treating these conditions should be aware of current research findings regarding these modalities, because their choice of modality may affect the ultimate outcome of the patient being treated. Through a better understanding of these modalities, clinicians can optimize their present treatment strategies. Although cold and hot treatment modalities both decrease pain and muscle spasm, they have opposite effects on tissue metabolism, blood flow, inflammation, edema, and connective tissue extensibility. Cryotherapy decreases these effects while thermotherapy increases them. Continuous low-level cryotherapy and thermotherapy are newer concepts in therapeutic modalities. Both modalities provide significant pain relief with a low side-effect profile. Contrast therapy, which alternates between hot and cold treatment modalities, provides no additional therapeutic benefits compared with cryotherapy or thermotherapy alone. Complications of cryotherapy include nerve damage, frostbite, Raynaud's phenomenon, cold-induced urticaria, and slowed wound healing. With thermotherapy, skin burns may occur, especially in patients with diabetes mellitus, multiple sclerosis, poor circulation, and spinal cord injuries. In individuals with rheumatoid arthritis, deep-heating modalities should be used with caution because increased inflammation may occur. Whirlpool and other types of hydrotherapy have caused infections of the skin, urogenital, and pulmonary systems. Additionally, ultrasound should not be used in patients with joint prostheses.

Predicting the early therapeutic alliance in the treatment of drug misuse.

PubMed

Meier, Petra S; Donmall, Michael C; Barrowclough, Christine; McElduff, Patrick; Heller, Richard F

2005-04-01

To predict the early therapeutic alliance from a range of potentially relevant factors, including clients' social relationships, motivation and psychological resources, and counsellors' professional experience and ex-user status. The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and client and counsellor ratings of the alliance were obtained during weeks 1, 2 and 3. The intake assessment battery included scales on psychological wellbeing, treatment motivation, coping strategies and attachment style. Client and counsellor versions of the Working Alliance Inventory (WAI-S) were used for weekly alliance measurement. Hierarchical linear models were used to examine the relationship between alliance and predictor variables. Clients who had better motivation, coping strategies, social support and a secure attachment style were more likely to develop good alliances. Findings with regard to counsellor characteristics were not clear cut: clients rated their relationships with ex-user counsellors, experienced counsellors and male counsellors as better, but more experienced counsellors rated their alliances as worse. The findings offer important leads as to what interventions might improve the therapeutic alliance. Further work will need to establish whether the therapeutic alliance and ultimately treatment outcomes can be enhanced by working on improving clients' motivation and psychosocial resources.

Mechanical ventilation in acute respiratory distress syndrome: The open lung revisited.

PubMed

Amado-Rodríguez, L; Del Busto, C; García-Prieto, E; Albaiceta, G M

2017-12-01

Acute respiratory distress syndrome (ARDS) is still related to high mortality and morbidity rates. Most patients with ARDS will require ventilatory support. This treatment has a direct impact upon patient outcome and is associated to major side effects. In this regard, ventilator-associated lung injury (VALI) is the main concern when this technique is used. The ultimate mechanisms of VALI and its management are under constant evolution. The present review describes the classical mechanisms of VALI and how they have evolved with recent findings from physiopathological and clinical studies, with the aim of analyzing the clinical implications derived from them. Lastly, a series of knowledge-based recommendations are proposed that can be helpful for the ventilator assisted management of ARDS at the patient bedside. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

Evaluation of the adhesion on the nano-scaled polymeric film systems.

PubMed

Park, Tae Sung; Park, Ik Keun; Yoshida, Sanichiro

2017-04-01

We applied scanning acoustic microscopy known as the V(z) curve technique to photoresist thin-film systems for the evaluation of the adhesive strength at the film-substrate interface. Through the measurement of the SAW (Surface Acoustic Wave) velocity, the V(z) curve analysis allows us to quantify the stiffness of the film-substrate interface. In addition, we conducted a nano-scratch test to quantify the ultimate strength of the adhesion through the evaluation of the critical load. To vary the adhesive conditions, we prepared thin-film specimens with three different types of pre-coating surface treatments, i.e., oxygen-plasma bombardment, HMDS (Hexametyldisilazane) treatment and untreated. The magnitudes of the quantified stiffness and ultimate strength are found consistent with each other for all the specimens tested, indicating that the pre-coating surface treatment can strengthen both the stiffness and ultimate strength of the adhesion. The results of this study demonstrate the usefulness of the V(Z) analysis as a nondestructive method to evaluate the adhesion strength of nano-structured thin-film systems. Copyright © 2017 Elsevier B.V. All rights reserved.

Treatment Fidelity: Its Importance and Reported Frequency in Aphasia Treatment Studies

ERIC Educational Resources Information Center

Hinckley, Jacqueline J.; Douglas, Natalie F.

2013-01-01

Purpose: Treatment fidelity is a measure of the reliability of the administration of an intervention in a treatment study. It is an important aspect of the validity of a research study, and it has implications for the ultimate implementation of evidence-supported interventions in typical clinical settings. Method: Aphasia treatment studies…

A two-way street: bridging implementation science and cultural adaptations of mental health treatments

PubMed Central

2013-01-01

Background Racial and ethnic disparities in the United States exist along the entire continuum of mental health care, from access and use of services to the quality and outcomes of care. Efforts to address these inequities in mental health care have focused on adapting evidence-based treatments to clients’ diverse cultural backgrounds. Yet, like many evidence-based treatments, culturally adapted interventions remain largely unused in usual care settings. We propose that a viable avenue to address this critical question is to create a dialogue between the fields of implementation science and cultural adaptation. In this paper, we discuss how integrating these two fields can make significant contributions to reducing racial and ethnic disparities in mental health care. Discussion The use of cultural adaptation models in implementation science can deepen the explicit attention to culture, particularly at the client and provider levels, in implementation studies making evidence-based treatments more responsive to the needs and preferences of diverse populations. The integration of both fields can help clarify and specify what to adapt in order to achieve optimal balance between adaptation and fidelity, and address important implementation outcomes (e.g., acceptability, appropriateness). A dialogue between both fields can help clarify the knowledge, skills and roles of who should facilitate the process of implementation, particularly when cultural adaptations are needed. The ecological perspective of implementation science provides an expanded lens to examine how contextual factors impact how treatments (adapted or not) are ultimately used and sustained in usual care settings. Integrating both fields can also help specify when in the implementation process adaptations may be considered in order to enhance the adoption and sustainability of evidence-based treatments. Summary Implementation science and cultural adaptation bring valuable insights and methods to how and to what extent treatments and/or context should be customized to enhance the implementation of evidence-based treatments across settings and populations. Developing a two-way street between these two fields can provide a better avenue for moving the best available treatments into practice and for helping to reduce racial and ethnic disparities in mental health care. PMID:23958445

Technology and surgery. Dilemma of the gimmick, true advances, and cost effectiveness.

PubMed

Traverso, L W

1996-02-01

The key to evaluating a procedure in regard to a true advance versus a gimmick is to determine its value. This can be done only by physicians cognizant of a disease process. The value is determined by assessing a procedure's utilization, outcomes, and costs. Utilization allows early treatment and avoids neglected disease. Therefore, the appropriateness of the utilization can be determined only by an outcome study. An outcome study is another term for quality assessment. Outcomes deal with morbidity, mortality, and also the long- and short-term effects of the procedure on the disease. Overall, an increase of quality in a global perspective decreases the costs of the procedure to the health care community. Costs must remain secondary to outcomes. An attempt to decrease costs directly is a maneuver that, when applied by nonmedical individuals, will most likely decrease quality. When the quality can be maintained (as assessed only by a practitioner), then a decrease in global costs will increase value. The concept of increasing value by increasing quality without an attempt to decrease costs is a very important principle that the health care system must learn in our ever-challenging medical environment. Is a new procedure a gimmick or a true advance? The decision is made jointly by the stakeholders in our health care system--the patient, provider, payer, employer, and industry. If the procedure does not receive negative votes, then its adoption is almost assured. Comparing two procedures through these perspectives ultimately allows us to determine the potential for new procedures. A procedure not adopted through this method could be called a gimmick.

Involving Latina/o parents in patient-centered outcomes research: Contributions to research study design, implementation and outcomes.

PubMed

Pérez Jolles, Mónica; Martinez, Maria; Garcia, San Juanita; Stein, Gabriela L; Thomas, Kathleen C

2017-10-01

Comparative effectiveness research (CER) is supported by policymakers as a way to provide service providers and patients with evidence-based information to make better health-care decisions and ultimately improve services for patients. However, Latina/o patients are rarely involved as study advisors, and there is a lack of documentation on how their voices contribute to the research process when they are included as collaborators. The purpose of this article was to contribute to the literature by presenting concrete contributions of Latina/o parent involvement to study design, implementation and outcomes in the context of a CER study called Padres Efectivos (Parent Activation). Researchers facilitated a collaborative relationship with parents by establishing a mentor parent group. The contributions of parent involvement in the following stages of the research process are described: (i) proposal development, (ii) implementation of protocols, (iii) analysis plan and (iv) dissemination of results. Mentor parents' contributions helped tailor the content of the intervention to their needs during proposal, increased recruitment, validated the main outcome measure and added two important outcome measures, emphasized the importance of controlling for novice treatment status and developed innovative dissemination strategies. Mentor parents' guidance to the researchers has contributed to reaching recruitment goals, strengthened the study protocol, expanded findings, supported broad ownership of study implications and enriched the overall study data collection efforts. These findings can inform future research efforts seeking an active Latino parent collaboration and the timely incorporation of parent voices in each phase of the research process. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

Probabilistic metrology or how some measurement outcomes render ultra-precise estimates

NASA Astrophysics Data System (ADS)

Calsamiglia, J.; Gendra, B.; Muñoz-Tapia, R.; Bagan, E.

2016-10-01

We show on theoretical grounds that, even in the presence of noise, probabilistic measurement strategies (which have a certain probability of failure or abstention) can provide, upon a heralded successful outcome, estimates with a precision that exceeds the deterministic bounds for the average precision. This establishes a new ultimate bound on the phase estimation precision of particular measurement outcomes (or sequence of outcomes). For probe systems subject to local dephasing, we quantify such precision limit as a function of the probability of failure that can be tolerated. Our results show that the possibility of abstaining can set back the detrimental effects of noise.

Elastin Is Differentially Regulated by Pressure Therapy in a Porcine Model of Hypertrophic Scar.

PubMed

Carney, Bonnie C; Liu, Zekun; Alkhalil, Abdulnaser; Travis, Taryn E; Ramella-Roman, Jessica; Moffatt, Lauren T; Shupp, Jeffrey W

Beneficial effects of pressure therapy for hypertrophic scars have been reported, but the mechanisms of action are not fully understood. This study evaluated elastin and its contribution to scar pliability. The relationship between changes in Vancouver Scar Scale (VSS) scores of pressure-treated scars and differential regulation of elastin was assessed. Hypertrophic scars were created and assessed weekly using VSS and biopsy procurement. Pressure treatment began on day 70 postinjury. Treated scars were compared with untreated shams. Treatment lasted 2 weeks, through day 84, and scars were assessed weekly through day 126. Transcript and protein levels of elastin were quantified. Pressure treatment resulted in lower VSS scores compared with sham-treated scars. Pliability (VSSP) was a key contributor to this difference. At day 70 pretreatment, VSSP = 2. Without treatment, sham-treated scars became less pliable, while pressure-treated scars became more pliable. The percentage of elastin in scars at day 70 was higher than in uninjured skin. Following treatment, the percentage of elastin increased and continued to increase through day 126. Untreated sham scars did not show a similar increase. Quantification of Verhoeff-Van Gieson staining corroborated the findings and immunofluorescence revealed the alignment of elastin fibers. Pressure treatment results in increased protein level expression of elastin compared with sham-untreated scars. These findings further characterize the extracellular matrix's response to the application of pressure as a scar treatment, which will contribute to the refinement of rehabilitation practices and ultimately improvements in functional and psychosocial outcomes for patients.

7 CFR 4274.343 - Application.

Code of Federal Regulations, 2010 CFR

2010-01-01

... charges it will assess the ultimate recipients; (v) Demonstrate to Agency satisfaction that the... organizations; (vi) Provide evidence to Agency satisfaction that the intermediary has a proven record of... intermediary's program. Outcomes should be expressed in quantitative or observable terms such as jobs created...

7 CFR 4274.343 - Application.

Code of Federal Regulations, 2011 CFR

2011-01-01

... charges it will assess the ultimate recipients; (v) Demonstrate to Agency satisfaction that the... organizations; (vi) Provide evidence to Agency satisfaction that the intermediary has a proven record of... intermediary's program. Outcomes should be expressed in quantitative or observable terms such as jobs created...

A systematic review of undisplaced femoral neck fracture treatments for patients over 65 years of age, with a focus on union rates and avascular necrosis.

PubMed

Xu, Dan-Feng; Bi, Fang-Gang; Ma, Chi-Yuan; Wen, Zheng-Fa; Cai, Xun-Zi

2017-02-10

It remains unclear whether conservative treatment should be used to treat the common undisplaced femoral neck fractures that develop in the elderly. Herein, we systematically review the rates of union and avascular necrosis after conservative and surgical treatment of undisplaced femoral neck fractures. We searched the EMBASE, PubMed, OVID, Cochrane Library, Web of Science, and Scopus databases for randomized controlled trials or observational studies that assessed the outcomes of conservative or surgical treatments of undisplaced femoral neck fractures. No language or publication year limitation was imposed. Statistical analyses were performed with the aid of the chi-squared test. We evaluated the quality of each publication and the risk of bias. Twenty-nine studies involving 5071 patients were ultimately included; 1120 patients were treated conservatively and 3951 surgically. The union rates were 68.8% (642/933) and 92.6% (635/686) in the former and latter groups, respectively (p < 0.001). The avascular necrosis rate in the conservatively treated group was 10.3% (39/380), while it was 7.7% (159/2074) in the surgically treated group (p = 0.09). Surgery to treat undisplaced femoral neck fractures was associated with a higher union rate and a tendency toward less avascular necrosis than conservative treatment.

Injection of Unicameral Bone Cysts with Bone Marrow Aspirate and Demineralized Bone Matrix Avoids Open Curettage and Bone Grafting in a Retrospective Cohort

PubMed Central

Gundle, Kenneth R.; Bhatt, Etasha M.; Punt, Stephanie E.; Bompadre, Viviana; Conrad, Ernest U.

2017-01-01

Background: Many treatment options exist for unicameral bone cysts (UBC), without clear evidence of superiority. Meta-analyses have been limited by small numbers of patients in specific anatomic and treatment subgroups. The purpose of this study was to report the outcomes of injecting bone marrow aspirate and demineralized bone matrix (BMA/DBM) for the treatment of proximal humerus UBC. Methods: Fifty-one patients with proximal humerus lesions treated by BMA/DBM injection were retrospectively reviewed from a single academic medical center. Results: The mean number of injections performed per patient was 2.14 (range 1-5). Eleven patients underwent only one injection (22%), an additional 19 patients completed treatment after two injections (37%), four patients healed after three injections (8%), and one patient healed after four injections (2%). The cumulative success rate of serial BMA/DBM injections was 22% (11/51), 58% (30/51), 67% (34/51), and 69% (35/51). Eleven patients (22%) ultimately underwent open curettage and bone grafting, and five patients (10%) were treated with injection of calcium phosphate bone substitute. Conclusion: A BMA/DBM injection strategy avoided an open procedure in 78% of patients with a proximal humerus UBC. The majority of patients underwent at least 2 injection treatments. Level of Evidence: Level IV retrospective cohort study. PMID:28694887

Removable esophageal stents have poor efficacy for the treatment of refractory benign esophageal strictures (RBES).

PubMed

Dan, D T; Gannavarapu, B; Lee, J G; Chang, K; Muthusamy, V R

2014-08-01

With the recent availability of removable esophageal stents, endoscopic stenting has been utilized to treat refractory benign esophageal strictures (RBES). The objective of this study was to review the feasibility and effectiveness of removable esophageal stents to treat RBES. Patients who received removable esophageal stents for the treatment of RBES at the institution between 2004-2010 using its stent implantation logs and endoscopic database were retrospectively identified. Patient demographics, stricture etiology and location, stent and procedure characteristics, and clinical outcomes were obtained. Twenty-five patients with a mean age of 70 (72% male) underwent initial stent placement; 24 were successful. Overall clinical success was achieved in five of the 19 patients (26%) ultimately undergoing stent removal. RBES etiologies included anastomotic (13), radiation (5), peptic (3), chemotherapy (1), scleroderma (1), and unknown (2). Alimaxx-E (Merit-Endotek, South Jordan, UT, USA) stents were placed in 20 patients and Polyflex (Boston Scientific, Natick, MA, USA) stents were used in five patients. Immediate complications included failed deployment (1) and chest pain (7). Five patients died prior to stent removal. Stent migration was found in 53% (10/19) of patients who underwent stent removal: nine required additional therapy and one had symptom resolution. Out of the nine patients without stent migration, five required additional therapy and four had symptom resolution. Although placement of removable esophageal stents for RBES is technically feasible, it is frequently complicated by stent migration and chest pain. In addition, few patients achieved long-term stricture resolution after initial stenting. In this study, most patients ultimately required repeated stenting and/or dilations to maintain relief of dysphagia. © 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Simultaneous improvement and worsening of vitiligo lesions during the course of NB-UVB phototherapy; vitiligo may not act as one unit.

PubMed

Anbar, Tag; Abdel-Rahman, Amal; Hegazy, Rehab; El-Khayyat, Mohamed; Ragaie, Maha

2017-01-01

Re-pigmentation and stabilization are the two ultimate goals of any re-pigmenting plan designed for vitiligo management. Furthermore, whether the improvement of some vitiligo lesions could be considered a guarantee for a similar response and/or stabilization of the rest of the lesions or not, remains to be clarified. To evaluate the behavior of non-segmental vitiligo (NSV), while on narrow band-ultraviolet B (NB-UVB) phototherapy. 25 patients with stable generalized NSV were included and received NB-UVB twice weekly. For the sake of ensuring accuracy of follow up, up to four lesions were randomly chosen in each patient and regularly measured using the point counting technique. The over-all point counting technique of all included patients showed a significant reduction (18.5 ± 8.4 cm 2 to 8.2± 3.1 cm 2 ) after 6 months of therapy (p < .001). Nine patients (36%), showed mixed response in the different lesions. Improvement was documented in some lesions, while other lesions showed no response or even worsening. No significant correlations were detected between the behavior of vitiligo during NB-UVB and any of the demographic or clinical data of the patients. NB-UVB is a pillar in the management of vitiligo, however close follow-up of the patient as a whole and his lesions, by both subjective and objective measures are mandatory to detect activity as early as possible, as vitiligo at many times may not act as one unit. This early detection of activity and the subsequent change in the treatment policy may ultimately change the final outcome of treatment. © 2016 Wiley Periodicals, Inc.

The Future is Now – Biologics for Non-Infectious Pediatric Anterior Uveitis

PubMed Central

Lerman, Melissa A.; Rabinovich, C. Egla

2015-01-01

Anterior uveitis (AU), inflammation of the iris, choroid, or ciliary body, can cause significant eye morbidity, including visual loss. In the pediatric age group, the most common underlying diagnosis for AU is juvenile idiopathic associated uveitis and idiopathic AU, which are the focus of this paper. AU is often resistant to medications such as topical corticosteroids and methotrexate. In the past 15 years, biologic agents (biologics) have transformed treatment. In this review, we discuss those in widespread use and those with more theoretical applications for anterior uveitis. Tumor Necrosis Factor alpha inhibitors (anti-TNFα) have been available the longest and are used widely to treat pediatric uveitis. The effects of anti-TNFα in children are described mostly in small retrospective case series. Together, the literature suggests that the majority of children treated with anti-TNFα achieve decreased uveitis activity and reduce corticosteroid burden. However, many will have disease flares even on treatment. Only a few small studies directly compare outcomes between alternate anti-TNFα (infliximab and adalimumab). The use of different uveitis grading systems, inclusion criteria, and outcome measures, makes cross-study comparisons difficult. Whether the achievement and maintenance of inactive disease occurs more frequently with certain anti-TNFα remains controversial. Newer biologics that modulate the immune system differently (e.g., interfere with TH17 activation through IL-17a and IL-6 blockade, limit T lymphocyte costimulation, and deplete B lymphocytes), have shown promise for uveitis. Studies of these agents are small and include mostly adults. Additional biologics are also being explored to treat uveitis. With their advent, we are hopeful that outcomes will ultimately be improved for children with AU. With many biologics available, much work remains to identify the optimal inflammatory pathway to target in AU. PMID:25893479

The Future Is Now: Biologics for Non-Infectious Pediatric Anterior Uveitis.

PubMed

Lerman, Melissa A; Rabinovich, C Egla

2015-08-01

Anterior uveitis (AU), inflammation of the iris, choroid or ciliary body, can cause significant eye morbidity, including visual loss. In the pediatric age group, the most common underlying diagnosis for AU is juvenile idiopathic associated uveitis and idiopathic AU, which are the focus of this paper. AU is often resistant to medications such as topical corticosteroids and methotrexate. In the past 15 years, biologic agents (biologics) have transformed treatment. In this review, we discuss those in widespread use and those with more theoretical applications for anterior uveitis. Tumor necrosis factor alpha inhibitors (anti-TNFα) have been available the longest and are used widely to treat pediatric uveitis. The effects of anti-TNFα in children are described mostly in small retrospective case series. Together, the literature suggests that the majority of children treated with anti-TNFα achieve decreased uveitis activity and reduced corticosteroid burden. However, many will have disease flares even on treatment. Only a few small studies directly compare outcomes between alternate anti-TNFα (infliximab and adalimumab). The use of different uveitis grading systems, inclusion criteria, and outcome measures makes cross-study comparisons difficult. Whether the achievement and maintenance of inactive disease occurs more frequently with certain anti-TNFα remains controversial. Newer biologics that modulate the immune system differently (e.g., interfere with Th17 activation through IL-17a and IL-6 blockade, limit T lymphocyte costimulation, and deplete B lymphocytes), have shown promise for uveitis. Studies of these agents are small and include mostly adults. Additional biologics are also being explored to treat uveitis. With their advent, we are hopeful that outcomes will ultimately be improved for children with AU. With many biologics available, much work remains to identify the optimal inflammatory pathway to target in AU.

Assisted reproductive technology: an overview of Cochrane Reviews.

PubMed

Farquhar, Cindy; Rishworth, Josephine R; Brown, Julie; Nelen, Willianne L D M; Marjoribanks, Jane

2015-07-15

As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART). Published Cochrane systematic reviews of couples undergoing ART (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The outcomes of the overview were live birth (primary outcome), clinical pregnancy, multiple pregnancy, miscarriage and ovarian hyperstimulation syndrome (secondary outcomes). Studies of intrauterine insemination and ovulation induction were excluded.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed by using the AMSTAR tool. Reviews were organised by their relevance to specific stages in the ART cycle. Their findings were summarised in the text and data for each outcome were reported in 'Additional tables'. Fifty-nine systematic reviews published in The Cochrane Library up to July 2015 were included. All were high quality. Thirty-two reviews identified interventions that were effective (n = 19) or promising (n = 13), 14 reviews identified interventions that were either ineffective (n = 2) or possibly ineffective (n = 12), and 13 reviews were unable to draw conclusions due to lack of evidence.An additional 11 protocols and five titles were identified for future inclusion in this overview. This overview provides the most up to date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Using the best available evidence to optimise outcomes is best practice. The evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, in order to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation and ovarian hyperstimulation syndrome.

Assisted reproductive technology: an overview of Cochrane reviews.

PubMed

Farquhar, Cindy; Rishworth, Josephine R; Brown, Julie; Nelen, Willianne L D M; Marjoribanks, Jane

2014-12-23

As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART). Published Cochrane systematic reviews of couples undergoing ART (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The outcomes of the overview were live birth (primary outcome), clinical pregnancy, multiple pregnancy, miscarriage and ovarian hyperstimulation syndrome (secondary outcomes). Studies of intrauterine insemination and ovulation induction were excluded.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed by using the AMSTAR tool. Reviews were organised by their relevance to specific stages in the ART cycle. Their findings were summarised in the text and data for each outcome were reported in 'Additional tables'. Fifty-eight systematic reviews published in The Cochrane Library were included. All were high quality. Thirty-two reviews identified interventions that were effective (n = 19) or promising (n = 13), 14 reviews identified interventions that were either ineffective (n = 3) or possibly ineffective (n=11), and 12 reviews were unable to draw conclusions due to lack of evidence.An additional 11 protocols and one title were identified for future inclusion in this overview. This overview provides the most up to date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Using the best available evidence to optimise outcomes is best practice. The evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, in order to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation and ovarian hyperstimulation syndrome.

Assisted reproductive technology: an overview of Cochrane Reviews.

PubMed

Farquhar, Cindy; Rishworth, Josephine R; Brown, Julie; Nelen, Willianne L D M; Marjoribanks, Jane

2013-08-22

As many as one in six couples will encounter problems with fertility, defined as failure to achieve a clinical pregnancy after regular intercourse for 12 months. Increasingly, couples are turning to assisted reproductive technology (ART) for help with conceiving and ultimately giving birth to a healthy live baby of their own. Fertility treatments are complex, and each ART cycle consists of several steps. If one of the steps is incorrectly applied, the stakes are high as conception may not occur. With this in mind, it is important that each step of the ART cycle is supported by good evidence from well-designed studies. To summarise the evidence from Cochrane systematic reviews on procedures and treatment options available to couples with subfertility undergoing assisted reproductive technology (ART). Published Cochrane systematic reviews of couples undergoing ART (in vitro fertilisation or intracytoplasmic sperm injection) were eligible for inclusion in the overview. We also identified Cochrane reviews in preparation, for future inclusion.The outcomes of the overview were live birth (primary outcome), clinical pregnancy, multiple pregnancy, miscarriage and ovarian hyperstimulation syndrome (secondary outcomes). Studies of intrauterine insemination and ovulation induction were excluded.Selection of systematic reviews, data extraction and quality assessment were undertaken in duplicate. Review quality was assessed by using the AMSTAR tool. Reviews were organised by their relevance to specific stages in the ART cycle. Their findings were summarised in the text and data for each outcome were reported in 'Additional tables'. Fifty-four systematic reviews published in The Cochrane Library were included. All were high quality. Thirty reviews identified interventions that were effective (n = 18) or promising (n = 12), 13 reviews identified interventions that were either ineffective (n = 3) or possibly ineffective (n=10), and 11 reviews were unable to draw conclusions due to lack of evidence.An additional 15 protocols and two titles were identified for future inclusion in this overview. This overview provides the most up to date evidence on ART cycles from systematic reviews of randomised controlled trials. Fertility treatments are costly and the stakes are high. Using the best available evidence to optimise outcomes is best practice. The evidence from this overview could be used to develop clinical practice guidelines and protocols for use in daily clinical practice, in order to improve live birth rates and reduce rates of multiple pregnancy, cycle cancellation and ovarian hyperstimulation syndrome.

Evaluation and integration of disparate classification systems for clefts of the lip

PubMed Central

Wang, Kathie H.; Heike, Carrie L.; Clarkson, Melissa D.; Mejino, Jose L. V.; Brinkley, James F.; Tse, Raymond W.; Birgfeld, Craig B.; Fitzsimons, David A.; Cox, Timothy C.

2014-01-01

Orofacial clefting is a common birth defect with wide phenotypic variability. Many systems have been developed to classify cleft patterns to facilitate diagnosis, management, surgical treatment, and research. In this review, we examine the rationale for different existing classification schemes and determine their inter-relationships, as well as strengths and deficiencies for subclassification of clefts of the lip. The various systems differ in how they describe and define attributes of cleft lip (CL) phenotypes. Application and analysis of the CL classifications reveal discrepancies that may result in errors when comparing studies that use different systems. These inconsistencies in terminology, variable levels of subclassification, and ambiguity in some descriptions may confound analyses and impede further research aimed at understanding the genetics and etiology of clefts, development of effective treatment options for patients, as well as cross-institutional comparisons of outcome measures. Identification and reconciliation of discrepancies among existing systems is the first step toward creating a common standard to allow for a more explicit interpretation that will ultimately lead to a better understanding of the causes and manifestations of phenotypic variations in clefting. PMID:24860508

Collaborative Efforts Driving Progress in Pediatric Acute Myeloid Leukemia

PubMed Central

Zwaan, C. Michel; Kolb, Edward A.; Reinhardt, Dirk; Abrahamsson, Jonas; Adachi, Souichi; Aplenc, Richard; De Bont, Eveline S.J.M.; De Moerloose, Barbara; Dworzak, Michael; Gibson, Brenda E.S.; Hasle, Henrik; Leverger, Guy; Locatelli, Franco; Ragu, Christine; Ribeiro, Raul C.; Rizzari, Carmelo; Rubnitz, Jeffrey E.; Smith, Owen P.; Sung, Lillian; Tomizawa, Daisuke; van den Heuvel-Eibrink, Marry M.; Creutzig, Ursula; Kaspers, Gertjan J.L.

2015-01-01

Diagnosis, treatment, response monitoring, and outcome of pediatric acute myeloid leukemia (AML) have made enormous progress during the past decades. Because AML is a rare type of childhood cancer, with an incidence of approximately seven occurrences per 1 million children annually, national and international collaborative efforts have evolved. This overview describes these efforts and includes a summary of the history and contributions of each of the main collaborative pediatric AML groups worldwide. The focus is on translational and clinical research, which includes past, current, and future clinical trials. Separate sections concern acute promyelocytic leukemia, myeloid leukemia of Down syndrome, and relapsed AML. A plethora of novel antileukemic agents that have emerged, including new classes of drugs, are summarized as well. Finally, an important aspect of the treatment of pediatric AML—supportive care—and late effects are discussed. The future is bright, with a wide range of emerging innovative therapies and with more and more international collaboration that ultimately aim to cure all children with AML, with fewer adverse effects and without late effects. PMID:26304895

Favorable outcome of early treatment of new onset child and adolescent migraine-implications for disease modification.

PubMed

Charles, James A; Peterlin, B L; Rapoport, Alan M; Linder, Steven L; Kabbouche, Marielle A; Sheftell, Fred D

2009-08-01

There is evidence that the prevalence of migraine in children and adolescents may be increasing. Current theories of migraine pathophysiology in adults suggest activation of central cortical and brainstem pathways in conjunction with the peripheral trigeminovascular system, which ultimately results in release of neuropeptides, facilitation of central pain pathways, neurogenic inflammation surrounding peripheral vessels, and vasodilatation. Although several risk factors for frequent episodic, chronic, and refractory migraine have been identified, the causes of migraine progression are not known. Migraine pathophysiology has not been fully evaluated in children. In this review, we will first discuss the evidence that early therapeutic interventions in the child or adolescent new onset migraineur, may halt or limit progression and disability. We will then review the evidence suggesting that many adults with chronic or refractory migraine developed their migraine as children or adolescents and may not have been treated adequately with migraine-specific therapy. Finally, we will show that early, appropriate and optimal treatment of migraine during childhood and adolescence may result in disease modification and prevent progression of this disease.

Nano Era of Dentistry-An Update.

PubMed

Maman, Paramjot; Nagpal, Manju; Gilhotra, Ritu Mehra; Aggarwal, Geeta

2018-02-14

Management of the health of oral tissues is a prime requirement in dentistry. The prevention of tooth decay and the treatment of lesions and cavities are ongoing challenges. The limitations in dental materials, medications, instruments, procedures put off the accomplishment of this goal. Rationalization of science and technology has made possible to work out these limitations. Nanotechnology which is the outcome of this rationalization has become one of the most favored technologies in medical and dental application. The substantial contribution of nano dental materials is the identification of oral health related problems by better diagnosis and management of dental disorders by bionanomaterials. Application of nanodentistry holds promise for comprehensive dental care by utilizing nanomaterials and ultimately by nanorobots. This review discusses the rationale of nanodentistry, nanocarriers researched in treatment of different dental diseases, the latest innovations in nanomaterials in various disciplines of dentistry; patent literature and related marketed products. Advances in nanotechnology have placed plenty of hopes in terms of improving the oral health care of dental patients. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Thermal fixation of swine liver tissue after magnetic resonance-guided high-intensity focused ultrasound ablation.

PubMed

Courivaud, Frédéric; Kazaryan, Airazat M; Lund, Alice; Orszagh, Vivian C; Svindland, Aud; Marangos, Irina Pavlik; Halvorsen, Per Steinar; Jebsen, Peter; Fosse, Erik; Hol, Per Kristian; Edwin, Bjørn

2014-07-01

The aim of this study was to investigate experimental conditions for efficient and controlled in vivo liver tissue ablation by magnetic resonance (MR)-guided high-intensity focused ultrasound (HIFU) in a swine model, with the ultimate goal of improving clinical treatment outcome. Histological changes were examined both acutely (four animals) and 1 wk after treatment (five animals). Effects of acoustic power and multiple sonication cycles were investigated. There was good correlation between target size and observed ablation size by thermal dose calculation, post-procedural MR imaging and histopathology, when temperature at the focal point was kept below 90°C. Structural histopathology investigations revealed tissue thermal fixation in ablated regions. In the presence of cavitation, mechanical tissue destruction occurred, resulting in an ablation larger than the target. Complete extra-corporeal MR-guided HIFU ablation in the liver is feasible using high acoustic power. Nearby large vessels were preserved, which makes MR-guided HIFU promising for the ablation of liver tumors adjacent to large veins. Copyright © 2014 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

Role of chemotherapy and molecularly targeted agents in the treatment of adenoid cystic carcinoma of the lacrimal gland.

PubMed

Le Tourneau, Christophe; Razak, Albiruni R A; Levy, Christine; Calugaru, Valentin; Galatoire, Olivier; Dendale, Rémi; Desjardins, Laurence; Gan, Hui K

2011-11-01

Adenoid cystic carcinoma (ACC) is the most common malignant epithelial cancer of the lacrimal gland. Despite a slow rate of growth, ACCs are ultimately associated with poor clinical outcome. Given the rarity of this disease, most recommendations regarding therapy are guided by expert opinion and retrospective data rather than level 1 evidence. Surgery and postoperative radiation therapy are commonly used as initial local treatment. In patients at high risk of recurrence, concomitant platinum-based chemotherapy may be added to postoperative radiotherapy in an attempt to enhance radio-sensitivity. While encouraging responses have been reported with intra-arterial neoadjuvant chemotherapy, this strategy is associated with substantial toxicity and should be considered investigational. For patients with metastatic disease not amenable to surgery or radiotherapy, chemotherapy may have a role based on its modest efficacy in non-lacrimal ACC. Similarly, molecular targeted agents may have a role, although the agents tested to date in non-lacrimal ACC have been disappointing. A better understanding of the biology of ACC will be crucial to the future success of developing targeted agents for this disease.

Collaborative Efforts Driving Progress in Pediatric Acute Myeloid Leukemia.

PubMed

Zwaan, C Michel; Kolb, Edward A; Reinhardt, Dirk; Abrahamsson, Jonas; Adachi, Souichi; Aplenc, Richard; De Bont, Eveline S J M; De Moerloose, Barbara; Dworzak, Michael; Gibson, Brenda E S; Hasle, Henrik; Leverger, Guy; Locatelli, Franco; Ragu, Christine; Ribeiro, Raul C; Rizzari, Carmelo; Rubnitz, Jeffrey E; Smith, Owen P; Sung, Lillian; Tomizawa, Daisuke; van den Heuvel-Eibrink, Marry M; Creutzig, Ursula; Kaspers, Gertjan J L

2015-09-20

Diagnosis, treatment, response monitoring, and outcome of pediatric acute myeloid leukemia (AML) have made enormous progress during the past decades. Because AML is a rare type of childhood cancer, with an incidence of approximately seven occurrences per 1 million children annually, national and international collaborative efforts have evolved. This overview describes these efforts and includes a summary of the history and contributions of each of the main collaborative pediatric AML groups worldwide. The focus is on translational and clinical research, which includes past, current, and future clinical trials. Separate sections concern acute promyelocytic leukemia, myeloid leukemia of Down syndrome, and relapsed AML. A plethora of novel antileukemic agents that have emerged, including new classes of drugs, are summarized as well. Finally, an important aspect of the treatment of pediatric AML--supportive care--and late effects are discussed. The future is bright, with a wide range of emerging innovative therapies and with more and more international collaboration that ultimately aim to cure all children with AML, with fewer adverse effects and without late effects. © 2015 by American Society of Clinical Oncology.

Photodynamic Synergistic Effect of Pheophorbide a and Doxorubicin in Combined Treatment against Tumoral Cells.

PubMed

Ruiz-González, Rubén; Milán, Paula; Bresolí-Obach, Roger; Stockert, Juan Carlos; Villanueva, Angeles; Cañete, Magdalena; Nonell, Santi

2017-02-17

A combination of therapies to treat cancer malignancies is at the forefront of research with the aim to reduce drug doses (ultimately side effects) and diminish the possibility of resistance emergence given the multitarget strategy. With this goal in mind, in the present study, we report the combination between the chemotherapeutic drug doxorubicin (DOXO) and the photosensitizing agent pheophorbide a (PhA) to inactivate HeLa cells. Photophysical studies revealed that DOXO can quench the excited states of PhA, detracting from its photosensitizing ability. DOXO can itself photosensitize the production of singlet oxygen; however, this is largely suppressed when bound to DNA. Photodynamic treatments of cells incubated with DOXO and PhA led to different outcomes depending on the concentrations and administration protocols, ranging from antagonistic to synergic for the same concentrations. Taken together, the results indicate that an appropriate combination of DOXO with PhA and red light may produce improved cytotoxicity with a smaller dose of the chemotherapeutic drug, as a result of the different subcellular localization, targets and mode of action of the two agents.

Photodynamic Synergistic Effect of Pheophorbide a and Doxorubicin in Combined Treatment against Tumoral Cells

PubMed Central

Ruiz-González, Rubén; Milán, Paula; Bresolí-Obach, Roger; Stockert, Juan Carlos; Villanueva, Angeles; Cañete, Magdalena; Nonell, Santi

2017-01-01

A combination of therapies to treat cancer malignancies is at the forefront of research with the aim to reduce drug doses (ultimately side effects) and diminish the possibility of resistance emergence given the multitarget strategy. With this goal in mind, in the present study, we report the combination between the chemotherapeutic drug doxorubicin (DOXO) and the photosensitizing agent pheophorbide a (PhA) to inactivate HeLa cells. Photophysical studies revealed that DOXO can quench the excited states of PhA, detracting from its photosensitizing ability. DOXO can itself photosensitize the production of singlet oxygen; however, this is largely suppressed when bound to DNA. Photodynamic treatments of cells incubated with DOXO and PhA led to different outcomes depending on the concentrations and administration protocols, ranging from antagonistic to synergic for the same concentrations. Taken together, the results indicate that an appropriate combination of DOXO with PhA and red light may produce improved cytotoxicity with a smaller dose of the chemotherapeutic drug, as a result of the different subcellular localization, targets and mode of action of the two agents. PMID:28218672

The Meniscus-Deficient Knee

PubMed Central

Rao, Allison J.; Erickson, Brandon J.; Cvetanovich, Gregory L.; Yanke, Adam B.; Bach, Bernard R.; Cole, Brian J.

2015-01-01

Meniscal tears are the most common knee injury, and partial meniscectomies are the most common orthopaedic surgical procedure. The injured meniscus has an impaired ability to distribute load and resist tibial translation. Partial or complete loss of the meniscus promotes early development of chondromalacia and osteoarthritis. The primary goal of treatment for meniscus-deficient knees is to provide symptomatic relief, ideally to delay advanced joint space narrowing, and ultimately, joint replacement. Surgical treatments, including meniscal allograft transplantation (MAT), high tibial osteotomy (HTO), and distal femoral osteotomy (DFO), are options that attempt to decrease the loads on the articular cartilage of the meniscus-deficient compartment by replacing meniscal tissue or altering joint alignment. Clinical and biomechanical studies have reported promising outcomes for MAT, HTO, and DFO in the postmeniscectomized knee. These procedures can be performed alone or in conjunction with ligament reconstruction or chondral procedures (reparative, restorative, or reconstructive) to optimize stability and longevity of the knee. Complications can include fracture, nonunion, patella baja, compartment syndrome, infection, and deep venous thrombosis. MAT, HTO, and DFO are effective options for young patients suffering from pain and functional limitations secondary to meniscal deficiency. PMID:26779547

Incorporating peer support during in vivo exposure to reverse dropout from prolonged exposure therapy for posttraumatic stress disorder: Clinical outcomes.

PubMed

Hernandez-Tejada, Melba A; Hamski, Stephanie; Sánchez-Carracedo, David

2017-01-01

Objective Prolonged exposure is characterized by reported dropout rates ranging from 25% to 40%. This premature attrition is also observed in other evidence-based treatments for posttraumatic stress disorder. While home-based telehealth delivery of prolonged exposure resolves logistical barriers to care such as travel time and cost, dropout appears unaffected. A previous study on dropouts from prolonged exposure delivered via telehealth found that Veterans, particularly those receiving care via telehealth, reported problems with in vivo exposure and that having a peer to offer support during in vivo exposure assignments might have prevented their attrition from treatment. Methods The present pilot study treatment was designed in a manner consistent with the aforementioned Veteran suggestions, specifically to involve peers offering verbal support and encouragement during in vivo exposure homework. Such a treatment modification might be particularly useful for those receiving care via telehealth, given increased difficulties with exposure reported when this treatment delivery modality is used. It was hypothesized that dropouts would agree to reengage in treatment with a peer and would subsequently evince improvement in posttraumatic stress disorder and depression scores as a result of this treatment reengagement. Results Of 82 dropouts from prolonged exposure, 29 reentered treatment when offered peer support during exposure (12 in telehealth and 17 in person). Conclusion Treatment reentry was effective insofar as indices of both posttraumatic stress disorder and depression were significantly reduced in both telehealth and in person groups, indicating that using peers in this way may be an effective means by which to return Veterans to care, and ultimately reduce symptomatology.

Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received.

PubMed

Bradbury, Andrew W; Adam, Donald J; Bell, Jocelyn; Forbes, John F; Fowkes, F Gerry R; Gillespie, Ian; Ruckley, Charles Vaughan; Raab, Gillian M

2010-05-01

An intention-to-treat analysis of randomized Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial data showed that initial randomization to a bypass surgery (BSX)-first strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. We describe the nature and timing of first, crossover, and reinterventions and examine AFS and OS by first treatment received. We also compare vein with prosthetic BSX and transluminal with subintimal balloon angioplasty (BAP) and examine outcomes from BSX after failed BAP. We randomly assigned 452 patients with SLI due to infrainguinal disease in 27 United Kingdom hospitals to a BSX first (n = 228) or a BAP first (n = 224) revascularization strategy. All patients have been monitored for 3 years and more than half for >5 years. We prospectively collected data on every procedure, major amputation, and death. Patients randomized to BAP were more likely to have their assigned treatment first (94% vs 85%, P = .01, chi(2)test). BAP had a higher immediate technical failure rate of 20% vs 2.6% (P = .01, chi(2)test). By 12 weeks after randomization 9 BAP (4%) vs 23 BSX (10%) patients had not undergone revascularization; 3 BAP (1.3%) vs 13 BSX (5.8%) had undergone the opposite treatment first; and 35 BAP (15.6%) and 2 (0.9%) BSX had received the assigned treatment and then undergone the opposite treatment. BSX distal anastomoses were divided approximately equally between the above and below knee popliteal and crural arteries; most originated from the common femoral artery. About 25% of the grafts were prosthetic and >90% of vein BSX used ipsilateral great saphenous vein. Most (80%) BAP patients underwent treatment of the SFA alone (38%) or combined with the popliteal artery (42%) and crural arteries (20%). Outcome of vein BSX was better for AFS (P = 0.003) but not OS (P = 0.38, log-rank tests) than prosthetic BSX. There were no differences in outcome between approximately equal numbers of transluminal and subintimal BAP. AFS (P = 0.006) but not OS (P = 0.06, log rank test) survival was significantly worse after BSX after failed BAP than after BSX as a first revascularization attempt. BAP was associated with a significantly higher early failure rate than BSX. Most BAP patients ultimately required surgery. BSX outcomes after failed BAP are significantly worse than for BSX performed as a first revascularization attempt. BSX with vein offers the best long term AFS and OS and, overall, BAP appears superior to prosthetic BSX. Crown Copyright (c) 2010. Published by Mosby, Inc. All rights reserved.

Outcomes with As-Needed Ranibizumab after Initial Monthly Therapy: Long-Term Outcomes of the Phase III RIDE and RISE Trials.

PubMed

Boyer, David S; Nguyen, Quan Dong; Brown, David M; Basu, Karen; Ehrlich, Jason S

2015-12-01

To determine whether the efficacy and safety achieved with monthly ranibizumab as treatment for diabetic macular edema (DME) can be maintained with less-than-monthly treatment. Open-label extension (OLE) phase of randomized, sham-controlled phase III trials: RIDE (NCT00473382) and RISE (NCT00473330). Five hundred of 582 adults who completed the 36-month randomized core studies elected to enter the OLE. All patients participating in the OLE were eligible to receive 0.5 mg ranibizumab according to predefined re-treatment criteria: Treatment was administered when DME was identified by the investigator on optical coherence tomography or when best-corrected visual acuity (BCVA) worsened by ≥5 Early Treatment Diabetic Retinopathy Study letters versus month 36. Patients were observed at 30-, 60-, or 90-day intervals depending on the need for treatment. The incidence and severity of ocular and nonocular events, proportion of patients with ≥15-letter best-corrected visual acuity (BCVA) gain from baseline, mean BCVA change from month 36 (final core study visit), mean central foveal thickness (CFT), and mean CFT change from month 36. A mean of 4.5 injections were administered over a mean follow-up of 14.1 months. Approximately 25% of patients did not require further treatment based on protocol-defined re-treatment criteria. Mean BCVA was sustained or improved in these patients through the end of follow-up. Approximately 75% of patients received ≥1 criteria-based re-treatment; mean time to first re-treatment was approximately 3 months after the last masked-phase visit. Mean BCVA remained stable in re-treated patients; CFT was generally stable with a trend toward slight thickening in all patients when mandatory monthly therapy was relaxed. Vision gains achieved after 1 or 3 years of monthly ranibizumab therapy were maintained with a marked reduction in treatment frequency; some patients required no additional treatment. These observations are consistent with other studies evaluating induction followed by maintenance ranibizumab therapy for DME. Patients whose treatment was deferred by 2 years (randomized initially to sham) did not ultimately achieve the same BCVA gains as patients who received ranibizumab from baseline. Ranibizumab's safety profile in the OLE appeared similar to that observed in the controlled core studies and other studies. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

76 FR 38655 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-01

... Request: New collection; Title of Information Collection: Analysis of Transportation Barriers to... of the proposed study is to identify and analyze transportation barriers associated with the... analyze the health outcomes resulting from those barriers, and ultimately to identify potential solutions...

Creating a winning team: lessons from football.

PubMed

Simons, Sherri Lee

2005-01-01

There are tasks best done on an individual basis when caring for a neonate, but the ultimate outcome for infants and their families results from a team effort. Incorporating ten strategies drawn from football can help the NICU manager create and foster effective teamwork.

A survey of radiation treatment planning peer-review activities in a provincial radiation oncology programme: current practice and future directions

PubMed Central

Brundage, Michael; Foxcroft, Sophie; McGowan, Tom; Gutierrez, Eric; Sharpe, Michael; Warde, Padraig

2013-01-01

Objectives To describe current patterns of practice of radiation oncology peer review within a provincial cancer system, identifying barriers and facilitators to its use with the ultimate aim of process improvement. Design A survey of radiation oncology programmes at provincial cancer centres. Setting All cancer centres within the province of Ontario, Canada (n=14). These are community-based outpatient facilities overseen by Cancer Care Ontario, the provincial cancer agency. Participants A delegate from each radiation oncology programme filled out a single survey based on input from their multidisciplinary team. Outcome measures Rated importance of peer review; current utilisation; format of the peer-review process; organisation and timing; case attributes; outcomes of the peer-review process and perceived barriers and facilitators to expanding peer-review processes. Results 14 (100%) centres responded. All rated the importance of peer review as at least 8/10 (10=extremely important). Detection of medical error and improvement of planning processes were the highest rated perceived benefits of peer review (each median 9/10). Six centres (43%) reviewed at least 50% of curative cases; four of these centres (29%) conducted peer review in more than 80% of cases treated with curative intent. Fewer than 20% of cases treated with palliative intent were reviewed in most centres. Five centres (36%) reported usually conducting peer review prior to the initiation of treatment. Five centres (36%) recorded the outcomes of peer review on the medical record. Thirteen centres (93%) planned to expand peer-review activities; a critical mass of radiation oncologists was the most important limiting factor (median 6/10). Conclusions Radiation oncology peer-review practices can vary even within a cancer system with provincial oversight. The application of guidelines and standards for peer-review processes, and monitoring of implementation and outcomes, will require effective knowledge translation activities. PMID:23903814

Metabolic autofluorescence imaging of head and neck cancer organoids quantifies cellular heterogeneity and treatment response (Conference Presentation)

NASA Astrophysics Data System (ADS)

Shah, Amy T.; Heaster, Tiffany M.; Skala, Melissa C.

2017-02-01

Treatment options for head and neck cancer are limited, and can cause an impaired ability to eat, talk, and breathe. Therefore, optimized and personalized therapies could reduce unnecessary toxicities from ineffective treatments. Organoids are generated from primary tumor tissue and provide a physiologically-relevant in vitro model to measure drug response. Additionally, multiphoton fluorescence lifetime imaging (FLIM) of the metabolic cofactors NAD(P)H and FAD can resolve dynamic cellular response to anti-cancer treatment. This study applies FLIM of NAD(P)H and FAD to head and neck cancer organoids. Head and neck cancer tissue was digested and grown in culture as three-dimensional organoids. Gold standard measures of therapeutic response in vivo indicate stable disease after treatment with cetuximab (antibody therapy) or cisplatin (chemotherapy), and treatment response after combination treatment. In parallel, organoids were treated with cetuximab, cisplatin, or combination therapy for 24 hours. Treated organoids exhibit decreased NAD(P)H lifetime (p<0.05) and increased FAD lifetime (p<0.05) compared with control organoids. Additionally, analysis of cellular heterogeneity identifies distinct subpopulations of cells in response to treatment. A quantitative heterogeneity index predicts in vivo treatment response and demonstrates increased cellular heterogeneity in organoids treated with cetuximab or cisplatin compared with combination treatment. Mapping of cell subpopulations enables characterization of spatial relationships between cell subpopulations. Ultimately, an organoid model combined with metabolic fluorescence imaging could provide a high-throughput platform for drug discovery. Organoids grown from patient tissue could enable individualized treatment planning. These achievements could optimize quality of life and treatment outcomes for head and neck cancer patients.

Approach to the obese adolescent with new-onset diabetes.

PubMed

Zeitler, Philip

2010-12-01

The prevalence of both type 1 and type 2 diabetes among children and adolescents has been steadily increasing over the last few decades. However, as the general pediatric population becomes more obese and more ethnically diverse, reliance on phenotypic characteristics for distinguishing between these types of diabetes is becoming increasingly untenable. Yet, the recognition of differences in treatment strategies, associated disorders, and both short- and long-term diabetes and cardiovascular outcomes supports the importance of diagnostic efforts to make a distinction between diabetes types. An approach to determination of diabetes type is discussed, focused on the presence or absence of autoimmunity and assessment of β-cell function. At the time of diagnosis, it is generally not possible to be certain of diabetes type, and therefore, initial treatment decisions must be made based on aspects of the presenting physiology, with adjustments in treatment approach made as the individual's course proceeds and additional information becomes available. The apparent overlap between type 1 and type 2 diabetes that occurs in obese adolescents has resulted in some controversy regarding mixed forms of diabetes that are ultimately semantic, but this does raise interesting questions about the treatment of type 1 diabetes in the presence of an insulin-resistant phenotype. Finally, the lack of information about the efficacy of treatment of cardiovascular risk factors, such as dyslipidemia and hypertension, along with the well-documented challenges in adherence to chronic illness treatment in this population, creates substantial challenges.

Positive psychology in rehabilitation medicine: a brief report.

PubMed

Bertisch, Hilary; Rath, Joseph; Long, Coralynn; Ashman, Teresa; Rashid, Tayyab

2014-01-01

The field of positive psychology has grown exponentially within the last decade. To date, however, there have been few empirical initiatives to clarify the constructs within positive psychology as they relate to rehabilitation medicine. Character strengths, and in particular resilience, following neurological trauma are clinically observable within rehabilitation settings, and greater knowledge of the way in which these factors relate to treatment variables may allow for enhanced treatment conceptualization and planning. The goal of this study was to explore the relationships between positive psychology constructs (character strengths, resilience, and positive mood) and rehabilitation-related variables (perceptions of functional ability post-injury and beliefs about treatment) within a baseline data set, a six-month follow-up data set, and longitudinally across time points. Pearson correlations and supplementary multiple regression analyses were conducted within and across these time points from a starting sample of thirty-nine individuals with acquired brain injury (ABI) in an outpatient rehabilitation program. Positive psychology constructs were related to rehabilitation-related variables within the baseline data set, within the follow-up data set, and longitudinally between baseline positive psychology variables and follow-up rehabilitation-related data. These preliminary findings support relationships between character strengths, resilience, and positive mood states with perceptions of functional ability and expectations of treatment, respectively, which are primary factors in treatment success and quality of life outcomes in rehabilitation medicine settings. The results suggest the need for more research in this area, with an ultimate goal of incorporating positive psychology constructs into rehabilitation conceptualization and treatment planning.

Scorecard cardiovascular medicine. Its impact and future directions.

PubMed

Topol, E J; Califf, R M

1994-01-01

Public release of operator-specific data for cardiovascular procedures has set a new precedent, introducing the "scorecard" era. Justification exists for public disclosure, but the mechanics of appropriate data release are complex from a clinical, statistical, and logistic standpoint. Scorecard medicine may appropriately promote regionalization of medical centers and consolidation of services, but unless the process is directed effectively, it may impair the development of new treatments because of a more restrictive clinical practice environment. We propose revamping our current system to facilitate rapid and accurate access to outcome data in the local practice environment so that improvement in practice occurs on a voluntary basis rather than in response to punitive restrictions. A rational plan needs to be developed for dealing with high-risk patients, perhaps through compensation in regression models used to calculate expected outcomes, and for the start-up of novice physicians. Special provisions are needed to promote clinical research. Before procedures are done, it would be ideal to provide a full disclosure informed consent, whereby the physician reports operator-specific data and the patient's decision-making process is facilitated. Overall, appropriate implementation of scorecards could ultimately lead to a substantial improvement in the quality of U.S. cardiovascular medicine.

Addressing mental health disparities through clinical competence not just cultural competence: the need for assessment of sociocultural issues in the delivery of evidence-based psychosocial rehabilitation services.

PubMed

Yamada, Ann-Marie; Brekke, John S

2008-12-01

Recognition of ethnic/racial disparities in mental health services has not directly resulted in the development of culturally responsive psychosocial interventions. There remains a fundamental need for assessment of sociocultural issues that have been linked with the expectations, needs, and goals of culturally diverse consumers with severe and persistent mental illness. The authors posit that embedding the assessment of sociocultural issues into psychosocial rehabilitation practice is one step in designing culturally relevant empirically supported practices. It becomes a foundation on which practitioners can examine the relevance of their interventions to the diversity encountered in everyday practice. This paper provides an overview of the need for culturally and clinically relevant assessment practices and asserts that by improving the assessment of sociocultural issues the clinical competence of service providers is enhanced. The authors offer a conceptual framework for linking clinical assessment of sociocultural issues to consumer outcomes and introduce an assessment tool adapted to facilitate the process in psychosocial rehabilitation settings. Emphasizing competent clinical assessment skills will ultimately offer a strategy to address disparities in treatment outcomes for understudied populations of culturally diverse consumers with severe and persistent mental illness.

Water Treatment Plant Sludges--An Update of the State of the Art: Part 2.

ERIC Educational Resources Information Center

American Water Works Association Journal, 1978

1978-01-01

This report outlines the state of the art with respect to nonmechanical and mechanical methods of dewatering water treatment plant sludge, ultimate solids disposal, and research and development needs. (CS)

Design of a compact antenna with flared groundplane for a wearable breast hyperthermia system.

PubMed

Curto, Sergio; Prakash, Punit

2015-01-01

Currently available microwave hyperthermia systems for breast cancer treatment do not conform to the intact breast and provide limited control of heating patterns, thereby hindering an effective treatment. A compact patch antenna with a flared groundplane that may be integrated within a wearable hyperthermia system for the treatment of the intact breast disease is proposed. A 3D simulation-based approach was employed to optimise the antenna design with the objective of maximising the hyperthermia treatment volume (41 °C iso-therm) while maintaining good impedance matching. The optimised antenna design was fabricated and experimentally evaluated with ex vivo tissue measurements. The optimised compact antenna yielded a -10 dB bandwidth of 90 MHz centred at 915 MHz, and was capable of creating hyperthermia treatment volumes up to 14.4 cm(3) (31 mm × 28 mm × 32 mm) with an input power of 15 W. Experimentally measured reflection coefficient and transient temperature profiles were in good agreement with simulated profiles. Variations of + 50% in blood perfusion yielded variations in the treatment volume up to 11.5%. When compared to an antenna with a similar patch element employing a conventional rectangular groundplane, the antenna with flared groundplane afforded 22.3% reduction in required power levels to reach the same temperature, and yielded 2.4 times larger treatment volumes. The proposed patch antenna with a flared groundplane may be integrated within a wearable applicator for hyperthermia treatment of intact breast targets and has the potential to improve efficiency, increase patient comfort, and ultimately clinical outcomes.

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management

PubMed Central

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-01-01

Abstract Background and Aims The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012–2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. Methods During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. Results The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Conclusions Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. PMID:28981622

Combination therapies for neurobehavioral and cognitive recovery after experimental traumatic brain injury: is more better?

PubMed Central

Kline, Anthony E.; Leary, Jacob B.; Radabaugh, Hannah L.; Cheng, Jeffrey P.; Bondi, Corina O.

2016-01-01

Traumatic brain injury (TBI) is a significant health care crisis that affects two million individuals in the United Sates alone and over ten million worldwide each year. While numerous monotherapies have been evaluated and shown to be beneficial at the bench, similar results have not translated to the clinic. One reason for the lack of successful translation may be due to the fact that TBI is a heterogeneous disease that affects multiple mechanisms, thus requiring a therapeutic approach that can act on complementary, rather than single, targets. Hence, the use of combination therapies (i.e., polytherapy) has emerged as a viable approach. Stringent criteria, such as verification of each individual treatment plus the combination, a focus on behavioral outcome, and post-injury vs. pre-injury treatments, were employed to determine which studies were appropriate for review. The selection process resulted in 37 papers that fit the specifications. The review, which is the first to comprehensively assess the effects of combination therapies on behavioral outcomes after TBI, encompasses five broad categories (inflammation, oxidative stress, neurotransmitter dysregulation, neurotrophins, and stem cells, with and without rehabilitative therapies). Overall, the findings suggest that combination therapies can be more beneficial than monotherapies as indicated by 46% of the studies exhibiting an additive or synergistic positive effect versus on 19% reporting a negative interaction. These encouraging findings serve as an impetus for continued combination studies after TBI and ultimately for the development of successful clinically relevant therapies. PMID:27166858

Communication in acute ambulatory care.

PubMed

Dean, Marleah; Oetzel, John; Sklar, David P

2014-12-01

Effective communication has been linked to better health outcomes, higher patient satisfaction, and treatment adherence. Communication in ambulatory care contexts is even more crucial, as providers typically do not know patients' medical histories or have established relationships, conversations are time constrained, interruptions are frequent, and the seriousness of patients' medical conditions may create additional tension during interactions. Yet, health communication often unduly emphasizes information exchange-the transmission and receipt of messages leading to a mutual understanding of a patient's condition, needs, and treatments. This approach does not take into account the importance of rapport building and contextual issues, and may ultimately limit the amount of information exchanged.The authors share the perspective of communication scientists to enrich the current approach to medical communication in ambulatory health care contexts, broadening the under standing of medical communication beyond information exchange to a more holistic, multilayered viewpoint, which includes rapport and contextual issues. The authors propose a socio-ecological model for understanding communication in acute ambulatory care. This model recognizes the relationship of individuals to their environment and emphasizes the importance of individual and contextual factors that influence patient-provider interactions. Its key elements include message exchange and individual, organizational, societal, and cultural factors. Using this model, and following the authors' recommendations, providers and medical educators can treat communication as a holistic process shaped by multiple layers. This is a step toward being able to negotiate conflicting demands, resolve tensions, and create encounters that lead to positive health outcomes.

The Effect of Furlow Palatoplasty Timing on Speech Outcomes in Submucous Cleft Palate.

PubMed

Swanson, Jordan W; Mitchell, Brianne T; Cohen, Marilyn; Solot, Cynthia; Jackson, Oksana; Low, David; Bartlett, Scott P; Taylor, Jesse A

2017-08-01

Because some patients with submucous cleft palate (SMCP) are asymptomatic, surgical treatment is conventionally delayed until hypernasal resonance is identified during speech production. We aim to identify whether speech outcomes after repair of a SMCP is influenced by age of repair. We retrospectively studied nonsyndromic children with SMCP. Speech results, before and after any surgical treatment or physical management of the palate were compared using the Pittsburgh Weighted Speech Scoring system. Furlow palatoplasty was performed on 40 nonsyndromic patients with SMCP, and 26 patients were not surgically treated. Total composite speech scores improved significantly among children repaired between 3 and 4 years of age (P = 0.02), but not older than 4 years (P = 0.63). Twelve (86%) of 14 patients repaired who are older than 4 years had borderline or incompetent speech (composite Pittsburgh Weighted Speech Scoring ≥3) compared with 2 (29%) of 7 repaired between 3 and 4 years of age (P = 0.0068), despite worse prerepair scores in the latter group. Resonance improved in children repaired who are older than 4 years, but articulation errors persisted to a greater degree than those treated before 4 years of age (P = 0.01.) CONCLUSIONS: Submucous cleft palate repair before 4 years of age appears associated with lower ultimate rates of borderline or incompetent speech. Speech of patients repaired at or after 4 years of age seems to be characterized by persistent misarticulation. These findings highlight the importance of timely diagnosis and management.

All the world’s a (clinical) stage: Rethinking bipolar disorder from a longitudinal perspective

PubMed Central

Frank, Ellen; Nimgaonkar, Vishwajit L.; Phillips, Mary L.; Kupfer, David J.

2014-01-01

Psychiatric disorders have traditionally been classified using a static, categorical approach. However, this approach falls short in facilitating understanding of the development, common comorbid diagnoses, prognosis, and treatment of these disorders. We propose a “staging” model of bipolar disorder that integrates genetic and neural information with mood and activity symptoms to describe how the disease progresses over time. From an early, asymptomatic, but “at risk” stage to severe, chronic illness, each stage is described with associated neuroimaging findings as well as strategies for mapping genetic risk factors. Integrating more biologic information relating to cardiovascular and endocrine systems, refining methodology for modeling dimensional approaches to disease, and developing outcome measures will all be crucial in examining the validity of this model. Ultimately, this approach should aid in developing targeted interventions for each group that will reduce the significant morbidity and mortality associated with bipolar disorder. PMID:25048003

Cancer care decision making in multidisciplinary meetings.

PubMed

Dew, Kevin; Stubbe, Maria; Signal, Louise; Stairmand, Jeannine; Dennett, Elizabeth; Koea, Jonathan; Simpson, Andrew; Sarfati, Diana; Cunningham, Chris; Batten, Lesley; Ellison-Loschmann, Lis; Barton, Josh; Holdaway, Maureen

2015-03-01

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes. © The Author(s) 2014.

Current Management Strategy for Active Surveillance in Prostate Cancer.

PubMed

Syed, Jamil S; Javier-Desloges, Juan; Tatzel, Stephanie; Bhagat, Ansh; Nguyen, Kevin A; Hwang, Kevin; Kim, Sarah; Sprenkle, Preston C

2017-02-01

Active surveillance has been increasingly utilized as a strategy for the management of favorable-risk, localized prostate cancer. In this review, we describe contemporary management strategies of active surveillance, with a focus on traditional stratification schemes, new prognostic tools, and patient outcomes. Patient selection, follow-up strategy, and indication for delayed intervention for active surveillance remain centered around PSA, digital rectal exam, and biopsy findings. Novel tools which include imaging, biomarkers, and genetic assays have been investigated as potential prognostic adjuncts; however, their role in active surveillance remains institutionally dependent. Although 30-50% of patients on active surveillance ultimately undergo delayed treatment, the vast majority will remain free of metastasis with a low risk of dying from prostate cancer. The optimal method for patient selection into active surveillance is unknown; however, cancer-specific mortality rates remain excellent. New prognostication tools are promising, and long-term prospective, randomized data regarding their use in active surveillance will be beneficial.

[Use of Cone Beam Computed Tomography in endodontics: rational case selection criteria].

PubMed

Rosen, E; Tsesis, I

2016-01-01

To present rational case selection criteria for the use of CBCT (Cone Beam Computed Tomography) in endodontics. This article reviews the literature concerning the benefits of CBCT in endodontics, alongside its radiation risks, and present case selection criteria for referral of endodontic patients to CBCT. Up to date, the expected ultimate benefit of CBCT to the endodontic patient is yet uncertain, and the current literature is mainly restricted to its technical efficacy. In addition, the potential radiation risks of CBCT scan are stochastic in nature and uncertain, and are worrying especially in pediatric patients. Both the efficacy of CBCT in supporting the endodontic practitioner decision making and in affecting treatment outcomes, and its long term potential radiation risks are yet uncertain. Therefore, a cautious rational decision making is essential when a CBCT scan is considered in endodontics. Risk-benefit considerations are presented.

Measuring homework completion in behavioral activation.

PubMed

Busch, Andrew M; Uebelacker, Lisa A; Kalibatseva, Zornitsa; Miller, Ivan W

2010-07-01

The aim of this study was to develop and validate an observer-based coding system for the characterization and completion of homework assignments during Behavioral Activation (BA). Existing measures of homework completion are generally unsophisticated, and there is no current measure of homework completion designed to capture the particularities of BA. The tested scale sought to capture the type of assignment, realm of functioning targeted, extent of completion, and assignment difficulty. Homework assignments were drawn from 12 (mean age = 48, 83% female) clients in two trials of a 10-session BA manual targeting treatment-resistant depression in primary care. The two coders demonstrated acceptable or better reliability on most codes, and unreliable codes were dropped from the proposed scale. In addition, correlations between homework completion and outcome were strong, providing some support for construct validity. Ultimately, this line of research aims to develop a user-friendly, reliable measure of BA homework completion that can be completed by a therapist during session.

New and Advanced Picosecond Lasers for Tattoo Removal.

PubMed

Adatto, Maurice A; Amir, Ruthie; Bhawalkar, Jayant; Sierra, Rafael; Bankowski, Richard; Rozen, Doran; Dierickx, Christine; Lapidoth, Moshe

2017-01-01

Early methods of tattoo removal ultimately resulted in unacceptable cosmetic outcomes. While the introduction of laser technology was an improvement over the existing chemical, mechanical, and surgical procedures, the use of nonselective tattoo removal with carbon dioxide and argon lasers led to scarring. Q-switched lasers with nanosecond (10-9) pulse domains were considered to have revolutionized tattoo treatment, by selectively heating the tattoo particles, while reducing the adverse sequelae to adjacent normal skin. Theoretical considerations of restricting pulse duration, to heat tattoo particles to higher temperatures, proposed the use of sub-nanosecond pulses to target particles with thermal relaxation times lower than the nanosecond pulses in Q-switched lasers. Initial studies demonstrated that picosecond (10-12) pulses were more effective than nanosecond pulses in clearing black tattoos. Advances in picosecond technology led to the development of commercially available lasers, incorporating several different wavelengths, to further refine pigment targeting. © 2017 S. Karger AG, Basel.

Metacognition in Early Phase Psychosis: Toward Understanding Neural Substrates

PubMed Central

Vohs, Jenifer L.; Hummer, Tom A.; Yung, Matthew G.; Francis, Michael M.; Lysaker, Paul H.; Breier, Alan

2015-01-01

Individuals in the early phases of psychotic illness have disturbed metacognitive capacity, which has been linked to a number of poor outcomes. Little is known, however, about the neural systems associated with metacognition in this population. The purpose of this study was to elucidate the neuroanatomical correlates of metacognition. We anticipated that higher levels of metacognition may be dependent upon gray matter density (GMD) of regions within the prefrontal cortex. Examining whole-brain structure in 25 individuals with early phase psychosis, we found positive correlations between increased medial prefrontal cortex and ventral striatum GMD and higher metacognition. These findings represent an important step in understanding the path through which the biological correlates of psychotic illness may culminate into poor metacognition and, ultimately, disrupted functioning. Such a path will serve to validate and promote metacognition as a viable treatment target in early phase psychosis. PMID:26132568

Platforms.

PubMed

Josko, Deborah

2014-01-01

The advent of DNA sequencing technologies and the various applications that can be performed will have a dramatic effect on medicine and healthcare in the near future. There are several DNA sequencing platforms available on the market for research and clinical use. Based on the medical laboratory scientist or researcher's needs and taking into consideration laboratory space and budget, one can chose which platform will be beneficial to their institution and their patient population. Although some of the instrument costs seem high, diagnosing a patient quickly and accurately will save hospitals money with fewer hospital stays and targeted treatment based on an individual's genetic make-up. By determining the type of disease an individual has, based on the mutations present or having the ability to prescribe the appropriate antimicrobials based on the knowledge of the organism's resistance patterns, the clinician will be better able to treat and diagnose a patient which ultimately will improve patient outcomes and prognosis.

Permanent Central Diabetes Insipidus as a Complication of S. pneumoniae Meningitis in the Pediatric Population.

PubMed

Statz, Hannah; Hsu, Benson S

2016-05-01

Diabetes insipidus is a rare but recognized complication of meningitis. The occurrence of diabetes insidipus has been previously attributed to Streptococcus pneumoniae (S. pneumoniae) in a handful of patients and only once within the pediatric subpopulation. We present the clinical course of a previously healthy 2-year, 8-month-old male child ultimately diagnosed with central diabetes insipidus (CDI) secondary to S. pneumoniae meningitis. Permanent CDI following S. pneumoniae meningitis is unique to our case and has not been previously described. Following the case presentation, we describe the etiology, pathophysiology, diagnosis, and treatment of CDI. The mechanism proposed for this clinical outcome is cerebral herniation for a sufficient duration and subsequent ischemia leading to the development of permanent CDI. Providers should be aware of CDI resulting from S. pneumoniae meningitis as prompt diagnosis and management may decrease the risk of permanent hypothalamo-pituitary axis damage. Copyright© South Dakota State Medical Association.

Towards diagnostic markers for the psychoses.

PubMed

Lawrie, Stephen M; O'Donovan, Michael C; Saks, Elyn; Burns, Tom; Lieberman, Jeffrey A

2016-04-01

Psychotic disorders are currently grouped under broad phenomenological diagnostic rubrics. Researchers hope that progress in identifying aetiological mechanisms will ultimately enable more precise division of heterogeneous diagnoses into specific and valid subgroups. This goal has been an aim of psychiatry since the 19th century, when patients with general paresis were thought to have "insanity" similar to dementia praecox and manic depressive illness. Nowadays, the constructs of organic-induced and substance-induced psychotic disorder show that our diagnostic classification system already reflects, in part, aetiological factors. Most recently, gene copy number variation and autoimmunity have been associated with schizophrenia. We suggest how, on the basis of recent scientific advances, we can progress the identification of further putative subgroups and make the most of currently available interventions. Prompt diagnosis and treatment, and a more routine search for causes, could preserve function and improve outcome, and therefore be more acceptable to patients and carers. Copyright © 2016 Elsevier Ltd. All rights reserved.

Implications of genome-wide association studies in cancer therapeutics.

PubMed

Patel, Jai N; McLeod, Howard L; Innocenti, Federico

2013-09-01

Genome wide association studies (GWAS) provide an agnostic approach to identifying potential genetic variants associated with disease susceptibility, prognosis of survival and/or predictive of drug response. Although these techniques are costly and interpretation of study results is challenging, they do allow for a more unbiased interrogation of the entire genome, resulting in the discovery of novel genes and understanding of novel biological associations. This review will focus on the implications of GWAS in cancer therapy, in particular germ-line mutations, including findings from major GWAS which have identified predictive genetic loci for clinical outcome and/or toxicity. Lessons and challenges in cancer GWAS are also discussed, including the need for functional analysis and replication, as well as future perspectives for biological and clinical utility. Given the large heterogeneity in response to cancer therapeutics, novel methods of identifying mechanisms and biology of variable drug response and ultimately treatment individualization will be indispensable. © 2013 The British Pharmacological Society.

Sonographic assisted diagnosis and treatment of bilateral gastrocnemius tendon rupture in a Labrador retriever repaired with fascia lata and polypropylene mesh.

PubMed

Swiderski, J; Fitch, R B; Staatz, A; Lowery, J

2005-01-01

This case report describes a four-year-old, eighty-five pound, male neutered Labrador retriever that was admitted with unilateral lameness and clinical findings consistent with a unilateral gostrocnemius tendon rupture. A prior history of trauma was not identified. Ultrasonagraphic evaluation revealed bilateral gastrocnemius tendon defects in which approximately 80% of the tendon was ruptured on the clinically normal side, yet mechanical function and anatomical length were not apparently altered. Bilateral surgical repair was performed utilizing primary tendon reconstruction, supported by fascia lata, autograft and polypropylene mesh. The repairs were protected with rigid costs for two weeks following surgery, and replaced with orthotics through the complete recovery period. Orthotics provided semi-rigid support and allowed removal for controlled intermittent physical therapy. This surgical repair technique, combined with orthotic support, allowed for early mobilization and good ultimate outcome for a complicated bilateral condition.

Tumor necrosis factor (TNF) biology and cell death.

PubMed

Bertazza, Loris; Mocellin, Simone

2008-01-01

Tumor necrosis factor (TNF) was the first cytokine to be used in humans for cancer therapy. However, its role in the treatment of cancer patients is debated. Most uncertainties in this field stem from the knowledge that the pathways directly activated or indirectly affected upon TNF engagement with its receptors can ultimately lead to very different outcomes in terms of cell survival. In this article, we summarize the fundamental molecular biology aspects of this cytokine. Such a basis is a prerequisite to critically approach the sometimes conflicting preclinical and clinical findings regarding the relationship between TNF, tumor biology and anticancer therapy. Although the last decade has witnessed remarkable advances in this field, we still do not know in detail how cells choose between life and death after TNF stimulation. Understanding this mechanism will not only shed new light on the physiological significance of TNF-driven programmed cell death but also help investigators maximize the anticancer potential of this cytokine.

Disease management: old wine in new bottles?

PubMed

Ritterband, D R

2000-01-01

Disease management is a holistic, patient-focused approach to the treatment of disease across the spectrum of healthcare delivery. In its current form, disease management was created in response to the societal and economic burden that chronic illness contributes. There has recently been rapid growth in the development of disease management programs and sponsors are widespread within the industry, with the largest increase in independent vendors. Although growth has been substantial, the hurdles these programs have encountered have kept them from reaching their full potential. The challenges that exist include clinical, financial, and regulatory issues, and these challenges have significant meaning to healthcare managers. In deciding whether to develop or enhance programs, executives must consider their capability of outcomes measurement, their provider relationships, and the arrangements for program implementation. Ultimately, if programs provide improved health and quality of life for participants, cost savings will follow.

Necrotizing fasciitis in a patient with type 2 diabetes mellitus.

PubMed

Kanuck, David M; Zgonis, Thomas; Jolly, Gary Peter

2006-01-01

Necrotizing fasciitis is a soft-tissue infection characterized by extensive necrosis of subcutaneous fat, neurovascular structures, and fascia. In general, fascial necrosis precedes muscle and skin involvement, hence its namesake. Initially, this uncommon and rapidly progressive disease process can present as a form of cellulitis or superficial abscess. However, the high morbidity and mortality rates associated with necrotizing fasciitis suggest a more serious, ominous condition. A delay in diagnosis can result in progressive advancement highlighted by widespread infection, multiple-organ involvement, and, ultimately, death. We present a case of limb salvage in a 52-year-old patient with type 2 diabetes mellitus and progressive fascial necrosis. A detailed review of the literature is presented, and current treatment modalities are described. Aggressive surgical debridement, comprehensive medical management of the sepsis and comorbidities, and timely closure of the resultant wound or wounds are essential for a successful outcome.

Mitochondrial Function in Sepsis

PubMed Central

Arulkumaran, Nishkantha; Deutschman, Clifford S.; Pinsky, Michael R.; Zuckerbraun, Brian; Schumacker, Paul T.; Gomez, Hernando; Gomez, Alonso; Murray, Patrick; Kellum, John A.

2015-01-01

Mitochondria are an essential part of the cellular infrastructure, being the primary site for high energy adenosine triphosphate (ATP) production through oxidative phosphorylation. Clearly, in severe systemic inflammatory states, like sepsis, cellular metabolism is usually altered and end organ dysfunction not only common but predictive of long term morbidity and mortality. Clearly, interest is mitochondrial function both as a target for intracellular injury and response to extrinsic stress have been a major focus of basic science and clinical research into the pathophysiology of acute illness. However, mitochondria have multiple metabolic and signaling functions that may be central in both the expression of sepsis and its ultimate outcome. In this review, the authors address five primary questions centered on the role of mitochondria in sepsis. This review should be used as both a summary source in placing mitochondrial physiology within the context of acute illness and as a focal point for addressing new research into diagnostic and treatment opportunities these insights provide. PMID:26871665

MITOCHONDRIAL FUNCTION IN SEPSIS.

PubMed

Arulkumaran, Nishkantha; Deutschman, Clifford S; Pinsky, Michael R; Zuckerbraun, Brian; Schumacker, Paul T; Gomez, Hernando; Gomez, Alonso; Murray, Patrick; Kellum, John A

2016-03-01

Mitochondria are an essential part of the cellular infrastructure, being the primary site for high-energy adenosine triphosphate production through oxidative phosphorylation. Clearly, in severe systemic inflammatory states, like sepsis, cellular metabolism is usually altered, and end organ dysfunction is not only common, but also predictive of long-term morbidity and mortality. Clearly, interest is mitochondrial function both as a target for intracellular injury and response to extrinsic stress have been a major focus of basic science and clinical research into the pathophysiology of acute illness. However, mitochondria have multiple metabolic and signaling functions that may be central in both the expression of sepsis and its ultimate outcome. In this review, the authors address five primary questions centered on the role of mitochondria in sepsis. This review should be used both as a summary source in placing mitochondrial physiology within the context of acute illness and as a focal point for addressing new research into diagnostic and treatment opportunities these insights provide.

Engineering 3D Models of Tumors and Bone to Understand Tumor-Induced Bone Disease and Improve Treatments.

PubMed

Kwakwa, Kristin A; Vanderburgh, Joseph P; Guelcher, Scott A; Sterling, Julie A

2017-08-01

Bone is a structurally unique microenvironment that presents many challenges for the development of 3D models for studying bone physiology and diseases, including cancer. As researchers continue to investigate the interactions within the bone microenvironment, the development of 3D models of bone has become critical. 3D models have been developed that replicate some properties of bone, but have not fully reproduced the complex structural and cellular composition of the bone microenvironment. This review will discuss 3D models including polyurethane, silk, and collagen scaffolds that have been developed to study tumor-induced bone disease. In addition, we discuss 3D printing techniques used to better replicate the structure of bone. 3D models that better replicate the bone microenvironment will help researchers better understand the dynamic interactions between tumors and the bone microenvironment, ultimately leading to better models for testing therapeutics and predicting patient outcomes.

A psychodynamic model of behavior after acute central nervous system damage.

PubMed

Groswasser, Z; Stern, M J

1998-02-01

This article describes a conceptual psychodynamic model for understanding the neurobehavioral manifestations of acute central nervous system damage (ACNSD) displayed by patients during the rehabilitation process. According to the proposed model, patientsO behavioral responses are viewed as their only means of emotional expression and therefore may not be considered entirely abnormal when viewed from the perspective of patientsO interpersonal contexts. An improved understanding of the dynamic processes through which recovering patients with ACNSD journey may lead to better interaction between the patient and the therapeutic environment, the interdisciplinary team, and family members. Combining this proposed psychodynamic model with an emerging understanding of the neurobehavioral foundations of aggression and depression may also lead to a more rational approach to intervention with various psychopharmacologic agents. During the rehabilitation process, understanding patients' cognitive deficits, motivational drives, and emotional needs and proper implementation of medical and environmental treatment can ultimately lead to a better psychosocial outcome.

Psychopathy: Developmental Perspectives and their Implications for Treatment

PubMed Central

Anderson, Nathaniel E.; Kiehl, Kent A.

2015-01-01

Psychopathy is a neuropsychiatric disorder marked by deficient emotional responses, lack of empathy, and poor behavioral controls, commonly resulting in persistent antisocial deviance and criminal behavior. Accumulating research suggests that psychopathy follows a developmental trajectory with strong genetic influences, and which precipitates deleterious effects on widespread functional networks, particularly within paralimbic regions of the brain. While traditional therapeutic interventions commonly administered in prisons and forensic institutions have been notoriously ineffective at combating these outcomes, alternative strategies informed by an understanding of these specific neuropsychological obstacles to healthy development, and which target younger individuals with nascent symptoms of psychopathy are more promising. Here we review recent neuropsychiatric and neuroimaging literature that informs our understanding of the brain systems compromised in psychopathy, and apply these data to a broader understanding of its developmental course, ultimately promoting more proactive intervention strategies profiting from adaptive neuroplasticity in youth. PMID:23542910

40 CFR 35.940-3 - Costs allowable, if approved.

Code of Federal Regulations, 2014 CFR

2014-07-01

... the treatment process, or that will be used for ultimate disposal of residues resulting from such... of compost residues which result from wastewater treatment, if EPA has approved a program for use of the compost. (d) Acquisition of an operable portion of a treatment works. This type of acquisition is...

40 CFR 35.940-3 - Costs allowable, if approved.

Code of Federal Regulations, 2012 CFR

2012-07-01

... the treatment process, or that will be used for ultimate disposal of residues resulting from such... of compost residues which result from wastewater treatment, if EPA has approved a program for use of the compost. (d) Acquisition of an operable portion of a treatment works. This type of acquisition is...

40 CFR 35.940-3 - Costs allowable, if approved.

Code of Federal Regulations, 2013 CFR

2013-07-01

... the treatment process, or that will be used for ultimate disposal of residues resulting from such... of compost residues which result from wastewater treatment, if EPA has approved a program for use of the compost. (d) Acquisition of an operable portion of a treatment works. This type of acquisition is...

Writing Treatment for Aphasia: A Texting Approach

ERIC Educational Resources Information Center

Beeson, Pelagie M.; Higginson, Kristina; Rising, Kindle

2013-01-01

Purpose: Treatment studies have documented the therapeutic and functional value of lexical writing treatment for individuals with severe aphasia. The purpose of this study was to determine whether such retraining could be accomplished using the typing feature of a cellular telephone, with the ultimate goal of using text messaging for…

Secondhand Smoke Exposure Reduction After NICU Discharge: Results of a Randomized Trial.

PubMed

Blaakman, Susan W; Borrelli, Belinda; Wiesenthal, Elise N; Fagnano, Maria; Tremblay, Paul J; Stevens, Timothy P; Halterman, Jill S

2015-01-01

Premature infants are at high risk for respiratory disease, and secondhand smoke (SHS) exposure further increases their risk for developing respiratory illness and asthma. Yet, SHS exposure remains problematic in this vulnerable population. Our objective was to evaluate the effects of brief asthma education plus motivational interviewing counseling on reducing SHS exposure and improving respiratory outcomes in premature infants compared to asthma education alone. Caregivers and their infants ≤32 weeks' gestational age were enrolled after discharge from a neonatal intensive care unit in Rochester, New York, from 2007 to 2011. Participants (N = 165, 61% Medicaid insurance, 35% Black, 19% Hispanic, 59% male) were stratified by infant SHS exposure and randomly assigned to treatment or comparison groups. Caregivers in the treatment group reported significantly more home smoking bans (96% vs 84%, P = .03) and reduced infant contact with smokers after the intervention (40% vs 58%, P = .03), but these differences did not persist long term. At study end (8 months after neonatal intensive care unit discharge), treatment group infants showed significantly greater reduction in salivary cotinine versus comparison (-1.32 ng/mL vs -1.08 ng/mL, P = .04), but no significant differences in other clinical outcomes. A community-based intervention incorporating motivational interviewing and asthma education may be helpful in reducing SHS exposure of premature infants in the short term. Further efforts are needed to support sustained protections for this high-risk group and ultimately, prevent acute and chronic respiratory morbidity. Strategies for successfully engaging families during this stressful period warrant attention. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

The antiplatelet effects of nitrates: is it of clinical significance in patients with cardiovascular disease?

PubMed

Zhou, Rui-Hai; Frishman, William H

2010-01-01

Organic nitrates have been used for over a century in cardiovascular therapy and are still widely used in the treatment of acute coronary syndromes, chronic angina pectoris, and congestive heart failure. Nitrates, together with sodium nitroprusside, generally referred to as nitrovasodilators, exert their biologic effects via the release of nitric oxide. They are also known as nitric oxide donors. The mechanism of action of these drugs is traditionally believed to lie in their arterial vasodilation and venodilation effects, resulting in an improvement of coronary artery blood supply and/or reduction of cardiac workload in the treatment of coronary artery disease and congestive heart failure. Recently it has been recognized that these drugs also have intrinsic antiplatelet and antithrombotic effects, demonstrated both in vitro and in vivo, which would add further rationale for the use of these drugs in atherothrombotic diseases. Research has shown that nitrovasodilators can nonselectively inhibit platelet aggregation induced by multiple stimuli. However, clinical trials have yielded conflicting results regarding clinical outcome, especially with long-term nitrate use. The potentially beneficial effects of nitrates could be negated by the development of tolerance and the generation of deleterious oxidative stress causing endothelial dysfunction during continuous nitrate administration. Much progress has been made in the development of new nitric oxide donors devoid of oxidant-generating properties. Novel combination therapies with nitrovasodilators plus antioxidants or agents with antioxidant properties have shown promise in reducing or reversing tolerance, potentiating antiplatelet effects, and improving clinical outcome. It is expected that clinical introduction of novel nitrovasodilator regimens will provide a new approach to the prevention and treatment of atherothrombotic diseases. Large-scale clinical trials will ultimately provide the evidence-based answers.

Neurodevelopmental consequences of pediatric cancer and its treatment: applying an early adversity framework to understanding cognitive, behavioral, and emotional outcomes.

PubMed

Marusak, Hilary A; Iadipaolo, Allesandra S; Harper, Felicity W; Elrahal, Farrah; Taub, Jeffrey W; Goldberg, Elimelech; Rabinak, Christine A

2018-06-01

Today, children are surviving pediatric cancer at unprecedented rates, making it one of modern medicine's true success stories. However, we are increasingly becoming aware of several deleterious effects of cancer and the subsequent "cure" that extend beyond physical sequelae. Indeed, survivors of childhood cancer commonly report cognitive, emotional, and psychological difficulties, including attentional difficulties, anxiety, and posttraumatic stress symptoms (PTSS). Cognitive late- and long-term effects have been largely attributed to neurotoxic effects of cancer treatments (e.g., chemotherapy, cranial irradiation, surgery) on brain development. The role of childhood adversity in pediatric cancer - namely, the presence of a life-threatening disease and endurance of invasive medical procedures - has been largely ignored in the existing neuroscientific literature, despite compelling research by our group and others showing that exposure to more commonly studied adverse childhood experiences (i.e., domestic and community violence, physical, sexual, and emotional abuse) strongly imprints on neural development. While these adverse childhood experiences are different in many ways from the experience of childhood cancer (e.g., context, nature, source), they do share a common element of exposure to threat (i.e., threat to life or physical integrity). Therefore, we argue that the double hit of early threat and cancer treatments likely alters neural development, and ultimately, cognitive, behavioral, and emotional outcomes. In this paper, we (1) review the existing neuroimaging research on child, adolescent, and adult survivors of childhood cancer, (2) summarize gaps in our current understanding, (3) propose a novel neurobiological framework that characterizes childhood cancer as a type of childhood adversity, particularly a form of early threat, focusing on development of the hippocampus and the salience and emotion network (SEN), and (4) outline future directions for research.

Outcomes of induction chemotherapy followed by chemoradiation using intensity-modulated radiation therapy for esophageal adenocarcinoma.

PubMed

Gerber, N; Ilson, D H; Wu, A J; Janjigian, Y Y; Kelsen, D P; Zheng, J; Zhang, Z; Bains, M S; Rizk, N; Rusch, V W; Goodman, K A

2014-04-01

This study looks at toxicity and survival data when chemoradiation (CRT) is delivered using intensity-modulated radiation therapy (IMRT) after induction chemotherapy. Forty-one patients with esophageal adenocarcinoma treated with IMRT from March 2007 to May 2009 at Memorial Sloan-Kettering Cancer Center were analyzed. All patients received induction chemotherapy prior to CRT. Thirty-nine percent (n = 16) of patients underwent surgical resection less than 4 months after completing CRT. Patients were predominantly male (78%), with a median age of 68 years (range 32-85 years). The majority of acute treatment-related toxicity was hematologic or gastrointestinal, with 17% of patients having grade 3+ hematologic toxicity and 12% of patients having grade 3+ gastrointestinal toxicity. Only two patients developed grade 2-3 pneumonitis (5%) and 5 patients experienced post-operative pulmonary complications (29%). Eight patients (20%) required a treatment break. With a median follow up of 41 months for surviving patients, 2-year overall survival was 61%, and the cumulative incidences of local failure (LF) and distant metastases were 40% and 51%, respectively. This rate of LF was reduced to 13% in patients who underwent surgical resection. Surgery and younger age were significant predictors of decreased time to LF on univariate analysis. Induction chemotherapy followed by CRT using IMRT in the treatment of esophageal cancer is well tolerated and is not associated with an elevated risk of postoperative pulmonary complications. The use of IMRT may allow for integration of more intensified systemic therapy or radiation dose escalation for esophageal adenocarcinoma, ultimately improving outcomes for patients with this aggressive disease. © 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.

Light on Body Image Treatment: Acceptance Through Mindfulness

ERIC Educational Resources Information Center

Stewart, Tiffany M.

2004-01-01

The treatment of body image has to be multifaceted and should be directed toward the treatment of the whole individual - body, mind, and spirit - with an ultimate culmination of acceptance and compassion for the self. This article presents information on a mindful approach to the treatment of body image as it pertains to concerns with body size…

Ultimate dynamics of the Kirschner-Panetta model: Tumor eradication and related problems

NASA Astrophysics Data System (ADS)

Starkov, Konstantin E.; Krishchenko, Alexander P.

2017-10-01

In this paper we consider the ultimate dynamics of the Kirschner-Panetta model which was created for studying the immune response to tumors under special types of immunotherapy. New ultimate upper bounds for compact invariant sets of this model are given, as well as sufficient conditions for the existence of a positively invariant polytope. We establish three types of conditions for the nonexistence of compact invariant sets in the domain of the tumor-cell population. Our main results are two types of conditions for global tumor elimination depending on the ratio between the proliferation rate of the immune cells and their mortality rate. These conditions are described in terms of simple algebraic inequalities imposed on model parameters and treatment parameters. Our theoretical studies of ultimate dynamics are complemented by numerical simulation results.

Patient profiling can identify patients with adult spinal deformity (ASD) at risk for conversion from nonoperative to surgical treatment: initial steps to reduce ineffective ASD management.

PubMed

Passias, Peter G; Jalai, Cyrus M; Line, Breton G; Poorman, Gregory W; Scheer, Justin K; Smith, Justin S; Shaffrey, Christopher I; Burton, Douglas C; Fu, Kai-Ming G; Klineberg, Eric O; Hart, Robert A; Schwab, Frank; Lafage, Virginie; Bess, Shay

2018-02-01

Non-operative management is a common initial treatment for patients with adult spinal deformity (ASD) despite reported superiority of surgery with regard to outcomes. Ineffective medical care is a large source of resource drain on the health system. Characterization of patients with ASD likely to elect for operative treatment from non-operative management may allow for more efficient patient counseling and cost savings. This study aimed to identify deformity and disability characteristics of patients with ASD who ultimately convert to operative treatment compared with those who remain non-operative and those who initially choose surgery. A retrospective review was carried out. A total of 510 patients with ASD (189 non-operative, 321 operative) with minimum 2-year follow-up comprised the patient sample. Oswestry Disability Index (ODI), Short-Form 36 Health Assessment (SF-36), Scoliosis Research Society questionnaire (SRS-22r), and spinopelvic radiographic alignment were the outcome measures. Demographic, radiographic, and patient-reported outcome measures (PROMs) from a cohort of patients with ASD prospectively enrolled into a multicenter database were evaluated. Patients were divided into three treatment cohorts: Non-operative (NON=initial non-operative treatment and remained non-operative), Operative (OP=initial operative treatment), and Crossover (CROSS=initial non-operative treatment with subsequent conversion to operative treatment). NON and OP groups were propensity score-matched (PSM) to CROSS for baseline demographics (age, body mass index, Charlson Comorbidity Index). Time to crossover was divided into early (<1 year) and late (>1 year). Outcome measures were compared across and within treatment groups at four time points (baseline, 6 weeks, 1 year, and 2 years). Following PSM, 118 patients were included (NON=39, OP=38, CROSS=41). Crossover rate was 21.7% (41/189). Mean time to crossover was 394 days. All groups had similar baseline sagittal alignment, but CROSS had larger pelvic incidence and lumbar lordosis (PI-LL) mismatch than NON (11.9° vs. 3.1°, p=.032). CROSS and OP had similar baseline PROM scores; however, CROSS had worse baseline ODI, PCS, SRS-22r (p<.05). At time of crossover, CROSS had worse ODI (35.7 vs. 27.8) and SRS Satisfaction (2.6 vs. 3.3) compared with NON (p<.05). Alignment remained similar for CROSS from baseline to conversion; however, PROMs (ODI, PCS, SRS Activity/Pain/Total) worsened (p<.05). Early and late crossover evaluation demonstrated CROSS-early (n=25) had worsening ODI, SRS Activity/Pain at time of crossover (p<.05). From time of crossover to 2-year follow-up, CROSS-early had less SRS Appearance/Mental improvement compared with OP. Both CROSS-early/late had worse baseline, but greater improvements, in ODI, PCS, SRS Pain/Total compared with NON (p<.05). Baseline alignment and disability parameters increased crossover odds-Non with Schwab T/L/D curves and ODI≥40 (odds ratio [OR]: 3.05, p=.031), and Non with high PI-LL modifier grades ("+"/'++') and ODI≥40 (OR: 5.57, p=.007) were at increased crossover risk. High baseline and increasing disability over time drives conversion from non-operative to operative ASD care. CROSS patients had similar spinal deformity but worse PROMs than NON. CROSS achieved similar 2-year outcome scores as OP. Profiling at first visit for patients at risk of crossover may optimize physician counseling and cost savings. Copyright © 2017. Published by Elsevier Inc.

Connecting Employers, Schools, and Youth through Intermediaries. Issue Brief.

ERIC Educational Resources Information Center

Mooney, Marianne; Crane, Kelli

Partnerships between education and business have proven to be an effective means for preparing young people with disabilities for positive postschool outcomes. Employers, however, are often inundated by requests to participate, causing confusion and ultimately hampering relationships between the two parties. This issue brief discusses how…

Public goods and procreation.

PubMed

Anomaly, Jonathan

2014-01-01

Procreation is the ultimate public goods problem. Each new child affects the welfare of many other people, and some (but not all) children produce uncompensated value that future people will enjoy. This essay addresses challenges that arise if we think of procreation and parenting as public goods. These include whether individual choices are likely to lead to a socially desirable outcome, and whether changes in laws, social norms, or access to genetic engineering and embryo selection might improve the aggregate outcome of our reproductive choices.

Human Trafficking, Sexual Assault, or Something Else? A Complicated Case With an Unexpected Outcome.

PubMed

Scott-Tilley, Donna; Crites, Heather

This case report presents a patient who presented multiple times with vaginal injuries and bleeding, reporting sexual assault with a foreign object. Findings from her history and physical examination were consistent with sexual assault and human trafficking. The outcome of this case was not what we initially expected when the patient first presented for care. However, the patient ultimately received the care she needed. This case illuminates the need for excellent continuing education, interdisciplinary communication, and continuity of care.

Clinical Outcome Assessments: Conceptual Foundation-Report of the ISPOR Clinical Outcomes Assessment - Emerging Good Practices for Outcomes Research Task Force.

PubMed

Walton, Marc K; Powers, John H; Hobart, Jeremy; Patrick, Donald; Marquis, Patrick; Vamvakas, Spiros; Isaac, Maria; Molsen, Elizabeth; Cano, Stefan; Burke, Laurie B

2015-09-01

An outcome assessment, the patient assessment used in an endpoint, is the measuring instrument that provides a rating or score (categorical or continuous) that is intended to represent some aspect of the patient's health status. Outcome assessments are used to define efficacy endpoints when developing a therapy for a disease or condition. Most efficacy endpoints are based on specified clinical assessments of patients. When clinical assessments are used as clinical trial outcomes, they are called clinical outcome assessments (COAs). COAs include any assessment that may be influenced by human choices, judgment, or motivation. COAs must be well-defined and possess adequate measurement properties to demonstrate (directly or indirectly) the benefits of a treatment. In contrast, a biomarker assessment is one that is subject to little, if any, patient motivational or rater judgmental influence. This is the first of two reports by the ISPOR Clinical Outcomes Assessment - Emerging Good Practices for Outcomes Research Task Force. This report provides foundational definitions important for an understanding of COA measurement principles. The foundation provided in this report includes what it means to demonstrate a beneficial effect, how assessments of patients relate to the objective of showing a treatment's benefit, and how these assessments are used in clinical trial endpoints. In addition, this report describes intrinsic attributes of patient assessments and clinical trial factors that can affect the properties of the measurements. These factors should be considered when developing or refining assessments. These considerations will aid investigators designing trials in their choice of using an existing assessment or developing a new outcome assessment. Although the focus of this report is on the development of a new COA to define endpoints in a clinical trial, these principles may be applied more generally. A critical element in appraising or developing a COA is to describe the treatment's intended benefit as an effect on a clearly identified aspect of how a patient feels or functions. This aspect must have importance to the patient and be part of the patient's typical life. This meaningful health aspect can be measured directly or measured indirectly when it is impractical to evaluate it directly or when it is difficult to measure. For indirect measurement, a concept of interest (COI) can be identified. The COI must be related to how a patient feels or functions. Procedures are then developed to measure the COI. The relationship of these measurements with how a patient feels or functions in the intended setting and manner of use of the COA (the context of use) could then be defined. A COA has identifiable attributes or characteristics that affect the measurement properties of the COA when used in endpoints. One of these features is whether judgment can influence the measurement, and if so, whose judgment. This attribute defines four categories of COAs: patient reported outcomes, clinician reported outcomes, observer reported outcomes, and performance outcomes. A full description as well as explanation of other important COA features is included in this report. The information in this report should aid in the development, refinement, and standardization of COAs, and, ultimately, improve their measurement properties. Copyright © 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Mechanical properties of Ti-6Al-4V specimens produced by shaped metal deposition

PubMed Central

Baufeld, Bernd; van der Biest, Omer

2009-01-01

Shaped metal deposition is a novel technique to build near net-shape components layer by layer by tungsten inert gas welding. Especially for complex shapes and small quantities, this technique can significantly lower the production cost of components by reducing the buy-to-fly ratio and lead time for production, diminishing final machining and preventing scrap. Tensile testing of Ti-6Al-4V components fabricated by shaped metal deposition shows that the mechanical properties are competitive to material fabricated by conventional techniques. The ultimate tensile strength is between 936 and 1014 MPa, depending on the orientation and location. Tensile testing vertical to the deposition layers reveals ductility between 14 and 21%, whereas testing parallel to the layers gives a ductility between 6 and 11%. Ultimate tensile strength and ductility are inversely related. Heat treatment within the α+β phase field does not change the mechanical properties, but heat treatment within the β phase field increases the ultimate tensile strength and decreases the ductility. The differences in ultimate tensile strength and ductility can be related to the α lath size and orientation of the elongated, prior β grains. The micro-hardness and Young’s modulus are similar to conventional Ti-6Al-4V with low oxygen content. PMID:27877271

Toward a Global Consensus on Outcome Measures for Clinical Trials in Tinnitus: Report From the First International Meeting of the COMiT Initiative, November 14, 2014, Amsterdam, The Netherlands

PubMed Central

Haider, Haúla; Kikidis, Dimitris; Mielczarek, Marzena; Mazurek, Birgit; Szczepek, Agnieszka J.; Cederroth, Christopher R.

2015-01-01

In Europe alone, over 70 million people experience tinnitus; for seven million people, it creates a debilitating condition. Despite its enormous socioeconomic relevance, progress in successfully treating the condition is somewhat limited. The European Union has approved funding to create a pan-European tinnitus research collaboration network (2014–2018). The goal of one working group is to establish an international standard for outcome measurements in clinical trials of tinnitus. Importantly, this would enhance tinnitus research by informing sample-size calculations, enabling meta-analyses, and facilitating the identification of tinnitus subtypes, ultimately leading to improved treatments. The first meeting followed a workshop on “Agreed Standards for Measurement: An International Perspective” with invited talks on clinimetrics and existing international initiatives to define core sets for outcome measurements in hearing loss (International classification of functioning, disability, and health core sets for hearing loss) and eczema (Harmonizing outcome measures for eczema). Both initiatives have taken an approach that clearly distinguishes the specification of what to measure from that of how to measure it. Meeting delegates agreed on taking a step-wise roadmap for which the first output would be a consensus on what outcome domains are essential for all trials. The working group seeks to embrace inclusivity and brings together clinicians, tinnitus researchers, experts on clinical research methodology, statisticians, and representatives of the health industry. People who experience tinnitus are another important participant group. This meeting report is a call to those stakeholders across the globe to actively participate in the initiative. PMID:25910505

Toward a Global Consensus on Outcome Measures for Clinical Trials in Tinnitus: Report From the First International Meeting of the COMiT Initiative, November 14, 2014, Amsterdam, The Netherlands.

PubMed

Hall, Deborah A; Haider, Haúla; Kikidis, Dimitris; Mielczarek, Marzena; Mazurek, Birgit; Szczepek, Agnieszka J; Cederroth, Christopher R

2015-04-24

In Europe alone, over 70 million people experience tinnitus; for seven million people, it creates a debilitating condition. Despite its enormous socioeconomic relevance, progress in successfully treating the condition is somewhat limited. The European Union has approved funding to create a pan-European tinnitus research collaboration network (2014-2018). The goal of one working group is to establish an international standard for outcome measurements in clinical trials of tinnitus. Importantly, this would enhance tinnitus research by informing sample-size calculations, enabling meta-analyses, and facilitating the identification of tinnitus subtypes, ultimately leading to improved treatments. The first meeting followed a workshop on "Agreed Standards for Measurement: An International Perspective" with invited talks on clinimetrics and existing international initiatives to define core sets for outcome measurements in hearing loss (International classification of functioning, disability, and health core sets for hearing loss) and eczema (Harmonizing outcome measures for eczema). Both initiatives have taken an approach that clearly distinguishes the specification of what to measure from that of how to measure it. Meeting delegates agreed on taking a step-wise roadmap for which the first output would be a consensus on what outcome domains are essential for all trials. The working group seeks to embrace inclusivity and brings together clinicians, tinnitus researchers, experts on clinical research methodology, statisticians, and representatives of the health industry. People who experience tinnitus are another important participant group. This meeting report is a call to those stakeholders across the globe to actively participate in the initiative. © The Author(s) 2015.

Connectivity in MEG resting-state networks increases after resective surgery for low-grade glioma and correlates with improved cognitive performance☆

PubMed Central

van Dellen, E.; de Witt Hamer, P.C.; Douw, L.; Klein, M.; Heimans, J.J.; Stam, C.J.; Reijneveld, J.C.; Hillebrand, A.

2012-01-01

Purpose Low-grade glioma (LGG) patients often have cognitive deficits. Several disease- and treatment related factors affect cognitive processing. Cognitive outcome of resective surgery is unpredictable, both for improvement and deterioration, especially for complex domains such as attention and executive functioning. MEG analysis of resting-state networks (RSNs) is a good candidate for presurgical prediction of cognitive outcome. In this study, we explore the relation between alterations in connectivity of RSNs and changes in cognitive processing after resective surgery, as a stepping stone to ultimately predict postsurgical cognitive outcome. Methods Ten patients with LGG were included, who had no adjuvant therapy. MEG recording and neuropsychological assessment were obtained before and after resective surgery. MEG data were recorded during a no-task eyes-closed condition, and projected to the anatomical space of the AAL atlas. Alterations in functional connectivity, as characterized by the phase lag index (PLI), within the default mode network (DMN), executive control network (ECN), and left- and right-sided frontoparietal networks (FPN) were compared to cognitive changes. Results Lower alpha band DMN connectivity was increased after surgery, and this increase was related to improved verbal memory functioning. Similarly, right FPN connectivity was increased after resection in the upper alpha band, which correlated with improved attention, working memory and executive functioning. Discussion Increased alpha band RSN functional connectivity in MEG recordings correlates with improved cognitive outcome after resective surgery. The mechanisms resulting in functional connectivity alterations after resection remain to be elucidated. Importantly, our findings indicate that connectivity of MEG RSNs may be used for presurgical prediction of cognitive outcome in future studies. PMID:24179752

[Treatment perspectives].

PubMed

Garnier-Lengliné, H; Malamut, G; Cerf-Bensussan, N; Ruemmele, F M

2013-06-01

Celiac disease (CD) is a chronic inflammatory enteropathy caused by the ingestion of gluten. A safe and efficient but unpleasant treatment exists for CD in form of a strict gluten-free diet. Thus, there is a need for new treatment strategies, which are based on the improved and advanced understanding of the pathophysiology of CD. The first strategy consists in reducing or even eliminating major antigenic motifs in gluten, responsible for the inflammatory reaction. The use of less immunogenic wheat was suggested but this seems rather difficult to realize. However, a complete digestion of the immunogenic parts of gluten looks very promising. This can be obtained by the use of polymers, capable to sequester gluten proteins or even better via the exogenous administration of propyl-endopeptidases, with two different enzymes under development. Another approach could be the use of inhibitors of tissue transglutaminase, a strategy which is under clinical investigation. Alternatively, inhibition of the site of liaison of immunostimulatory peptides with HLA molecules was suggested and is also under investigation in vivo. For patients suffering from refractory sprue, the inhibition of IL15 might be of therapeutic interest with the hope to improve the fatal outcome of many of these patients. However, the ultimate treatment approach is in form of prevention and the role of infectious agents, such as Rotavirus, in disease onset has to be considered. Copyright © 2011. Published by Elsevier SAS.

Initial treatment of complete rotator cuff tear and transition to surgical treatment: systematic review of the evidence

PubMed Central

Abdul-Wahab, Taiceer A.; Betancourt, Jean P.; Hassan, Fadi; Thani, Saeed Al.; Choueiri, Hened; Jain, Nitin B.; Malanga, Gerard A.; Murrell, William D.; Prasad, Anil; Verborgt, Olivier

2016-01-01

Summary Background rotator cuff tear affects many people. Natural history, and evidence for non-operative treatment remains limited. Our objective is to assess evidence available for the efficacy and morbidity of commonly used systemic medications, physiotherapy, and injections alongside evaluating any negative long-term effects. Methods a systematic search was performed of PubMed, Cochrane, EMBASE and CINAHL dates (1 January 1960 – 1 December 2014), search terms: ‘rotator cuff tear’, ‘natural history’, ‘atraumatic’, ‘injection’, ‘physiotherapy’ or ‘physical therapy’, ‘injection’, ‘corticosteroid’, ‘PRP‘, ‘MSC’, risk of conservative treatment’, and ‘surgical indication’. Results eleven studies were included. The mean Coleman Methodology Score modified for conservative therapy is 69.21 (range 88–44) (SD 12.31). This included 2 RCTs, 7 prospective, and 2 retrospective studies. Evidence suggests it is safe to monitor symptomatic rotator cuff tears, as tear size and symptoms are not correlated with pain, function, and/or ultimate outcome. Conclusions complete rotator cuff tears may be effectively treated with injections, exercise in the short and intermediate terms respectively. Negative effect of corticosteroids on rotator cuff tissue has not been demonstrated. Timing to end conservative treatment is unknown, but likely indicated when a patient demonstrates increased weakness and loss of function not recoverable by physiotherapy. PMID:27331030

Safety Behaviors in Adults With Social Anxiety: Review and Future Directions.

PubMed

Piccirillo, Marilyn L; Taylor Dryman, M; Heimberg, Richard G

2016-09-01

Safety behaviors are considered an important factor in the maintenance of social anxiety disorder (SAD). Safety behaviors are typically employed by socially anxious individuals to reduce anxiety in feared social situations. However, by preventing individuals with social anxiety from gathering evidence that would disconfirm their maladaptive beliefs about social situations, the use of safety behaviors ultimately maintains social anxiety over time. Twenty years ago, Wells and colleagues (1995) demonstrated that use of safety behaviors diminishes the efficacy of exposure treatment for SAD, suggesting that reduction in the use of safety behaviors during exposure can enhance treatment response. Research on safety behaviors has expanded considerably since Wells et al.'s seminal publication, and our understanding of the role safety behaviors may play in the maintenance of social anxiety has grown in breadth and depth. In this paper, we present a detailed review of the published research on safety behaviors relevant to social anxiety and social-anxiety-related processes. Finally, we evaluate the impact of safety behaviors on the outcome of treatment for SAD, and we look to the literature on safety behaviors in other anxiety disorders to inform our understanding of use of safety behaviors during exposure and to facilitate future research in SAD. Copyright © 2015. Published by Elsevier Ltd.

p53 and Ca(2+) signaling from the endoplasmic reticulum: partners in anti-cancer therapies.

PubMed

Bittremieux, Mart; Bultynck, Geert

2015-01-01

Ca(2+) transfer from the endoplasmic reticulum (ER) to the mitochondria critically controls cell survival and cell death decisions. Different oncogenes and deregulation of tumor suppressors exploit this mechanism to favor the survival of altered, malignant cells. Two recent studies of the Pinton team revealed a novel, non-transcriptional function of cytosolic p53 in cell death. During cell stress, p53 is recruited to the ER and the ER-mitochondrial contact sites. This results in augmented ER Ca(2+) levels by enhancing sarco/endoplasmic reticulum Ca(2+) ATPase (SERCA) activity, ultimately promoting mitochondrial Ca(2+) overload. The boosting of "toxic" Ca(2+) signaling by p53 appears to be a critical component of the cell death-inducing properties of chemotherapeutic agents and anti-cancer treatments, like photodynamic stress. Strikingly, the resistance of p53-deficient cancer cells to these treatments could be overcome by facilitating Ca(2+) transfer between the ER and the mitochondria via overexpression of SERCA or of the mitochondrial Ca(2+) uniporter (MCU). Importantly, these concepts have also been supported by in vivo Ca(2+) measurements in tumor masses in mice. Collectively, these studies link for the first time the major tumor suppressor, p53, to Ca(2+) signaling in dictating cell-death outcomes and by the success of anti-cancer treatments.

FANCD2 re-expression is associated with glioma grade and chemical inhibition of the Fanconi Anaemia pathway sensitises gliomas to chemotherapeutic agents.

PubMed

Patil, Abhijit A; Sayal, Parag; Depondt, Marie-Lise; Beveridge, Ryan D; Roylance, Anthony; Kriplani, Deepti H; Myers, Katie N; Cox, Angela; Jellinek, David; Fernando, Malee; Carroll, Thomas A; Collis, Spencer J

2014-08-15

Brain tumours kill more children and adults under 40 than any other cancer. Around half of primary brain tumours are glioblastoma multiforme (GBMs) where treatment remains a significant challenge, where survival rates have improved little over the last 40 years, thus highlighting an unmet need for the identification/development of novel therapeutic targets and agents to improve GBM treatment. Using archived and fresh glioma tissue, we show that in contrast to normal brain or benign schwannomas GBMs exhibit re-expression of FANCD2, a key protein of the Fanconi Anaemia (FA) DNA repair pathway, and possess an active FA pathway. Importantly, FANCD2 expression levels are strongly associated with tumour grade, revealing a potential exploitable therapeutic window to allow inhibition of the FA pathway in tumour cells, whilst sparing normal brain tissue. Using several small molecule inhibitors of the FA pathway in combination with isogenic FA-proficient/deficient glioma cell lines as well as primary GBM cultures, we demonstrate that inhibition of the FA pathway sensitises gliomas to the chemotherapeutic agents Temozolomide and Carmustine. Our findings therefore provide a strong rationale for the development of novel and potent inhibitors of the FA pathway to improve the treatment of GBMs, which may ultimately impact on patient outcome.

The resistance mechanisms and treatment strategies for EGFR-mutant advanced non-small-cell lung cancer

PubMed Central

Zhong, Wen-Zhao; Zhou, Qing; Wu, Yi-Long

2017-01-01

Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKI) have been established as the standard therapy for EGFR-sensitizing mutant advanced non-small-cell lung cancer (NSCLC). However, patients ultimately develop resistance to these drugs. There are several mechanisms of both primary and secondary resistance to EGFR-TKIs. The primary resistance mechanisms include point mutations in exon 18, deletions or insertions in exon 19, insertions, duplications and point mutations in exon 20 and point mutation in exon 21 of EGFR gene. Secondary resistance to EGFR-TKIs is due to emergence of T790M mutation, activation of alternative signaling pathways, bypassing downstream signaling pathways and histological transformation. Strategies to overcome these intrinsic and acquired resistance mechanisms are complex. With the development of the precision medicine for advanced NSCLC, available systemic and local treatment options have expanded, requiring new clinical algorithms that take into account resistance mechanism. Though combination therapy is emerging as the standard of to overcome resistance mechanisms. Personalized treatment modalities based on molecular diagnosis and monitoring is essential for disease management. Emerging data from the ongoing clinical trials on combination therapy of third generation TKIs and antibodies in EGFR mutant NSCLC are promising for better survival outcomes. PMID:29050366

The present state of treatments for articular cartilage defects in the knee

PubMed Central

Perera, JR; Gikas, PD; Bentley, G

2012-01-01

INTRODUCTION Chondral and osteochondral lesions of the knee are notoriously difficult to treat due to the poor healing capacity of articular cartilage and the hostile environment of moving joints, ultimately causing disabling pain and early osteoarthritis. There are many different reconstructive techniques used currently but few are proven to be of value. However, some have been shown to produce a better repair with hyaline-like cartilage rather than fibrocartilage. METHODS A systematic search of all available online databases including PubMed, MEDLINE® and Embase™ was undertaken using several keywords. All the multiple treatment options and methods available were considered. These were summarised and the evidence for and against them was scrutinised. RESULTS A total of 460 articles were identified after cross-referencing the database searches using the keywords. These revealed that autologous and matrix assisted chondrocyte implantation demonstrated both ‘good to excellent’ histological results and significant improvement in clinical outcomes. CONCLUSIONS Autologous and matrix assisted chondrocyte implantation have been shown to treat symptomatic lesions successfully with significant histological and clinical improvement. There is, however, still a need for further randomised clinical trials, perfecting the type of scaffold and the use of adjuncts such as growth factors. A list of recommendations for treatment and the potential future trends of managing these lesions are given. PMID:22943326

Management of adverse events in patients with hormone receptor-positive breast cancer treated with everolimus: observations from a phase III clinical trial.

PubMed

Peterson, Mary E

2013-08-01

Everolimus is a mammalian target of rapamycin (mTOR) inhibitor approved for the treatment of advanced renal cell carcinoma, pancreatic neuroendocrine tumors, subependymal giant cell astrocytoma associated with tuberous sclerosis complex, renal angiomyolipoma and tuberous sclerosis complex, and, in combination with exemestane, for hormone receptor-positive HER2-negative advanced breast cancer after failure of treatment with letrozole or anastrozole. Results from the phase III BOLERO-2 trial demonstrated that everolimus in combination with exemestane provided significant clinical benefit to patients with advanced hormone receptor-positive breast cancer. Although everolimus is generally well tolerated, as with most therapies administered in an advanced cancer setting, drug-related adverse events (AEs) inevitably occur. Most common AEs observed in the everolimus studies include stomatitis, rash, infection, noninfectious pneumonitis, and hyperglycemia. Clinical awareness and early identification of such AEs by oncology nurses are essential to dosing (interruptions, reduction, and treatment discontinuation); quality of life; and, ultimately, patient outcomes. Because everolimus has already been shown to significantly improve clinical efficacy in patients with advanced breast cancer, a proactive approach to the practical management of AEs associated with this mTOR inhibitor as well as other most common AEs observed in this patient population has been reviewed and outlined here.

Assessing motivation to change in eating disorders: a systematic review.

PubMed

Hoetzel, Katrin; von Brachel, Ruth; Schlossmacher, Lena; Vocks, Silja

2013-01-01

Patients with anorexia and bulimia nervosa are often ambivalent about their eating disorder symptoms. Therefore, a lack of motivation to change is a frequent problem in the treatment of eating disorders. This is of high relevance, as a low motivation to change is a predictor of an unfavourable treatment outcome and high treatment dropout rates. In order to quantify the degree of motivation to change, valid and reliable instruments are required in research and practice. The transtheoretical model of behaviour change (TTM) offers a framework for these measurements. This paper reviews existing instruments assessing motivation to change in eating disorders. We screened N = 119 studies from the databases Medline and Psycinfo found by combinations of the search keywords 'eating disorder', 'anorexia nervosa', 'bulimia nervosa', 'motivation', 'readiness to change', 'assessment', 'measurement', and 'questionnaire'. Ultimately, n = 15 studies investigating psychometric properties of different assessment tools of motivation to change in eating disorders were identified. Reviewed instruments can be divided into those assessing the stages of change according to the TTM (6 instruments) and those capturing decisional balance (3 instruments). Overall, the psychometric properties of these instruments are satisfactory to good. Advantages, disadvantages, and limitations of the reviewed assessment tools are discussed. So far, the TTM provides the only framework to assess motivation to change in eating disorders.

FANCD2 re-expression is associated with glioma grade and chemical inhibition of the Fanconi Anaemia pathway sensitises gliomas to chemotherapeutic agents

PubMed Central

Patil, Abhijit A.; Sayal, Parag; Depondt, Marie-Lise; Beveridge, Ryan D.; Roylance, Anthony; Kriplani, Deepti H.; Myers, Katie N.; Cox, Angela; Jellinek, David; Fernando, Malee; Carroll, Thomas A.; Collis, Spencer J.

2014-01-01

Brain tumours kill more children and adults under 40 than any other cancer. Around half of primary brain tumours are glioblastoma multiforme (GBMs) where treatment remains a significant challenge. GBM survival rates have improved little over the last 40 years, thus highlighting an unmet need for the identification/development of novel therapeutic targets and agents to improve GBM treatment. Using archived and fresh glioma tissue, we show that in contrast to normal brain or benign schwannomas GBMs exhibit re-expression of FANCD2, a key protein of the Fanconi Anaemia (FA) DNA repair pathway, and possess an active FA pathway. Importantly, FANCD2 expression levels are strongly associated with tumour grade, revealing a potential exploitable therapeutic window to allow inhibition of the FA pathway in tumour cells, whilst sparing normal brain tissue. Using several small molecule inhibitors of the FA pathway in combination with isogenic FA-proficient/deficient glioma cell lines as well as primary GBM cultures, we demonstrate that inhibition of the FA pathway sensitises gliomas to the chemotherapeutic agents Temozolomide and Carmustine. Our findings therefore provide a strong rationale for the development of novel and potent inhibitors of the FA pathway to improve the treatment of GBMs, which may ultimately impact on patient outcome. PMID:25071006

The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk.

PubMed

Jobes, David A

2012-12-01

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based clinical intervention that has significantly evolved over 25 years of clinical research. CAMS is best understood as a therapeutic framework that emphasizes a unique collaborative assessment and treatment planning process between the suicidal patient and clinician. This process is designed to enhance the therapeutic alliance and increase treatment motivation in the suicidal patient. Central to the CAMS approach is the use of the Suicide Status Form (SSF), which is a multipurpose clinical assessment, treatment planning, tracking, and outcome tool. The original development of CAMS was largely rooted in SSF-based quantitative and qualitative assessment of suicidal risk. As this line of research progressed, CAMS emerged as a problem-focused clinical intervention that is designed to target and treat suicidal "drivers" and ultimately eliminate suicidal coping. To date, CAMS (and the clinical use of the SSF) has been supported by six published correlational studies and one randomized clinical trial (RCT). Currently, two well-powered RCTs are under way, and various new CAMS-related projects are also being pursued. The clinical and empirical evolution of CAMS-how it was developed and what are the next steps for this clinical approach-are described here. © 2012 The American Association of Suicidology.

The role of social support in post-treatment surveillance among African American colorectal cancer survivors

PubMed Central

Le, Daisy; Holt, Cheryl L.; Pisu, Maria; Brown-Galvan, Aquila; Fairley, Temeika L.; Smith, Judith Lee; White, Arica; Hall, Ingrid J.; Oster, Robert A.; Martin, Michelle Y.

2017-01-01

Objectives African Americans are less likely than other groups to receive appropriate surveillance after colorectal cancer (CRC) treatment. The objective of this study is to qualitatively explore the role of social support in post-CRC treatment surveillance and ultimately, inform interventions to promote surveillance in African American CRC survivors. Design Interviews were conducted with 60 African American CRC survivors recruited from the Cancer Care Outcomes Research and Surveillance (CanCORS) study and the Alabama Statewide Cancer Registry. Interviews were recorded and transcribed. Transcripts were reviewed and coded independently by the authors. The NVivo software package was used to facilitate coding and data management. Results Survivors were from 4 to 6 years post diagnosis, 57% female, 60% older than 65 years, 57% from rural Alabama, 30% with stage 1, 32% with stage 2, and 38% with stage 3 disease. Material and emotional social support from family and one’s faith community were cited as playing an important role in coping with the disease and post-treatment surveillance. Survivors who reported being adherent with post-treatment surveillance recommendations (according to stage of disease based on self-report of colonoscopy, CT scans, and blood work) reported more religious material and non-material social support, and support from other CRC survivors. Conclusion In these African American CRC survivors, support from family, other cancer survivors, and the faith community was perceived as being important for adherence to post-treatment surveillance. Interventions to increase post-treatment surveillance in this population may be enhanced by including components that emphasize familial, other cancer survivor, and religious support. PMID:24611486

Pediatric paradoxical vocal-fold motion: presentation and natural history.

PubMed

Maturo, Stephen; Hill, Courtney; Bunting, Glenn; Baliff, Cathy; Ramakrishna, Jyoti; Scirica, Christina; Fracchia, Shannon; Donovan, Abigail; Hartnick, Christopher

2011-12-01

To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment. This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period. Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8-18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period. To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

Ursodeoxycholic acid for cystic fibrosis-related liver disease.

PubMed

Cheng, Katharine; Ashby, Deborah; Smyth, Rosalind L

2017-09-11

Abnormal biliary secretion leads to the thickening of bile and the formation of plugs within the bile ducts; the consequent obstruction and abnormal bile flow ultimately results in the development of cystic fibrosis-related liver disease. This condition peaks in adolescence with up to 20% of adolescents with cystic fibrosis developing chronic liver disease. Early changes in the liver may ultimately result in end-stage liver disease with people needing transplantation. One therapeutic option currently used is ursodeoxycholic acid. This is an update of a previous review. To analyse evidence that ursodeoxycholic acid improves indices of liver function, reduces the risk of developing chronic liver disease and improves outcomes in general in cystic fibrosis. We searched the Cochrane CF and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. We also contacted drug companies and searched online trial registries.Date of the most recent search of the Group's trials register: 09 April 2017. Randomised controlled trials of the use of ursodeoxycholic acid for at least three months compared with placebo or no additional treatment in people with cystic fibrosis. Two authors independently assessed trial eligibility and quality. The authors used GRADE to assess the quality of the evidence. Twelve trials have been identified, of which four trials involving 137 participants were included; data were only available from three of the trials (118 participants) since one cross-over trial did not report appropriate data. The dose of ursodeoxycholic acid ranged from 10 to 20 mg/kg/day for up to 12 months. The complex design used in two trials meant that data could only be analysed for subsets of participants. There was no significant difference in weight change, mean difference -0.90 kg (95% confidence interval -1.94 to 0.14) based on 30 participants from two trials. Improvement in biliary excretion was reported in only one trial and no significant change after treatment was shown. There were no data available for analysis for long-term outcomes such as death or need for liver transplantation. There are few trials assessing the effectiveness of ursodeoxycholic acid. The quality of the evidence identified ranged from low to very low. There is currently insufficient evidence to justify its routine use in cystic fibrosis.

Perception of Problem Severity, Treatment Motivations, Experiences, and Long-Term Plans among Pregnant Women in a Detoxification Inpatient Unit

ERIC Educational Resources Information Center

Jackson, Afton; Shannon, Lisa

2013-01-01

The purpose of this study was to examine pregnant women's substance use from initial use, to recognition of problem severity, motivations for treatment, and ultimately to treatment entry. The sample consisted of 114 pregnant women receiving inpatient detoxification treatment at the University of Kentucky Chandler Medical Center. Qualitative and…

The Power of Teacher Expectations: How Racial Bias Hinders Student Attainment

ERIC Educational Resources Information Center

Gershenson, Seth; Papageorge, Nicholas

2018-01-01

Despite abundant anecdotes and theories suggesting a causal effect of teachers' expectations on student outcomes, documenting its presence and size has been challenging. The reason is simple: positive correlations between what teachers expect and what students ultimately accomplish might simply result from teachers being skilled observers. In…

Mental Toughness

ERIC Educational Resources Information Center

Quinn, Tori; Cavanaugh, Lauren

2017-01-01

Mental toughness (MT) is defined as a set of attributes that allow an individual to persevere through difficult circumstances that ultimately can lead to successful outcomes. It is also a critical component of maximizing the performance of an athlete. These attributes assist with and promote a state of mind that enhances performance. A negative…

The nuclear debate: Deterrence and the lapse of faith

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

Tucker, R.W.

1985-01-01

This essay examines the growth of skepticism about the present system of nuclear deterrence. Tucker resists predicting the ultimate outcome, but he views the nuclear debate of this decade as an important ''lapse of faith'' in deterrence and he doubts there will ever be a full restoration of confidence.

The Expected Adjustment and Academic Outcomes of Honors College Students

ERIC Educational Resources Information Center

Washington, Christina R.

2012-01-01

The transition to an institution of higher education can present challenges and difficulties, but it is a student's expectations that can ultimately predict adjustment (Jackson, Pancer, Pratt, & Hunsberger, 2000). A larger number of students who experience difficulties in their adjustment end up withdrawing from the institution (Baker…

DEVELOPMENT OF AN IN VITRO TEST AND A PROTOTYPE MODEL TO PREDICT CELLULAR PENETRATION OF NANOPARTICLES

EPA Science Inventory

This research will aid in developing a common language that describes NPs and their characteristics. The outcomes will set the stage for correlating the properties of nanoparticles with their impact on epithelial cells and ultimately their biological fate and toxicity. The pro...

Research Methodology: A Practitioner Approach

ERIC Educational Resources Information Center

Singh, Sukhpal; Chana, Inderveer; Singh, Maninder

2015-01-01

The ultimate goal of scientific research is publication so as to showcase the research outcomes. Scientists, starting as graduate students, are measured primarily not by their dexterity in laboratory manipulations, not by their innate knowledge of either broad or narrow scientific subjects, and certainly not by their wit or charm; they are…

Dealing with Human Death: The Floating Perspective.

ERIC Educational Resources Information Center

Kenyon, Gary M.

1991-01-01

Explores approach to dealing with human death. Describes floating perspective, based on insights from Choron and Jaspers, as suggesting it is possible to deal with human death by refraining from taking ultimate position on the problem. Position encourages openness to death. Examines role of anxiety and describes possible meaningful outcomes of…

The Collaborative Case: From Class Assignment to Publication

ERIC Educational Resources Information Center

Sharen, Colleen; Feltham, Mark; Braecker, Michelle

2017-01-01

This essay describes an undergraduate research project involving collaboration among two professors and a student. The result, a business case about the student's workplace, was ultimately presented at an academic conference and is now under consideration for publication. We describe the circumstances that led to the project, its outcomes, and our…

Machine Vision Giving Eyes to Robots. Resources in Technology.

ERIC Educational Resources Information Center

Technology Teacher, 1990

1990-01-01

This module introduces machine vision, which can be used for inspection, robot guidance and part sorting. The future for machine vision will include new technology and will bring vision systems closer to the ultimate vision processor, the human eye. Includes a student quiz, outcomes, and activities. (JOW)

Core-Course Faculty Development Series on Methodology.

ERIC Educational Resources Information Center

Alewynse, John

This report describes a three-year project at Hampton University (Virginia) to improve the core freshman year curriculum and, ultimately, to improve student learning outcomes. The project involved the development of annual week-long seminars on the teaching of freshman courses in composition, speech, history, and mathematics. Emphasis was on…

Understanding College Students' Problems: Dysfunctional Thinking, Mental Health, and Maladaptive Behavior

ERIC Educational Resources Information Center

Mandracchia, Jon T.; Pendleton, Shandrea

2015-01-01

Many college students experience mental health problems and engage in risky behavior. These problems perpetuate negative outcomes such as poor academic performance and health problems, which may ultimately result in dropping out of college. Maladaptive cognitions, such as criminogenic thinking, have been established as an important contributor to…

Documenting Instructional Practices in Large Introductory STEM Lecture Courses

ERIC Educational Resources Information Center

Vu, Viet Quoc

2017-01-01

STEM education reform in higher education is framed around the need to improve student learning outcomes, increase student retention, and increase the number of underrepresented minorities and female students in STEM fields, all of which would ultimately contribute to America's competitiveness and prosperity. To achieve these goals, education…

Step 7: Choose the "Best" Risk Management Alternative

USDA-ARS?s Scientific Manuscript database

The ultimate purpose of the SRM tactical phase is to choose how to manage risk. Prior to this stage, we determined the sources of risk, identified the relevant management actions and estimated the likelihood of all known outcomes. Next, we combine this information with your personal risk preference...

Neurologist-patient communication about epilepsy in the United States, Spain, and Germany.

PubMed

Stern, John M; Cendes, Fernando; Gilliam, Frank; Kwan, Patrick; Ryvlin, Philippe; Sirven, Joseph; Smith, Brien; Adomas, Aleksandra; Walter, Lauren

2018-04-01

Effective communication between patients and their health care providers is recognized as critically important to improve the quality of health services for individuals with epilepsy. We aimed to describe in-office neurologist-patient conversations about epilepsy and focus on disease identification, shared decision-making, and care planning. Transcripts and audio recordings of conversations between patients and neurologists in the United States, Spain, and Germany were analyzed linguistically in the topic areas of epilepsy identification and diagnosis, disease education, treatments, and care planning. Analyses included word-level assessments, topic switching, strategies of information elicitation, identification of topics discussed, quantification of questions asked, and assessment of types of questions asked. Conversations of 17 neurologists in the United States, 12 in Spain, and 6 in Germany, with 50, 20, and 16 patients, respectively, were analyzed. Neurologists tended to utilize an event-based, patient-friendly vocabulary to refer to seizures, and in the United States, they avoided using the term "epilepsy." Regardless of who initiated the treatment discussion, the neurologists in all 3 countries were unilaterally responsible for the treatment decision and choice of medication. When describing a new medication, neurologists most often discussed potential side effects but did not review potential benefits. Neurologists rarely defined seizure control and did not ask patients what seizure control meant to them. We identified opportunities related to vocabulary, decision-making, and treatment goal setting that could be targeted to improve neurologist-patient communication about epilepsy, and ultimately, the overall treatment experience and outcomes for patients.

The effects of acupoint-catgut embedment combined with medical treatment on the BODE index scores of chronic obstructive pulmonary disease (COPD) patients

NASA Astrophysics Data System (ADS)

Giri, P. B. S. W.; Srilestari, A.; Abdurrohim, K.; Yunus, F.

2017-08-01

Chronic Obstructive Pulmonary Disease (COPD) is now the fourth leading cause of death in the world. As COPD medications are associated with high mortality levels, continuous research into the improvement of treatment modalities is being conducted. This study aimed to identify the effects of acupoint-catgut embedment combined with medical treatment on the Body mass index, airflow Obstruction, Dyspnea and Exercise capacity (BODE) index scores of COPD patients. A single-blind randomized controlled trial was conducted on 48 patients; participants were allocated into either the acupoint-catgut embedment with medication group (case group) or the sham acupuncture with medication group (control group). Acupoint-catgut embedment was conducted at the BL13 Feishu, BL43 Gaohuangshu, BL20 Pishu, BL23 Shenshu, and ST40 Fenglong points two times at an interval of 15 days. The BODE index, a primary outcome indicator, was assessed on Day 1 and Day 30. The results showed statistically and clinically significant differences between the two groups—in fact, BODE index scores were reduced by 1.83 points in the case group (p = 0.000). Ultimately, BODE index scores were lower in the intervention group than in the control group, thus indicating a statistically significant and clinically important improvement of COPD-related symptoms. According to these results, acupoint-catgut embedment combined with medical treatment is concluded to be more effective than medical treatment alone in reducing BODE index scores.

Effect of thermomechanical treatment on the microstructure, phase composition, and mechanical properties of Al-Cu-Mn-Mg-Zr alloy

NASA Astrophysics Data System (ADS)

Zuiko, I. S.; Gazizov, M. R.; Kaibyshev, R. O.

2016-09-01

The effect of the thermomechanical treatment on the microstructure, phase composition, and mechanical properties of heat-treatable AA2519 aluminum alloy (according to the classification of the Aluminum Association) has been considered. After solid-solution treatment, quenching, and artificial aging (T6 treatment) at 180°C for the peak strength, the yield stress, ultimate tensile strength, and elongation to failure are ~300 MPa, 435 MPa, and 21.7%, respectively. It has been shown that treatments that include intermediate plastic deformations with degrees of 7 and 15% (T87 and T815 treatments, respectively) have a significant effect on the phase composition and morphology of strengthening particles precipitated during peak aging T8X type, where X is pre-strain percent, treatments initiate the precipitation of significant amounts of particles of the θ'- and Ω-phases. After T6 treatment, predominantly homogeneously distributed particles of θ″-phase have been observed. Changes in the microstructure and phase composition of the AA2519 alloy, which are caused by intermediate deformation, lead to a significant increase in the yield stress and ultimate tensile strength (by ~40 and ~8%, respectively), whereas the plasticity decreases by 40-50%.

Hooking-Up, Religiosity, and Sexting Among College Students.

PubMed

Hall, Michael; Williams, Ronald D; Ford, M Allison; Cromeans, Erin Murphy; Bergman, Randall J

2016-07-28

The purpose of this study was to evaluate the mediation effect of sexting, and taking sexually suggestive photos on religiosity and hooking-up with three separate sexual outcomes. A web-based survey examined the relationship between religiosity and the three hooking-up outcomes among students reporting sexting or taking a sexually suggestive photo in the last 30 days (n = 231). Sexting, as well as taking sexually suggestive photos mediated the relationship between religiosity and hooking-up among females. Sexting may be initiated by females as a way to engage in a nonphysical sexual interaction, which ultimately predisposes them to a physical sexual outcome.

Management of iatrogenic urorectal fistulae in men with pelvic cancer

PubMed Central

Martins, Francisco E.; Martins, Natália M.; Pinheiro, Luís Campos; Ferraz, Luís; Xambre, Luís; Lopes, Tomé M.

2017-01-01

Introduction Urorectal fistula (URF) is a devastating complication of pelvic cancer treatments and a surgical challenge for the reconstructive surgeon. We report a series of male patients with URF resulting from pelvic cancer treatments, specifically prostate (PCa), bladder (BCa), and rectal cancer (RCa), and explore the differences and impact on outcomes between purely surgical and non-surgical treatment modalities. Methods Between October 2008 and June 2015, 15 male patients, aged 59–78 years (mean 67), with URF induced by pelvic cancer treatments were identified in our institutions. Patients with a history of diverticulitis, inflammatory bowel disease, or other benign conditions were excluded. We reviewed the patients’ medical records for symptoms, diagnostic tests performed, type and etiology of the fistula, type of surgical reconstruction, followup, and outcomes. Results Fourteen patients underwent surgical reconstruction. One patient developed metastatic disease before URF repair and, therefore, was excluded from this study. Mean followup (FU) was 32.7 months (14–79). All patients received diverting colostomy and temporary urinary diversion. An exclusively transperineal approach was used in nine (64.3%) patients and a combined abdominoperineal in five (35.7%). Overall successful URF closure was achieved in 12 (85.7%) patients, nine (64.3%) of whom at the first reconstructive attempt, two (14.3%) after two attempts (in our institution), and one (7.1%) after three attempts (two of which elsewhere). An interposition flap was used in seven (50%) patients. Surgical reconstruction failed ultimately in two (14.3%) patients who still have a colostomy and do not wish any further reconstruction. Conclusions Our study has several limitations, including its retrospective nature and the heterogeneity of our small patient cohort. Nonetheless, although surgical reconstruction of URF may be extremely difficult and complex in the non-surgical/energy ablation patients, its successful reconstruction is possible in most through a transperineal, or a more aggressive abdominoperineal, approach with tissue interposition in selected patients. PMID:29382460

An Australian government dental scheme: Doctor-dentist-patient tensions in the triangle.

PubMed

Weerakoon, Arosha; Fitzgerald, Lisa; Porter, Suzette

2014-11-30

Autonomy of participants is challenged when legislation to provide a public health service is weakly designed and implemented. Australia's Chronic Disease Dental Scheme was instigated to provide a government subsidy for private dental treatment for people suffering chronic illness impacting their oral health or vice versa. They were allocated AUD$4250 towards comprehensive treatment over 2 years with their eligibility determined by their general medical doctor. A qualitative research study was conducted to explore the experiences from the perspectives of the patient, medical and dental practitioner. One of the research outcomes identified a frequently reported level of discomfort in the patient/doctor/dentist triangle. Doctors and dentists reported feeling forced by patients into positions that compromised their autonomy in obeying the intent (if not the law) of the scheme. Additionally, dentists felt under pressure from doctors and patients to provide subsidized treatment to those eligible. In turn, the patients reported difficulties in gaining access to the scheme and in some cases, experiencing full or partially unmet oral health needs. REASON FOR CONFLICT: Poor inter-professional communication and lack of understanding about profession-unique patient-driven pressures, ultimately contributed to dissonance. Ill-defined eligibility guidelines rendered the doctor's ability to gate-keep challenging. OUTCOME OF CONFLICT: Inefficient gate-keeping led to exponential increase in referrals, resulting in unprecedented cost blow-outs. Ensuing government-led audits caused political tensions and contributed to the media-induced vilification of dentists. In December 2013, government financing of dental treatment through Chronic Disease Dental Scheme was discontinued, leaving many Australians without a viable alternative. There is a need for qualitative research methods to help identify social issues that affect public health policy process. In order to succeed, new health policies should respect, consider and attempt to understand the autonomy of key participants, prior to and throughout.

Phosphofructokinase and mitochondria partially explain the high ultimate pH of broiler pectoralis major muscle.

PubMed

Matarneh, Sulaiman K; Yen, Con-Ning; Elgin, Jennifer M; Beline, Mariane; da Luz E Silva, Saulo; Wicks, Jordan C; England, Eric M; Dalloul, Rami A; Persia, Michael E; Omara, Islam I; Shi, Hao; Gerrard, David E

2018-05-01

During postmortem metabolism, muscle pH gradually declines to reach an ultimate pH near 5.6 across most meat species. Yet, broiler pectoralis major (P. major) muscle generates meat with high ultimate pH (pH ∼ 5.9). For better understanding of the underlying mechanism responsible for this phenomenon, we evaluated the involvement of breast muscle chilling on the extent of postmortem metabolism. Broiler breast muscles were either subjected to chilling treatment (control) or left at room temperature (RT) for 120 min. P. major muscle from the RT treatment had lower ultimate pH, greater glycogen degradation and lactate accumulation. While these findings suggest that carcass chilling can contribute to the premature termination of postmortem metabolism, chilling did not fully explain the high ultimate pH of P. major muscle. Our results also revealed that glucose-6-phosphate (G6P) was very low at 24 h, and therefore we hypothesized that G6P was limiting. To test this hypothesis, muscle samples from P. major and porcine longissimus lumborum (LL) muscle were homogenized into a reaction buffer that mimics postmortem glycolysis with or without 0.5 mg/mL isolated mitochondria. While samples containing porcine LL muscle reached the normal level of ultimate pH, P. major muscle samples reached a value similar to that observed in vivo even in the presence of excess G6P, indicating that G6P was not limiting. Mitochondria enhanced the glycolytic flux and pH decline in systems containing muscle from both species. More importantly, however, was that in vitro system containing chicken with mitochondria reached pH value similar to that of samples containing LL muscle without mitochondria. To investigate further, phosphofructokinase (PFK) activity was compared in broiler P. major and porcine LL muscle at different pH values. PFK activity was lower in P. major muscle at pH 7, 6.5, and 6.2 than LL muscle. In conclusion, carcass chilling can partially contribute to the high ultimate pH of broiler P. major muscle, while low PFK activity and mitochondria content limit the flux through glycolysis.

A Comparison of Outcomes of Particulated Juvenile Articular Cartilage and Bone Marrow Aspirate Concentrate for Articular Cartilage Lesions of the Talus.

PubMed

Lanham, Nathan S; Carroll, John J; Cooper, Minton T; Perumal, Venkat; Park, Joseph S

2017-08-01

Articular cartilage lesions of the talus remain a challenging clinical problem because of the lack of natural regeneration and limited treatment options. Microfracture is often the first-line therapy, however lesions larger than 1.5 cm 2 have been shown to not do as well with this treatment method. The objective of this retrospective study was to evaluate the outcomes of iliac crest bone marrow aspirate concentrate/collagen scaffold (ICBMA) and particulated juvenile articular cartilage (PJAC) for larger articular cartilage lesions of the talus. Fifteen patients undergoing ICBMA or PJAC for articular cartilage lesions of the talus from 2010 to 2013 were reviewed. Twelve patients, 6 from each treatment option, were included in the study. American Orthopaedic Foot and Ankle Surgeons (AOFAS), Foot and Ankle Ability Measure (FAAM), and Short Form-12 (SF-12) outcome scores were collected for each patient. The mean age was 34.7 ± 14.8 years for ICBMA and 31.5 ± 7.4 years for PJAC. Lesion size was 2.0 ± 1.1 cm 2 for ICBMA and 1.9 ± 0.9 cm 2 for PJAC. At a mean follow-up of 25.7 months (range, 12-42 months), the mean AOFAS score was 71.33 for ICBMA and 95.83 for PJAC (  P = .019). The FAAM activities of daily living subscale mean was 77.77 for ICBMA and 97.02 for PJAC (   P = .027). The mean FAAM sports subscale was 45.14 for ICBMA and 86.31 for PJAC (  P = .054). The SF-12 physical health mean was 47.58 for ICBMA and 53.98 for PJAC (  P = .315). The SF-12 mental health mean was 53.25 for ICBMA and 57.8 for PJAC (  P = .315). One patient in treated initially with ICBMA underwent revision fixation for nonunion of their medial malleolar osteotomy, which ultimately resulted in removal of hardware and tibiotalar arthrodesis at 2 years from the index procedure. In the present analysis, PJAC yields better clinical outcomes at 2 years when compared with ICBMA for articular cartilage lesions of the talus that were on average greater than 1.5cm 2 . Therapeutic, Level IV: Retrospective, Case series.

A Values-Based Motivational Interviewing (MI) Intervention for Pediatric Obesity: Study Design and Methods for MI Values

PubMed Central

Bean, Melanie K.; Mazzeo, Suzanne E.; Stern, Marilyn; Bowen, Deborah; Ingersoll, Karen

2011-01-01

To reduce pediatric obesity in clinical settings, multidisciplinary behaviorally-based treatment programs are recommended. High attrition and poor compliance are two difficulties frequently encountered in such programs. A brief, empathic and directive clinical intervention, Motivational Interviewing (MI), might help address these motivational and behavioral issues, ultimately resulting in more positive health outcomes. The efficacy of MI as an adjunct in the treatment of pediatric obesity remains relatively understudied. MI Values was developed to implement within an existing multidisciplinary treatment program for obese, ethnically diverse adolescents, the T.E.E.N.S. Program (Teaching, Encouragement, Exercise, Nutrition, Support). T.E.E.N.S. participants who consent to MI Values are randomized to either MI or an education control condition. At weeks 1 and 10 of T.E.E.N.S. participation, the subset of participants assigned to the MI condition engage in individual MI sessions and control participants view health education videos. All MI sessions are audiotaped and coded to monitor treatment fidelity, which has been satisfactory thus far. Participants complete comprehensive assessments at baseline, 3-and 6-month follow-up. We hypothesize that MI participants will demonstrate greater reductions in Body Mass Index (BMI) percentile, improved diet and physical activity behaviors, better compliance with T.E.E.N.S., and lower attrition than participants in the control group. We present study design and methods for MI Values as well as data on feasibility of recruitment methods and treatment integrity. At study completion, findings will contribute to the emerging literature examining the efficacy of MI in the treatment of pediatric obesity. PMID:21554994

High-throughput autofluorescence flow cytometry of breast cancer metabolism (Conference Presentation)

NASA Astrophysics Data System (ADS)

Shah, Amy T.; Cannon, Taylor M.; Higginbotham, Jim N.; Skala, Melissa C.

2016-02-01

Tumor heterogeneity poses challenges for devising optimal treatment regimens for cancer patients. In particular, subpopulations of cells can escape treatment and cause relapse. There is a need for methods to characterize tumor heterogeneity of treatment response. Cell metabolism is altered in cancer (Warburg effect), and cells use the autofluorescent cofactor NADH in numerous metabolic reactions. Previous studies have shown that microscopy measurements of NADH autofluorescence are sensitive to treatment response in breast cancer, and these techniques typically assess hundreds of cells per group. An alternative approach is flow cytometry, which measures fluorescence on a single-cell level and is attractive for characterizing tumor heterogeneity because it achieves high-throughput analysis and cell sorting in millions of cells per group. Current applications for flow cytometry rely on staining with fluorophores. This study characterizes flow cytometry measurements of NADH autofluorescence in breast cancer cells. Preliminary results indicate flow cytometry of NADH is sensitive to cyanide perturbation, which inhibits oxidative phosphorylation, in nonmalignant MCF10A cells. Additionally, flow cytometry is sensitive to higher NADH intensity for HER2-positive SKBr3 cells compared with triple-negative MDA-MB-231 cells. These results agree with previous microscopy studies. Finally, a mixture of SKBr3 and MDA-MB-231 cells were sorted into each cell type using NADH intensity. Sorted cells were cultured, and microscopy validation showed the expected morphology for each cell type. Ultimately, flow cytometry could be applied to characterize tumor heterogeneity based on treatment response and sort cell subpopulations based on metabolic profile. These achievements could enable individualized treatment strategies and improved patient outcomes.

Rewarding healthy behaviors--pay patients for performance.

PubMed

Wu, Joanne

2012-01-01

Despite a considerable investment of resources into pay for performance, preliminary studies have found that it may not be significantly more effective in improving health outcome measures when compared with voluntary quality improvement programs. Because patient behaviors ultimately affect health outcomes, I would propose a novel pay-for-performance program that rewards patients directly for achieving evidence-based health goals. These rewards would be in the form of discounts towards co-payments for doctor's visits, procedures, and medications, thereby potentially reducing cost and compliance issues. A pilot study recruiting patients with diabetes or hypertension, diseases with clear and objective outcome measures, would be useful to examine true costs, savings, and health outcomes of such a reward program. Offering incentives to patients for reaching health goals has the potential to foster a stronger partnership between doctors and patients and improve health outcomes.

Targeted Proteomics to Assess the Response to Anti-Angiogenic Treatment in Human Glioblastoma (GBM).

PubMed

Demeure, Kevin; Fack, Fred; Duriez, Elodie; Tiemann, Katja; Bernard, Amandine; Golebiewska, Anna; Bougnaud, Sébastien; Bjerkvig, Rolf; Domon, Bruno; Niclou, Simone P

2016-02-01

Glioblastoma (GBM) is a highly aggressive primary brain tumor with dismal outcome for affected patients. Because of the significant neo-angiogenesis exhibited by GBMs, anti-angiogenic therapies have been intensively evaluated during the past years. Recent clinical studies were however disappointing, although a subpopulation of patients may benefit from such treatment. We have previously shown that anti-angiogenic targeting in GBM increases hypoxia and leads to a metabolic adaptation toward glycolysis, suggesting that combination treatments also targeting the glycolytic phenotype may be effective in GBM patients. The aim of this study was to identify marker proteins that are altered by treatment and may serve as a short term readout of anti-angiogenic therapy. Ultimately such proteins could be tested as markers of efficacy able to identify patient subpopulations responsive to the treatment. We applied a proteomics approach based on selected reaction monitoring (SRM) to precisely quantify targeted protein candidates, selected from pathways related to metabolism, apoptosis and angiogenesis. The workflow was developed in the context of patient-derived intracranial GBM xenografts developed in rodents and ensured the specific identification of human tumor versus rodent stroma-derived proteins. Quality control experiments were applied to assess sample heterogeneity and reproducibility of SRM assays at different levels. The data demonstrate that tumor specific proteins can be precisely quantified within complex biological samples, reliably identifying small concentration differences induced by the treatment. In line with previous work, we identified decreased levels of TCA cycle enzymes, including isocitrate dehydrogenase, whereas malectin, calnexin, and lactate dehydrogenase A were augmented after treatment. We propose the most responsive proteins of our subset as potential novel biomarkers to assess treatment response after anti-angiogenic therapy that warrant future analysis in clinical GBM samples. © 2016 by The American Society for Biochemistry and Molecular Biology, Inc.

Targeted Proteomics to Assess the Response to Anti-Angiogenic Treatment in Human Glioblastoma (GBM)*

PubMed Central

Demeure, Kevin; Fack, Fred; Duriez, Elodie; Tiemann, Katja; Bernard, Amandine; Golebiewska, Anna; Bougnaud, Sébastien; Bjerkvig, Rolf; Domon, Bruno; Niclou, Simone P.

2016-01-01

Glioblastoma (GBM) is a highly aggressive primary brain tumor with dismal outcome for affected patients. Because of the significant neo-angiogenesis exhibited by GBMs, anti-angiogenic therapies have been intensively evaluated during the past years. Recent clinical studies were however disappointing, although a subpopulation of patients may benefit from such treatment. We have previously shown that anti-angiogenic targeting in GBM increases hypoxia and leads to a metabolic adaptation toward glycolysis, suggesting that combination treatments also targeting the glycolytic phenotype may be effective in GBM patients. The aim of this study was to identify marker proteins that are altered by treatment and may serve as a short term readout of anti-angiogenic therapy. Ultimately such proteins could be tested as markers of efficacy able to identify patient subpopulations responsive to the treatment. We applied a proteomics approach based on selected reaction monitoring (SRM) to precisely quantify targeted protein candidates, selected from pathways related to metabolism, apoptosis and angiogenesis. The workflow was developed in the context of patient-derived intracranial GBM xenografts developed in rodents and ensured the specific identification of human tumor versus rodent stroma-derived proteins. Quality control experiments were applied to assess sample heterogeneity and reproducibility of SRM assays at different levels. The data demonstrate that tumor specific proteins can be precisely quantified within complex biological samples, reliably identifying small concentration differences induced by the treatment. In line with previous work, we identified decreased levels of TCA cycle enzymes, including isocitrate dehydrogenase, whereas malectin, calnexin, and lactate dehydrogenase A were augmented after treatment. We propose the most responsive proteins of our subset as potential novel biomarkers to assess treatment response after anti-angiogenic therapy that warrant future analysis in clinical GBM samples. PMID:26243272

AED discontinuation may be dangerous for seizure-free patients.

PubMed

Schmidt, Dieter

2011-02-01

Despite its benefits, stopping antiepileptic drugs (AEDs) in seizure-free patients is associated with several risks. AED discontinuation doubles the risk of seizure recurrence for up to 2 years compared with continued treatment. On average, one in three patients has a seizure recurrence, though the range can go up to 66% (34%, range 12-66%, 95% CI: 27-43). Furthermore, the outcome of treating a seizure recurrence in patients who have been seizure-free for years is surprisingly poor in some patients. Although the long-term prognosis is not worsened by drug discontinuation, one in five patients does not re-enter remission and for some patients, it may take several years to become seizure-free again. The risk of seizure recurrence is particularly high for those with juvenile myoclonic epilepsy and symptomatic focal epilepsy, the most frequent epilepsies in adults. Seizure-recurrence may have devastating, medical, psychological and social consequences for the individual, for example injury, loss of self-esteem, unemployment and losing a driver's license. Discontinuation should be avoided in patients with a high risk of seizure recurrence. Given these risks, patients will ultimately have to decide themselves whether they wish to discontinue drug treatment after full informed consent.

[Development and implementation of an integrated care pathway at the POLIKUM health centers using the example of anemia].

PubMed

Bierbaum, M; Grad, M O; Wulff, H; Kewenig, S; Schöffski, O

2014-04-01

Integrated treatment pathways are an appropriate means for increasing the quality of treatment and outcome via process optimization. Taking the POLIKUM Health Centers as an example, we intend to demonstrate how the implementation can be effected for the indication of anemia. The development and implementation were executed by an interdisciplinary workgroup in several workshops. In addition, the diagnoses and hemoglobin values of all patients with requests for hemograms were obtained and analyzed at two locations. Developing the pathway required significantly greater efforts than initially planned. The biggest challenge was to adequately map the complexity of the different forms of anemia and, concomitantly, to design a pathway that can actually be realized in everyday life. Moreover, evaluation of the patient data demonstrated that there are a large number of cases where existing anemias are not reflected in the respective diagnoses. While the ultimate effects of the new pathway cannot yet be assessed conclusively, it was possible to obtain valuable findings for practical use even at this point. Despite the limitations of the sample, the surprisingly high number of undetected anemias should give physicians cause for taking diagnostic measures even in patients with mild anemia.

Neural Correlates for Intrinsic Motivational Deficits of Schizophrenia; Implications for Therapeutics of Cognitive Impairment

PubMed Central

Takeda, Kazuyoshi; Sumiyoshi, Tomiki; Matsumoto, Madoka; Murayama, Kou; Ikezawa, Satoru; Matsumoto, Kenji; Nakagome, Kazuyuki

2018-01-01

The ultimate goal of the treatment of schizophrenia is recovery, a notion related to improvement of cognitive and social functioning. Cognitive remediation therapies (CRT), one of the most effective cognition enhancing methods, have been shown to moderately improve social functioning. For this purpose, intrinsic motivation, related to internal values such as interest and enjoyment, has been shown to play a key role. Although the impairment of intrinsic motivation is one of the characteristics of schizophrenia, its neural mechanisms remain unclear. This is related to the lack of feasible measures of intrinsic motivation, and its response to treatment. According to the self-determination theory (SDT), not only intrinsic motivation, but extrinsic motivation has been reported to enhance learning and memory in healthy subjects to some extent. This finding suggests the contribution of different types of motivation to potentiate the ability of the CRT to treat cognitive impairment of schizophrenia. In this paper, we provide a review of psychological characteristics, assessment methods, and neural correlates of intrinsic motivation in healthy subjects and patients with schizophrenia. Particularly, we focus on neuroimaging studies of intrinsic motivation, including our own. These considerations are relevant to enhancement of functional outcomes of schizophrenia. PMID:29922185

Neural Correlates for Intrinsic Motivational Deficits of Schizophrenia; Implications for Therapeutics of Cognitive Impairment.

PubMed

Takeda, Kazuyoshi; Sumiyoshi, Tomiki; Matsumoto, Madoka; Murayama, Kou; Ikezawa, Satoru; Matsumoto, Kenji; Nakagome, Kazuyuki

2018-01-01

The ultimate goal of the treatment of schizophrenia is recovery, a notion related to improvement of cognitive and social functioning. Cognitive remediation therapies (CRT), one of the most effective cognition enhancing methods, have been shown to moderately improve social functioning. For this purpose, intrinsic motivation, related to internal values such as interest and enjoyment, has been shown to play a key role. Although the impairment of intrinsic motivation is one of the characteristics of schizophrenia, its neural mechanisms remain unclear. This is related to the lack of feasible measures of intrinsic motivation, and its response to treatment. According to the self-determination theory (SDT), not only intrinsic motivation, but extrinsic motivation has been reported to enhance learning and memory in healthy subjects to some extent. This finding suggests the contribution of different types of motivation to potentiate the ability of the CRT to treat cognitive impairment of schizophrenia. In this paper, we provide a review of psychological characteristics, assessment methods, and neural correlates of intrinsic motivation in healthy subjects and patients with schizophrenia. Particularly, we focus on neuroimaging studies of intrinsic motivation, including our own. These considerations are relevant to enhancement of functional outcomes of schizophrenia.

Neglected evidence in idiopathic pulmonary fibrosis and the importance of early diagnosis and treatment.

PubMed

Cottin, Vincent; Richeldi, Luca

2014-03-01

In idiopathic pulmonary fibrosis (IPF), some facts or concepts based on substantial evidence, whilst implicit for learned subspecialists, have previously been neglected and/or not explicitly formulated or made accessible to a wider audience. IPF is strongly associated with cigarette smoking and is predominantly a disease of ageing. However, its cause(s) remain elusive and, thus, it is one of the most challenging diseases for the development of novel effective and safe therapies. With the approval of pirfenidone for patients with mild-to-moderate IPF, an earlier diagnosis of IPF is a prerequisite for earlier treatment and, potentially, improvement of the long-term clinical outcome of this progressive and ultimately fatal disease. An earlier diagnosis may be achieved in IPF by promoting thin-slice chest high-resolution computed tomography screening of interstitial lung disease as a "by-product" of large-scale lung cancer screening strategies in smokers, but other techniques, which have been neglected in the past, are now available. Lung auscultation and early identification of "velcro" crackles has been proposed as a key component of early diagnosis of IPF. An ongoing study is exploring correlations between lung sounds on auscultation obtained using electronic stethoscopes and high-resolution computed tomography patterns.

Practical insights into gluten-free diets.

PubMed

See, Jacalyn A; Kaukinen, Katri; Makharia, Govind K; Gibson, Peter R; Murray, Joseph A

2015-10-01

Coeliac disease is a global disease, and the only currently available treatment is a gluten-free diet (GFD). Although conceptually simple, the diet changes are substantial and have a profound effect on a patient's life. Untreated coeliac disease is associated with complications, including excess mortality, most of which can be avoided with a strict GFD. However, there are many barriers, including availability, cost and safety of gluten-free foods, and gluten cross-contamination. The GFD can be restrictive in social situations, leading to poor quality of life and, ultimately, nonadherence. As the number of patients with coeliac disease increases worldwide, clinicians need to be aware of the challenges patients face. Heightened awareness by physicians, dietitians and other providers can help maximize successful treatment, improve outcomes, and reduce health-care costs and disease burden. Routine follow-up is necessary to reinforce the need for a GFD, provide social and emotional support, and achieve mucosal healing, leading to reduced risk of complications. Unfortunately, there is wide variation in follow-up practices. The objective of this Review is to increase awareness of the challenges, management and follow-up of patients with coeliac disease to help them achieve GFD adherence and prevent complications whilst preserving their quality of life.

Pharmacological pain management in chronic pancreatitis

PubMed Central

Olesen, Søren S; Juel, Jacob; Graversen, Carina; Kolesnikov, Yuri; Wilder-Smith, Oliver HG; Drewes, Asbjørn M

2013-01-01

Intense abdominal pain is a prominent feature of chronic pancreatitis and its treatment remains a major clinical challenge. Basic studies of pancreatic nerves and experimental human pain research have provided evidence that pain processing is abnormal in these patients and in many cases resembles that seen in neuropathic and chronic pain disorders. An important ultimate outcome of such aberrant pain processing is that once the disease has advanced and the pathophysiological processes are firmly established, the generation of pain can become self-perpetuating and independent of the initial peripheral nociceptive drive. Consequently, the management of pain by traditional methods based on nociceptive deafferentation (e.g., surgery and visceral nerve blockade) becomes difficult and often ineffective. This novel and improved understanding of pain aetiology requires a paradigm shift in pain management of chronic pancreatitis. Modern mechanism based pain treatments taking into account altered pain processing are likely to increasingly replace invasive therapies targeting the nociceptive source, which should be reserved for special and carefully selected cases. In this review, we offer an overview of the current available pharmacological options for pain management in chronic pancreatitis. In addition, future options for pain management are discussed with special emphasis on personalized pain medicine and multidisciplinarity. PMID:24259960

Intracochlear Drug Delivery Systems

PubMed Central

Borenstein, Jeffrey T.

2011-01-01

Introduction Advances in molecular biology and in the basic understanding of the mechanisms associated with sensorineural hearing loss and other diseases of the inner ear, are paving the way towards new approaches for treatments for millions of patients. However, the cochlea is a particularly challenging target for drug therapy, and new technologies will be required to provide safe and efficacious delivery of these compounds. Emerging delivery systems based on microfluidic technologies are showing promise as a means for direct intracochlear delivery. Ultimately, these systems may serve as a means for extended delivery of regenerative compounds to restore hearing in patients suffering from a host of auditory diseases. Areas covered in this review Recent progress in the development of drug delivery systems capable of direct intracochlear delivery is reviewed, including passive systems such as osmotic pumps, active microfluidic devices, and systems combined with currently available devices such as cochlear implants. The aim of this article is to provide a concise review of intracochlear drug delivery systems currently under development, and ultimately capable of being combined with emerging therapeutic compounds for the treatment of inner ear diseases. Expert Opinion Safe and efficacious treatment of auditory diseases will require the development of microscale delivery devices, capable of extended operation and direct application to the inner ear. These advances will require miniaturization and integration of multiple functions, including drug storage, delivery, power management and sensing, ultimately enabling closed-loop control and timed-sequence delivery devices for treatment of these diseases. PMID:21615213

Understanding Treatment Effect Estimates When Treatment Effects Are Heterogeneous for More Than One Outcome.

PubMed

Brooks, John M; Chapman, Cole G; Schroeder, Mary C

2018-06-01

Patient-centred care requires evidence of treatment effects across many outcomes. Outcomes can be beneficial (e.g. increased survival or cure rates) or detrimental (e.g. adverse events, pain associated with treatment, treatment costs, time required for treatment). Treatment effects may also be heterogeneous across outcomes and across patients. Randomized controlled trials are usually insufficient to supply evidence across outcomes. Observational data analysis is an alternative, with the caveat that the treatments observed are choices. Real-world treatment choice often involves complex assessment of expected effects across the array of outcomes. Failure to account for this complexity when interpreting treatment effect estimates could lead to clinical and policy mistakes. Our objective was to assess the properties of treatment effect estimates based on choice when treatments have heterogeneous effects on both beneficial and detrimental outcomes across patients. Simulation methods were used to highlight the sensitivity of treatment effect estimates to the distributions of treatment effects across patients across outcomes. Scenarios with alternative correlations between benefit and detriment treatment effects across patients were used. Regression and instrumental variable estimators were applied to the simulated data for both outcomes. True treatment effect parameters are sensitive to the relationships of treatment effectiveness across outcomes in each study population. In each simulation scenario, treatment effect estimate interpretations for each outcome are aligned with results shown previously in single outcome models, but these estimates vary across simulated populations with the correlations of treatment effects across patients across outcomes. If estimator assumptions are valid, estimates across outcomes can be used to assess the optimality of treatment rates in a study population. However, because true treatment effect parameters are sensitive to correlations of treatment effects across outcomes, decision makers should be cautious about generalizing estimates to other populations.

Improving the Working Relationship between Doctors and Pharmacists: Is Inter-Professional Education the Answer?

ERIC Educational Resources Information Center

Gallagher, Ruth M.; Gallagher, Helen C.

2012-01-01

Despite their common history, there are many cultural, attitudinal and practical differences between the professions of medicine and pharmacy that ultimately influence patient care and health outcomes. While poor communication between doctors and pharmacists is a major cause of medical errors, it is clear that effective, deliberate…

Mathematical Tasks, Study Approaches, and Course Grades in Undergraduate Mathematics: A Year-by-Year Analysis

ERIC Educational Resources Information Center

Maciejewski, Wes; Merchant, Sandra

2016-01-01

Students approach learning in different ways, depending on the experienced learning situation. A deep approach is geared toward long-term retention and conceptual change while a surface approach focuses on quickly acquiring knowledge for immediate use. These approaches ultimately affect the students' academic outcomes. This study takes a…

New Instruments for Studying the Impacts of Science Teacher Professional Development

ERIC Educational Resources Information Center

Trygstad, Peggy J.; Banilower, Eric R.; Smith, P. Sean; Nelson, Courtney L.

2014-01-01

The logic model that implicitly drives most professional development (PD) efforts asserts that PD leads to changes in teacher knowledge and beliefs, which leads to improved classroom practice, and ultimately, better student outcomes. However, efforts to study the impacts of PD programs are often hampered by the scarcity of high-quality…

How Robustly Does Cannabis Use Associate to College Grades? Findings from Two Cohorts

ERIC Educational Resources Information Center

Martinez, Julia A.; Roth, Madeline G.; Johnson, Douglas N.; Jones, Jane A.

2015-01-01

Along with recent changes in cannabis legalization and decriminalization, there has been an increasing amount of attention aimed at cannabis use and outcomes in college. Although some amount of cannabis use might be expected under theories of collegiate identity development, public health research indicates that cannabis use ultimately associates…

Early Identification of Individuals at Risk for Psychosis: Recommendations for Colleges and Universities

ERIC Educational Resources Information Center

Lares, Sylvia Lizette

2018-01-01

Psychotic disorders can instill a tremendous amount of distress on affected individuals (Srihari et al., 2014). Research has established that decreasing the duration of untreated psychosis can yield moderate improvements in the ultimate outcome of persons with schizophrenia-spectrum disorders (Goncalves, de Rosalmeida Dantas, & Banzato, 2016;…

Research and Teaching: Delivery of Summative Assessment Matters for Improving At-Risk Student Learning

ERIC Educational Resources Information Center

Agboola, Oluwaseun Omowunmi; Hiatt, Anna C.

2017-01-01

Summative assessments are customarily used to evaluate ultimate student outcomes and typically occur less frequently during instruction than formative assessments. Few studies have examined how the use of summative assessments may influence student learning among at-risk groups of students. Summative assessments are typically used to evaluate how…

The Role of Psychological and Developmental Science in Efforts to Improve Teacher Quality

ERIC Educational Resources Information Center

Rimm-Kaufman, Sara E.; Hamre, Bridget K.

2010-01-01

Background: Theory, methods, and knowledge gained from years of study in psychological science and human development apply to the understanding and improvement of teacher quality and, ultimately, student achievement and social and emotional outcomes. With these applications, educational research has stronger potential to make more effective and…

The Role of Parents in the Perfectionistic Tendencies of University Music Students

ERIC Educational Resources Information Center

Botha, Madaleen; Panebianco, Clorinda

2018-01-01

Perfectionism is a complex multidimensional state with positive and negative outcomes. Research has identified that parents could influence perfectionistic inclinations, which may lead to increased levels of anxiety and ultimately lead to maladaptive tendencies. The aim of the study is to explore the role of parents in the experience of…

Predictive Models of Cognitive Outcomes of Developmental Insults

NASA Astrophysics Data System (ADS)

Chan, Yupo; Bouaynaya, Nidhal; Chowdhury, Parimal; Leszczynska, Danuta; Patterson, Tucker A.; Tarasenko, Olga

2010-04-01

Representatives of Arkansas medical, research and educational institutions have gathered over the past four years to discuss the relationship between functional developmental perturbations and their neurological consequences. We wish to track the effect on the nervous system by developmental perturbations over time and across species. Except for perturbations, the sequence of events that occur during neural development was found to be remarkably conserved across mammalian species. The tracking includes consequences on anatomical regions and behavioral changes. The ultimate goal is to develop a predictive model of long-term genotypic and phenotypic outcomes that includes developmental insults. Such a model can subsequently be fostered into an educated intervention for therapeutic purposes. Several datasets were identified to test plausible hypotheses, ranging from evoked potential datasets to sleep-disorder datasets. An initial model may be mathematical and conceptual. However, we expect to see rapid progress as large-scale gene expression studies in the mammalian brain permit genome-wide searches to discover genes that are uniquely expressed in brain circuits and regions. These genes ultimately control behavior. By using a validated model we endeavor to make useful predictions.

Early markers of reperfusion injury after liver transplantation: association with primary dysfunction.

PubMed

Bruns, Helge; Heil, Jan; Schultze, Daniel; Al Saeedi, Mohammed; Schemmer, Peter

2015-06-01

In patients with end-stage liver disease, liver transplantation is the only available curative treatment. Although the outcome and quality of life in the patients have improved over the past decades, primary dys- or nonfunction (PDF/PNF) can occur. Early detection of PDF and PNF is crucial and could lead to individual therapies. This study was designed to identify early markers of reperfusion injury and PDF in liver biopsies taken during the first hour after reperfusion. Biopsies from donor livers were prospectively taken as a routine during the first hour after reperfusion. Recipient data, transaminases and outcome were routinely monitored. In total, 10 biopsy specimens taken from patients with 90-day mortality and PDF, and patients with long-term survival but without PDF were used for DNA microarrays. Markers that were significantly up- or down-regulated in the microarray were verified using quantitative real-time PCR. Age, indications and labMELD score were similar in both groups. Peak-transaminases during the first week after transplantation were significantly different in the two groups. In total, 20 differentially regulated markers that correlated to PDF were identified using microarray analysis and verified with quantitative real-time PCR. The markers identified in this study could predict PDF at a very early time point and might point to interventions that ameliorate reperfusion injury and thus prevent PDF. Identification of patients and organs at risk might lead to individualized therapies and could ultimately improve outcome.

Culture-positive sepsis in neonatal camelids: 21 cases.

PubMed

Dolente, Brett A; Lindborg, Susan; Palmer, Jonathan E; Wilkins, Pamela A

2007-01-01

There is limited literature on neonatal bacterial sepsis in New World (NW) camelids. Bacterial culture-positive crias have clinical differences based on the specific bacterial genera isolated. Bacterial culture-positive NW camelid crias <21 days of age from 1990 to 2005 were included. Historic physical examination and cliniopathologic data were retrieved from medical records as were the identity and antibiograms of bacterial isolates. Cases were categorized by outcome (survival versus nonsurvival) and type of sepsis (gram-negative or gram-positive). Kruskal-Wallis and chi-square testing were used to evaluate differences between groups. Twenty-one crias met the inclusion criteria. Median age was 2 days. Failure of passive transfer was common. There were few differences identified on the basis of outcome or type of sepsis. Crias without gastrointestinal or central nervous system involvement survived in greater numbers. Forty-six percent of isolates were gram-positive. The most common isolates were the following: Escherichia coli, Enterococcus spp., Listeria monocytogenes, and Citrobacter spp. Overall survival was 67% (14/21). Crias with sepsis do not appear to present with major biochemical, hematologic, or blood gas abnormalities, potentially complicating diagnosis. Affected crias may not have localizing signs at presentation and are not usually febrile, although hypothermia, tachypnea, and tachycardia are relatively common. Total protein concentration was not a substitute for immunoglobulin G measurement in septic crias in this study. Familiarity with the clinical presentation and common pathogens isolated should improve early recognition and treatment and ultimately outcome of crias with sepsis.

Epidemiological characteristics, hospital course and outcome of snakebite victims in West Texas.

PubMed

Abbey, James M; Jaffar, Nabil A; Abugrara, Hazem L; Nazim, Muhammad; Smalligan, Roger D; Khasawneh, Faisal A

2015-01-01

Numerous snakebites are reported every spring and summer in the United States especially in the Southwestern part of the country. This is usually associated with significant morbidity but fatalities are rare. Most victims are male and the majority of bites are on the extremities. A search for all cases coded with a discharge diagnosis of snakebite injury revealed 90 patients admitted to Northwest Texas Hospital, the trauma center in Amarillo, Texas, between January 2002 and December 2012. These charts were retrospectively reviewed and data extracted including patient demographics, severity of snakebite, treatment given, and ultimate outcome. Ninety patients were admitted to the hospital due to snakebite. It was a rattlesnake in 83 cases. The mean age of the victims was 29.7 years and 74 of them were male. Fifty-one bites were on the upper extremities, thirty-eight bites were on the lower extremities and one bite was on the abdominal wall. About 95% of the lower extremity bites were moderate or severe compared to 74.5% of the upper extremity bites, Cramer's coefficient 0.3, p=0.02. Thirty-one patients had complications and twenty patients required surgical intervention. Eighty-eight patients received a median of 10 vials of antivenin that was well tolerated. Median hospital length of stay was 3 days. None of the patients died. Rattlesnake bites cause significant morbidity although mortality is rare. Early administration of antivenin and appropriate supportive measures and monitoring for complications with surgical intervention when needed leads to improved patient outcomes.

Standard-Fractionated Radiotherapy for Optic Nerve Sheath Meningioma: Visual Outcome Is Predicted by Mean Eye Dose

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

Abouaf, Lucie; Girard, Nicolas; Claude Bernard University, Lyon

2012-03-01

Purpose: Radiotherapy has shown its efficacy in controlling optic nerve sheath meningiomas (ONSM) tumor growth while allowing visual acuity to improve or stabilize. However, radiation-induced toxicity may ultimately jeopardize the functional benefit. The purpose of this study was to identify predictive factors of poor visual outcome in patients receiving radiotherapy for ONSM. Methods and Materials: We conducted an extensive analysis of 10 patients with ONSM with regard to clinical, radiologic, and dosimetric aspects. All patients were treated with conformal radiotherapy and subsequently underwent biannual neuroophthalmologic and imaging assessments. Pretreatment and posttreatment values of visual acuity and visual field were comparedmore » with Wilcoxon's signed rank test. Results: Visual acuity values significantly improved after radiotherapy. After a median follow-up time of 51 months, 6 patients had improved visual acuity, 4 patients had improved visual field, 1 patient was in stable condition, and 1 patient had deteriorated visual acuity and visual field. Tumor control rate was 100% at magnetic resonance imaging assessment. Visual acuity deterioration after radiotherapy was related to radiation-induced retinopathy in 2 patients and radiation-induced mature cataract in 1 patient. Study of radiotherapy parameters showed that the mean eye dose was significantly higher in those 3 patients who had deteriorated vision. Conclusions: Our study confirms that radiotherapy is efficient in treating ONSM. Long-term visual outcome may be compromised by radiation-induced side effects. Mean eye dose has to be considered as a limiting constraint in treatment planning.« less

Esophageal dilation in head and neck cancer patients: A systematic review and meta-analysis.

PubMed

Moss, William J; Pang, John; Orosco, Ryan K; Weissbrod, Philip A; Brumund, Kevin T; Weisman, Robert A; Brigger, Matthew T; Coffey, Charles S

2018-01-01

To characterize the safety profile and effectiveness of esophageal dilation in head and neck cancer patients. A systematic review was undertaken for articles reporting outcomes of esophageal dilation in head and neck cancer patients. The Medline, Scopus, Web of Science, and Cochrane databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Complications related to esophageal dilation in head and neck cancer patients was the primary outcome of interest. Success rates, demographic data, cancer staging, and treatment data were assessed secondarily. Statistical analyses included both qualitative and quantitative assessments. A limited meta-analysis and pooling of the data was performed using a random effects model. Of the collective 8,243 initial candidate articles, 15 retrospective studies containing data for a collective 449 patients were ultimately included in the analysis. There was significant heterogeneity in the outcomes data. With an overall complication rate of 10.6% (95% confidence interval [CI]: 4.1%,17%) and a pooled success rate of 72.9% (95% CI: 65.7%,80.1%) per patient, the articles generally supported the use of dilation. Head and neck cancer patients experience a higher rate of complications following dilation compared to patients with other causes of benign stricture. Esophageal dilation is effective in improving dysphagia, but these benefits are often transient and thus necessitate repeat interventions. Laryngoscope, 128:111-117, 2018. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Quality of Life in Individuals Surgically Treated for Congenital Hydrocephalus During Infancy: A Single-Institution Experience.

PubMed

Khan, Saad Akhtar; Khan, Muhammad Faheem; Bakhshi, Saqib Kamran; Irfan, Omar; Khan, Hamza Abdur Rahim; Abbas, Asad; Awan, Safia; Bari, Muhammad Ehsan

2017-05-01

Congenital hydrocephalus (CH) is a frequently encountered birth anomaly that can hinder long-term neurologic maturity and social well-being of affected children. This study was undertaken to assess quality of life (QOL) 10-15 years after surgical treatment for primary CH during infancy at a tertiary care hospital in a developing country. This retrospective cohort study included individuals who presented to Aga Khan University Hospital, Karachi, Pakistan, between 1995 and 2005 at <1 year old and underwent surgery for primary CH. The Hydrocephalus Outcome Questionnaire was used to assess outcomes with respect to QOL. Of 118 patients, 90 patients participated in the study. Mean age at first admission was 6.2 months. Mean length of follow-up was 5.4 years. Of these, 28 patients had died after surgery. Shunt infection (P = 0.012) and delayed milestones (P = 0.003) were found to be statistically significant factors affecting mortality in the patients who died. The mean overall health score was 0.67 ± 0.30. Age <6 months at the time of first surgery was a poor predictor of overall health on the Hydrocephalus Outcome Questionnaire (P = 0.039). In our analysis, we assessed the QOL associated with CH. We hope that these results will provide insight for future prospective work with the ultimate goal of improving long-term QOL in children with CH. Copyright © 2017 Elsevier Inc. All rights reserved.

Assessment of outcome after severe brain damage.

PubMed

Jennett, B; Bond, M

1975-03-01

Persisting disability after brain damage usually comprises both mental and physical handicap. The mental component is often the more important in contributing to overall social disability. Lack of an objective scale leads to vague and over-optimistic estimates of outcome, which obscure the ultimate results of early management. A five-point scale is described--death, persistent vegetative state, severe disability, moderate disability, and good recovery. Duration as well as intensity of disability should be included in an index of ill-health; this applies particularly after head injury, because many disabled survivors are young.

Decellularized Human Dental Pulp as a Scaffold for Regenerative Endodontics.

PubMed

Song, J S; Takimoto, K; Jeon, M; Vadakekalam, J; Ruparel, N B; Diogenes, A

2017-06-01

Teeth undergo postnatal organogenesis relatively late in life and only complete full maturation a few years after the crown first erupts in the oral cavity. At this stage, development can be arrested if the tooth organ is damaged by either trauma or caries. Regenerative endodontic procedures (REPs) are a treatment alternative to conventional root canal treatment for immature teeth. These procedures rely on the transfer of apically positioned stem cells, including stem cells of the apical papilla (SCAP), into the root canal system. Although clinical success has been reported for these procedures, the predictability of expected outcomes and the organization of the newly formed tissues are affected by the lack of an available suitable scaffold that mimics the complexity of the dental pulp extracellular matrix (ECM). In this study, we evaluated 3 methods of decellularization of human dental pulp to be used as a potential autograft scaffold. Tooth slices of human healthy extracted third molars were decellularized by 3 different methods. One of the methods generated the maximum observed decellularization with minimal impact on the ECM composition and organization. Furthermore, recellularization of the scaffold supported the proliferation of SCAP throughout the scaffold with differentiation into odontoblast-like cells near the dentinal walls. Thus, this study reports that human dental pulp from healthy extracted teeth can be successfully decellularized, and the resulting scaffold supports the proliferation and differentiation of SCAP. The future application of this form of an autograft in REPs can fulfill a yet unmet need for a suitable scaffold, potentially improving clinical outcomes and ultimately promoting the survival and function of teeth with otherwise poor prognosis.

The 5C Concept and 5S Principles in Inflammatory Bowel Disease Management.

PubMed

Hibi, Toshifumi; Panaccione, Remo; Katafuchi, Miiko; Yokoyama, Kaoru; Watanabe, Kenji; Matsui, Toshiyuki; Matsumoto, Takayuki; Travis, Simon; Suzuki, Yasuo

2017-10-27

The international Inflammatory Bowel Disease [IBD] Expert Alliance initiative [2012-2015] served as a platform to define and support areas of best practice in IBD management to help improve outcomes for all patients with IBD. During the programme, IBD specialists from around the world established by consensus two best practice charters: the 5S Principles and the 5C Concept. The 5S Principles were conceived to provide health care providers with key guidance for improving clinical practice based on best management approaches. They comprise the following categories: Stage the disease; Stratify patients; Set treatment goals; Select appropriate treatment; and Supervise therapy. Optimised management of patients with IBD based on the 5S Principles can be achieved most effectively within an optimised clinical care environment. Guidance on optimising the clinical care setting in IBD management is provided through the 5C Concept, which encompasses: Comprehensive IBD care; Collaboration; Communication; Clinical nurse specialists; and Care pathways. Together, the 5C Concept and 5S Principles provide structured recommendations on organising the clinical care setting and developing best-practice approaches in IBD management. Consideration and application of these two dimensions could help health care providers optimise their IBD centres and collaborate more effectively with their multidisciplinary team colleagues and patients, to provide improved IBD care in daily clinical practice. Ultimately, this could lead to improved outcomes for patients with IBD. Copyright © 2017 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com

ranibizumab in the management of advanced Coats disease Stages 3B and 4: long-term outcomes.

PubMed

Gaillard, Marie-Claire; Mataftsi, Assimina; Balmer, Aubin; Houghton, Susan; Munier, Francis L

2014-11-01

Laser photocoagulation and cryotherapy to completely destroy telangiectatic vessels and ischemic retina in Coats disease is barely applicable in advanced cases with total retinal detachment, and globe survival is notoriously poor in Stages 3B and 4. Anti-vascular endothelial growth factor intravitreal injections may offer new prospects for these patients. This study is a retrospective review of all consecutive patients with Coats disease treated with neoadjuvant or adjuvant intravitreal ranibizumab plus conventional and amblyopia treatment as appropriate. Nine patients (median age, 13 months) presenting Coats Stages 3B and 4 (5 and 4 eyes, respectively) were included. Iris neovascularization resolved within 2 weeks and retinal reapplication within 4 months in all patients. At last follow-up, globe survival was 100% with anatomical success in 8 of the 9 eyes. With a median follow-up of 50 months, fibrotic vitreoretinopathy was developed in 5 of the 9 cases, one leading to tractional retinal detachment and ultimately phthisis bulbi. The remaining 4 of the 9 eyes achieved some vision (range, 0.02-0.063). To the best of the authors' knowledge, this is the largest reported series of late-stage Coats undergoing anti-vascular endothelial growth factor therapy, a homogenous cohort of patients treated with a single agent and with the longest follow-up. This study supports the role of ranibizumab in advanced disease by transient restoration of the hemato-retinal barrier and suppression of neovascularization to facilitate classic treatment. At the last follow-up, the authors report unprecedented anatomical success and functional outcome.

Osteochondroma of the fifth rib resulting in recurrent hemothorax.

PubMed

Patel, Mital; Bauer, Thomas W; Santoscoy, Thomas; Ilaslan, Hakan

2015-12-01

A 48-year-old man presented with recurrent spontaneous hemothoraces, which ultimately were found to be secondary to a pedunculated costal osteochondroma causing vascular injury. After initially undergoing endovascular coil embolization, he ultimately required segmental rib resection containing the offending lesion for definite treatment. Although a few cases of symptomatic costal osteochondromas have been reported in the literature, as far as we know, no previous reports have provided direct radiologic confirmation of active bleeding or the role of angiographic intervention. In this report, we highlight the importance of CT angiography in establishing a direct link between an osteochondroma and recurrent hemothorax. We also discuss the diagnostic imaging challenges associated with this condition and the use of a multidisciplinary treatment strategy involving both angiographic and operative management.

Social Determinants of Racial Disparities in CKD

PubMed Central

Norton, Jenna M.; Moxey-Mims, Marva M.; Eggers, Paul W.; Narva, Andrew S.; Star, Robert A.; Rodgers, Griffin P.

2016-01-01

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups. PMID:27178804

Social Ecology of Child Soldiers: Child, Family, and Community Determinants of Mental Health, Psychosocial Wellbeing, and Reintegration in Nepal

PubMed Central

Kohrt, Brandon A.; Jordans, Mark J.D.; Tol, Wietse A.; Perera, Em; Karki, Rohit; Koirala, Suraj; Upadhaya, Nawaraj

2013-01-01

This study employs social ecology to evaluate psychosocial wellbeing in a cross-sectional sample of 142 former child soldiers in Nepal. Outcome measures included the Depression Self Rating Scale (DSRS), Child Posttraumatic Stress Scale (CPSS), and locally developed measures of function impairment and reintegration. At the child level, traumatic exposures, especially torture, predicted poor outcomes, while education improved outcomes. At the family level, conflict-related death of a relative, physical abuse in the household, and loss of wealth during the conflict predicted poor outcomes. At the community level, living in high caste Hindu communities predicted fewer reintegration supports. Ultimately, social ecology is well-suited to identify intervention foci across ecological levels, based on community differences in vulnerability and protective factors. PMID:21088102

A modular case-mix classification system for medical rehabilitation illustrated.

PubMed

Stineman, M G; Granger, C V

1997-01-01

The authors present a modular set of patient classification systems designed for medical rehabilitation that predict resource use and outcomes for clinically similar groups of individuals. The systems, based on the Functional Independence Measure, are referred to as Function-Related Groups (FIM-FRGs). Using data from 23,637 lower extremity fracture patients from 458 inpatient medical rehabilitation facilities, 1995 benchmarks are provided and illustrated for length of stay, functional outcome, and discharge to home and skilled nursing facilities (SNFs). The FIM-FRG modules may be used in parallel to study interactions between resource use and quality and could ultimately yield an integrated strategy for payment and outcomes measurement. This could position the rehabilitation community to take a pioneering role in the application of outcomes-based clinical indicators.

Ionotropic GABA receptor antagonism-induced adverse outcome pathways for potential neurotoxicity biomarkers.

PubMed

Gong, Ping; Hong, Huixiao; Perkins, Edward J

2015-01-01

Antagonism of ionotropic GABA receptors (iGABARs) can occur at three distinct types of receptor binding sites causing chemically induced epileptic seizures. Here we review three adverse outcome pathways, each characterized by a specific molecular initiating event where an antagonist competitively binds to active sites, negatively modulates allosteric sites or noncompetitively blocks ion channel on the iGABAR. This leads to decreased chloride conductance, followed by depolarization of affected neurons, epilepsy-related death and ultimately decreased population. Supporting evidence for causal linkages from the molecular to population levels is presented and differential sensitivity to iGABAR antagonists in different GABA receptors and organisms discussed. Adverse outcome pathways are poised to become important tools for linking mechanism-based biomarkers to regulated outcomes in next-generation risk assessment.

A systematic review of surgeon-patient communication: strengths and opportunities for improvement.

PubMed

Levinson, Wendy; Hudak, Pamela; Tricco, Andrea C

2013-10-01

Effective communication is critical to patient satisfaction, outcomes of care and malpractice prevention. Surgeons need particularly effective communication skills to discuss complicated procedures and help patients make informed choices. We conducted a systematic review of the literature on surgeon-patient communication. Searches were conducted in MEDLINE, PsycINFO, and Sociological Abstract. Two reviewers screened citations and full-text articles. Quality was appraised using the Critical Appraisal Skills Program tool. Studies were categorized into content of communication, patient satisfaction, relationship of communication to malpractice, and duration of visits. 2794 citations and 74 full-text articles, 21 studies and 13 companion reports were included. Surgeons spent the majority of their time educating patients and helping them to make choices. Surgeons were generally thorough in providing details about surgical conditions and treatments. Surgeons often did not explore the emotions or concerns of patients. Potential areas of improvement included discussing some elements of informed decision making, and expressing empathy. Surgeons can enhance their communication skills, particularly in areas of relative deficiency. Studies in primary care demonstrate communication programs are effective in teaching these skills. These can be adapted to surgical training and ultimately lead to improved outcomes and satisfaction with care. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Addressing Mental Health Disparities through Clinical Competence Not Just Cultural Competence: The Need for Assessment of Sociocultural Issues in the Delivery of Evidence-Based Psychosocial Rehabilitation Services

PubMed Central

Yamada, Ann-Marie; Brekke, John S

2008-01-01

Recognition of ethnic/racial disparities in mental health services has not directly resulted in the development of culturally responsive psychosocial interventions. There remains a fundamental need for assessment of sociocultural issues that have been linked with the expectations, needs, and goals of culturally diverse consumers with severe and persistent mental illness. The authors posit that embedding the assessment of sociocultural issues into psychosocial rehabilitation practice is one step in designing culturally relevant empirically supported practices. It becomes a foundation on which practitioners can examine the relevance of their interventions to the diversity encountered in everyday practice. This paper provides an overview of the need for culturally and clinically relevant assessment practices and asserts that by improving the assessment of sociocultural issues the clinical competence of service providers is enhanced. The authors offer a conceptual framework for linking clinical assessment of sociocultural issues to consumer outcomes and introduce an assessment tool adapted to facilitate the process in psychosocial rehabilitation settings. Emphasizing competent clinical assessment skills will ultimately offer a strategy to address disparities in treatment outcomes for understudied populations of culturally diverse consumers with severe and persistent mental illness. PMID:18778881

Testing the 4Rs and 2Ss Multiple Family Group intervention: study protocol for a randomized controlled trial.

PubMed

Acri, Mary; Hamovitch, Emily; Mini, Maria; Garay, Elene; Connolly, Claire; McKay, Mary

2017-12-04

Oppositional defiant disorder (ODD) is a major mental health concern and highly prevalent among children living in poverty-impacted communities. Despite that treatments for ODD are among the most effective, few children living in poverty receive these services due to substantial barriers to access, as well as difficulties in the uptake and sustained adoption of evidence-based practices (EBPs) in community settings. The purpose of this study is to examine implementation processes that impact uptake of an evidence-based practice for childhood ODD, and the impact of a Clinic Implementation Team (CIT)-driven structured adaptation to enhance its fit within the public mental health clinic setting. This study, a Hybrid Type II effectiveness-implementation research trial, blends clinical effectiveness and implementation research methods to examine the impact of the 4Rs and 2Ss Multiple Family Group (MFG) intervention, family level mediators of child outcomes, clinic/provider-level mediators of implementation, and the impact of CITs on uptake and long-term utilization of this model. All New York City public outpatient mental health clinics have been invited to participate. A sampling procedure that included randomization at the agency level and a sub-study to examine the impact of clinic choice upon outcomes yielded a distribution of clinics across three study conditions. Quantitative data measuring child outcomes, organizational factors and implementation fidelity will be collected from caregivers and providers at baseline, 8, and 16 weeks from baseline, and 6 months from treatment completion. The expected participation is 134 clinics, 268 providers, and 2688 caregiver/child dyads. We will use mediation analysis with a multi-level Structural Equation Modeling (SEM) (MSEM including family level variables, provider variables, and clinic variables), as well as mediation tests to examine study hypotheses. The aim of the study is to generate knowledge about effectiveness and mediating factors in the treatment of ODDs in children in the context of family functioning, and to propose an innovative approach to the adaptation and implementation of new treatment interventions within clinic settings. The proposed CIT adaptation and implementation model has the potential to enhance implementation and sustainability, and ultimately increase the extent to which effective interventions are available and can impact children and families in need of services for serious behavior problems. ClinicalTrials.gov, ID: NCT02715414 . Registered on 3 March 2016.

Fuels planning: science synthesis and integration; economic uses fact sheet 04: My Fuel Treatment Planner

Treesearch

Rocky Mountain Research Station USDA Forest Service

2004-01-01

In the face of rapidly changing public and political attitudes toward fire and fuel planning, one thing remains constant: the fuel planner is ultimately responsible for making decisions on the land. This fact sheet discusses the options for fuel treatments, and the need, development, and use of the MS Excel-based tool, My Fuel Treatment Planner.

The cost benefit and efficiency of waste water treatment using domestic ponds—the ultimate solution in Southern Africa

NASA Astrophysics Data System (ADS)

Ntengwe, F. W.

Wastewater treatment has become a challenge to most countries in Southern Africa because of the fluctuating economies that have been hit by high levels of debts. The treatment of domestic wastewater using ponds, if carefully utilized, as has been observed in most countries in the world, is the most cost effective means of handling wastewaters. When compared to the conventional use of treatment plants, the ponds have been observed to be the ultimate solution for the countries in Southern Africa especially those that are classified as Highly Indebted Poor Countries (HIPC) because of little or no operating costs associated with the treatment. The study conducted on Kitwe Waste Water Treatment Ponds to evaluate the cost benefit and efficiencies has revealed low levels of operating cost and high removal efficiencies of oxygen demanding wastes (BOD removal of 86% and TSS removal of 75%), pH values ranged from 7 to 8 indicating an increasing alkalinity from facultative to maturation ponds while other parameters such as nitrates, phosphates and temperature were found to be within acceptable levels thereby releasing effluent that makes the environment sustainable. The overall social benefit was found to be much higher than the operating costs.

Methodological issues in the design of clinical trials for the treatment of multidrug-resistant tuberculosis: challenges and opportunities.

PubMed

Lienhardt, C; Davies, G

2010-05-01

The burden of multidrug-resistant tuberculosis (MDR-TB) is increasing dramatically in the world today, severely hampering global TB control. Treatment of MDR-TB is complex, prolonged, expensive and requires appropriate clinical and laboratory infrastructure. The majority of MDR-TB patients still do not have access to adequate diagnostic services or quality assured second-line drugs, leading to high levels of morbidity and mortality. More effective and efficient MDR-TB treatment with reduced toxicity that could be safely delivered to patients co-infected with human immunodeficiency virus (HIV) is an urgent research priority that could be cost-saving for health systems overall. In this context, understanding how best to design and execute randomised controlled trials to improve MDR-TB treatment has taken on new urgency, to identify the optimal combination(s) of existing and new drugs to assemble in efficient and safe regimen(s), preferably of short duration, that can be easily delivered to patients and safely combined with antiretroviral treatment. In the present report, we address the methodological issues in the design and execution of Phase II and Phase III trials arising from this goal. We suggest that a rational selection of appropriate designs and outcome measures, associated with the application of new diagnostic technology, could overcome many of the methodological and logistical problems. These advances could be key to historic improvements in the treatment of patients suffering from MDR-TB, and perhaps ultimately drug-susceptible TB. As with HIV, clinical trials in patients with drug-resistant disease may provide a quicker and less expensive path to licensure than trials for treatment of drug-susceptible disease.

Dysbiosis, inflammation, and response to treatment: a longitudinal study of pediatric subjects with newly diagnosed inflammatory bowel disease.

PubMed

Shaw, Kelly A; Bertha, Madeline; Hofmekler, Tatyana; Chopra, Pankaj; Vatanen, Tommi; Srivatsa, Abhiram; Prince, Jarod; Kumar, Archana; Sauer, Cary; Zwick, Michael E; Satten, Glen A; Kostic, Aleksandar D; Mulle, Jennifer G; Xavier, Ramnik J; Kugathasan, Subra

2016-07-13

Gut microbiome dysbiosis has been demonstrated in subjects with newly diagnosed and chronic inflammatory bowel disease (IBD). In this study we sought to explore longitudinal changes in dysbiosis and ascertain associations between dysbiosis and markers of disease activity and treatment outcome. We performed a prospective cohort study of 19 treatment-naïve pediatric IBD subjects and 10 healthy controls, measuring fecal calprotectin and assessing the gut microbiome via repeated stool samples. Associations between clinical characteristics and the microbiome were tested using generalized estimating equations. Random forest classification was used to predict ultimate treatment response (presence of mucosal healing at follow-up colonoscopy) or non-response using patients' pretreatment samples. Patients with Crohn's disease had increased markers of inflammation and dysbiosis compared to controls. Patients with ulcerative colitis had even higher inflammation and dysbiosis compared to those with Crohn's disease. For all cases, the gut microbial dysbiosis index associated significantly with clinical and biological measures of disease severity, but did not associate with treatment response. We found differences in specific gut microbiome genera between cases/controls and responders/non-responders including Akkermansia, Coprococcus, Fusobacterium, Veillonella, Faecalibacterium, and Adlercreutzia. Using pretreatment microbiome data in a weighted random forest classifier, we were able to obtain 76.5 % accuracy for prediction of responder status. Patient dysbiosis improved over time but persisted even among those who responded to treatment and achieved mucosal healing. Although dysbiosis index was not significantly different between responders and non-responders, we found specific genus-level differences. We found that pretreatment microbiome signatures are a promising avenue for prediction of remission and response to treatment.

Patient-Centred Care of Older Adults With Cardiovascular Disease and Multiple Chronic Conditions.

PubMed

Kim, Dae Hyun; Rich, Michael W

2016-09-01

Multimorbidity, defined as the presence of 2 or more chronic conditions, is common among older adults with cardiovascular disease. These individuals are at increased risk for poor health outcomes and account for a large proportion of health care utilization. Clinicians are challenged with the heterogeneity of this population, the complexity of the treatment regimen, limited high-quality evidence, and fragmented health care systems. Each treatment recommended by a clinical practice guideline for a single cardiovascular disease might be rational, but the combination of all evidence-based recommendations can be impractical or even harmful to individuals with multimorbidity. These challenges can be overcome with a patient-centred approach that incorporates the individual's preferences, relevant evidence, the overall and condition-specific prognosis, clinical feasibility of treatments, and interactions with other treatments and coexisting chronic conditions. The ultimate goal is to maximize benefits and minimize harms by optimizing adherence to the most essential treatments, while acknowledging trade-offs between treatments for different health conditions. It might be necessary to discontinue therapies that are not essential or potentially harmful to decrease the risk of drug-drug and drug-disease interactions from polypharmacy. A decision to initiate, withhold, or stop a treatment should be on the basis of the time horizon to benefits vs the individual's prognosis. In this review, we illustrate how cardiologists and general practitioners can adopt a patient-centred approach to focus on the aspects of cardiovascular and noncardiovascular health that have the greatest effect on functioning and quality of life in older adults with cardiovascular disease and multimorbidity. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Neurocognitive Defects and Their Impact on Substance Abuse Treatment.

ERIC Educational Resources Information Center

Fals-Stewart, William

1993-01-01

Examined prevalence of cognitive deficits in substance abusers (n=108) referred by criminal justice system to complete treatment in drug-free therapeutic community. Findings revealed that substance abusers with neuropsychological deficits were more likely to be removed from program for failure to follow rules and ultimately stayed in residence…

Effect of Treatment Modality on Long-Term Outcomes in Attention-Deficit/Hyperactivity Disorder: A Systematic Review

PubMed Central

Arnold, L. Eugene; Hodgkins, Paul; Caci, Hervé; Kahle, Jennifer; Young, Susan

2015-01-01

Background Evaluation of treatments for attention-deficit/hyperactivity disorder (ADHD) previously focused on symptom control, but attention has shifted to functional outcomes. The effect of different ADHD treatment periods and modalities (pharmacological, non-pharmacological, and combination) on long-term outcomes needs to be more comprehensively understood. Methods A systematic search of 12 literature databases using Cochrane’s guidelines yielded 403 English-language peer-reviewed, primary studies reporting long-term outcomes (≥2 years). We evaluated relative effects of treatment modalities and durations and effect sizes of outcomes reported as statistically significantly improved with treatment. Results The highest proportion of improved outcomes was reported with combination treatment (83% of outcomes). Among significantly improved outcomes, the largest effect sizes were found for combination treatment. The greatest improvements were associated with academic, self-esteem, or social function outcomes. A majority of outcomes improved regardless of age of treatment initiation (60%–75%) or treatment duration (62%–72%). Studies with short treatment duration had shorter follow-up times (mean 3.2 years total study length) than those with longer treatment durations (mean 7.1 years total study length). Studies with follow-up times <3 years reported benefit with treatment for 93% of outcomes, whereas those with follow-up times ≥3 years reported treatment benefit for 57% of outcomes. Post-hoc analysis indicated that this result was related to the measurement of outcomes at longer periods (3.2 versus 0.4 years) after treatment cessation in studies with longer total study length. Conclusions While the majority of long-term outcomes of ADHD improve with all treatment modalities, the combination of pharmacological and non-pharmacological treatment was most consistently associated with improved long-term outcomes and large effect sizes. Older treatment initiation age or longer durations did not markedly affect proportion of improved outcomes reported, but measurement of outcomes long periods after treatment cessation may attenuate results. PMID:25714373

Is it possible to stop nucleos(t)ide analogue treatment in chronic hepatitis B patients?

PubMed Central

Moreno-Cubero, Elia; del Arco, Robert T Sánchez; Peña-Asensio, Julia; de Villalobos, Eduardo Sanz; Míquel, Joaquín; Larrubia, Juan Ramón

2018-01-01

Chronic hepatitis B (CHB) remains a challenging global health problem, with nearly one million related deaths per year. Nucleos(t)ide analogue (NA) treatment suppresses viral replication but does not provide complete cure of the hepatitis B virus (HBV) infection. The accepted endpoint for therapy is the loss of hepatitis B surface antigen (HBsAg), but this is hardly ever achieved. Therefore, indefinite treatment is usually required. Many different studies have evaluated NA therapy discontinuation after several years of NA treatment and before HBsAg loss. The results have indicated that the majority of patients can remain off therapy, with some even reaching HBsAg seroconversion. Fortunately, this strategy has proved to be safe, but it is essential to consider the risk of liver damage and other comorbidities and to ensure a close follow-up of the candidates before considering this strategy. Unanswered questions remain, namely in which patients could this strategy be effective and what is the optimal time point at which to perform it. To solve this enigma, we should keep in mind that the outcome will ultimately depend on the equilibrium between HBV and the host’s immune system. Viral parameters that have been described as good predictors of response in HBeAg(+) cases, have proven useless in HBeAg(-) ones. Since antiviral immunity plays an essential role in the control of HBV infection, we sought to review and explain potential immunological biomarkers to predict safe NA discontinuation in both groups. PMID:29740199

Novel approaches against epidermal growth factor receptor tyrosine kinase inhibitor resistance

PubMed Central

Heydt, Carina; Michels, Sebastian; Thress, Kenneth S.; Bergner, Sven; Wolf, Jürgen; Buettner, Reinhard

2018-01-01

Background The identification and characterization of molecular biomarkers has helped to revolutionize non-small-cell lung cancer (NSCLC) management, as it transitions from target-focused to patient-based treatment, centered on the evolving genomic profile of the individual. Determination of epidermal growth factor receptor (EGFR) mutation status represents a critical step in the diagnostic process. The recent emergence of acquired resistance to “third-generation” EGFR tyrosine kinase inhibitors (TKIs) via multiple mechanisms serves to illustrate the important influence of tumor heterogeneity on prognostic outcomes in patients with NSCLC. Design This literature review examines the emergence of TKI resistance and the course of disease progression and, consequently, the clinical decision-making process in NSCLC. Results Molecular markers of acquired resistance, of which T790M and HER2 or MET amplifications are the most common, help to guide ongoing treatment past the point of progression. Although tissue biopsy techniques remain the gold standard, the emergence of liquid biopsies and advances in analytical techniques may eventually allow “real-time” monitoring of tumor evolution and, in this way, help to optimize targeted treatment approaches. Conclusions The influence of inter- and intra-tumor heterogeneity on resistance mechanisms should be considered when treating patients using resistance-specific therapies. New tools are necessary to analyze changes in heterogeneity and clonal composition during drug treatment. The refinement and standardization of diagnostic procedures and increased accessibility to technology will ultimately help in personalizing the management of NSCLC. PMID:29632655

[Influence of sterilization treatments on continuous carbon-fiber reinforced polyolefin composite].

PubMed

Guan, Shi-bing; Hou, Chun-lin; Chen, Ai-min; Zhang, Wei; Wang, Ji-e

2007-08-21

To evaluate the influence of sterilization treatment on continuous carbon-fiber reinforced polyolefin composite (CFRP) so as to provide experimental reference for selection of sterilization method for CFRP. Seventy bars of CFRP were divided into 7 equal groups to undergo sterilization by autoclave, 2% glutaraldehyde soaking, 75% alcohol soaking, ethylene oxide sterilization, and Co-60 gamma ray irradiation of the dosages 11 kGy, 25 kGy, and 18 kGy respectively, and another 10 bars were used as blank controls. Then the bars underwent three-point bending test and longitudinal compression test so as to measure the biomechanical changes after sterilization treatment, including the maximum load, ultimate strength, and elastic modulus. Three-point bending test showed that the levels of maximum load of the all experimental groups were lower than that of the control group, however, only those of the 3 Co-60 irradiation groups were significantly lower than that of the control group and that Co-60 radiation lowered the level of maximum load dose-dependently; and that the levels of ultimate strength of all the all experimental groups were lower than that of the control group, however, only those of the 3 Co-60 groups were significantly lower than that of the control group and that the higher the dosage of Co-60 radiation the lower the level of ultimate strength, however, not dose-dependently. The elastic modulus of the Co-60 25 KGy group was significantly higher than that of the control group, and there was no significant difference in the level of ultimate strength among the other groups. Longitudinal compression test showed that the levels of maximum load and ultimate strength of the 3 Co-60 irradiation groups, autoclave group, and circular ethylene groups were significantly lower than that of the control group, and there was no significant difference in elastic modulus among different groups. During sterilized package of CFRP products produced in quantity autoclave sterilization and Co-60 gamma ray irradiation sterilization should be avoided. Ethylene oxide is proposed as the best sterilization method. If gamma ray irradiation is to be used further technology improvement is necessary.

Light therapy for multiple sclerosis-associated fatigue: Study protocol for a randomized controlled trial.

PubMed

Mateen, Farrah J; Manalo, Natalie C; Grundy, Sara J; Houghton, Melissa A; Hotan, Gladia C; Erickson, Hans; Videnovic, Aleksandar

2017-09-01

Fatigue is the most commonly reported symptom among multiple sclerosis (MS) patients, more than a quarter of whom consider fatigue to be their most disabling symptom. However, there are few effective treatment options for fatigue. We aim to investigate whether supplemental exposure to bright white light will reduce MS-associated fatigue. Eligible participants will have clinically confirmed multiple sclerosis based on the revised McDonald criteria (2010) and a score ≥36 on the Fatigue Severity Scale (FSS). Participants will be randomized 1:1 to bright white light (10,000 lux; active condition) or dim red light (<300 lux; control condition) self-administered for 1 hour twice daily. The study will include a 2-week baseline period, a 4-week treatment period, and a 4-week washout period. Participants will record their sleep duration, exercise, caffeine, and medication intake daily. Participants will record their fatigue using the Visual Analogue Fatigue Scale (VAFS) 4 times every third day, providing snapshots of their fatigue level at different times of day. Participants will self-report their fatigue severity using FSS on 3 separate visits: at baseline (week 0), following completion of the treatment phase (week 6), and at study completion (week 10). The primary outcome will be the change in the average FSS score after light therapy. We will perform an intention-to-treat analysis, comparing the active and control groups to assess the postintervention difference in fatigue levels reported on FSS. Secondary outcome measures include change in global VAFS scores during the light therapy and self-reported quality of life in the Multiple Sclerosis Quality of Life-54. We present a study design and rationale for randomizing a nonpharmacological intervention for MS-associated fatigue, using bright light therapy. The study limitations relate to the logistical issues of a self-administered intervention requiring frequent participant self-report in a relapsing condition. Ultimately, light therapy for the treatment of MS-associated fatigue may provide a low-cost, noninvasive, self-administered treatment for one of the most prevalent and burdensome symptoms experienced by people with MS.

Seventh Joint Meeting of K-J-CaP and CaPSURE: extending the global initiative to improve prostate cancer management

PubMed Central

Akaza, Hideyuki; Kim, Choung Soo; Carroll, Peter; Choi, In Young; Chung, Byung Ha; Cooperberg, Matthew R.; Hirao, Yoshihiko; Hinotsu, Shiro; Horie, Shigeo; Lee, Ji Youl; Namiki, Mikio; Ng, Chi-Fai; Onozawa, Mizuki; Ozono, Seiichiro; Ueno, Satoru; Umbas, Rainy; Ye, Dingwei; Zhu, Gang

2014-01-01

This report summarizes the presentations and discussions that took place at the Seventh Joint Meeting of the Korea–Japan Study Group of Prostate Cancer (K-J-CaP) and the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) held in Seoul, Korea, in September 2013. The original J-CaP and CaPSURE Joint Initiative has now been established since 2007 and since the initial collaboration between research teams in the United States (US) and Japan, the project has expanded to include several other Asian countries. The objective of the initiative is to analyze and compare data for prostate cancer patients in the participating countries, looking at similarities and differences in patient management and outcomes. Until now the focus has been primarily on data generated within J-CaP and CaPSURE, both large-scale, longitudinal, observational databases of prostate cancer patients in Japan and the US, respectively. This year’s meeting was hosted for the first time in Korea which has recently established its own national database–K-CaP–to add to the wealth of data generated by J-CaP and CaPSURE. As a newly-developed database, K-CaP has also provided a valuable ‘template’ for other countries, such as China and Indonesia, planning to establish their own national databases and this will ultimately allow greater opportunities for international data comparisons. A range of topics was discussed at this Seventh Joint Meeting including comparison of outcomes following androgen deprivation therapy or radical prostatectomy in patients with localized prostate cancer, the use of active surveillance as a treatment option and the triggers for intervention when employing this regimen, patient quality of life during treatment, the impact of comorbidities on outcomes, and a comparison of recent outcomes data between J-CaP and CaPSURE. The participants recognized that prostate cancer was now a global disease and therefore major insights into understanding and improving the management of this condition would arise from global interactions such as this joint initiative. PMID:26153555

Seventh Joint Meeting of K-J-CaP and CaPSURE: extending the global initiative to improve prostate cancer management.

PubMed

Akaza, Hideyuki; Kim, Choung Soo; Carroll, Peter; Choi, In Young; Chung, Byung Ha; Cooperberg, Matthew R; Hirao, Yoshihiko; Hinotsu, Shiro; Horie, Shigeo; Lee, Ji Youl; Namiki, Mikio; Ng, Chi-Fai; Onozawa, Mizuki; Ozono, Seiichiro; Ueno, Satoru; Umbas, Rainy; Ye, Dingwei; Zhu, Gang

2014-01-01

This report summarizes the presentations and discussions that took place at the Seventh Joint Meeting of the Korea-Japan Study Group of Prostate Cancer (K-J-CaP) and the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) held in Seoul, Korea, in September 2013. The original J-CaP and CaPSURE Joint Initiative has now been established since 2007 and since the initial collaboration between research teams in the United States (US) and Japan, the project has expanded to include several other Asian countries. The objective of the initiative is to analyze and compare data for prostate cancer patients in the participating countries, looking at similarities and differences in patient management and outcomes. Until now the focus has been primarily on data generated within J-CaP and CaPSURE, both large-scale, longitudinal, observational databases of prostate cancer patients in Japan and the US, respectively. This year's meeting was hosted for the first time in Korea which has recently established its own national database-K-CaP-to add to the wealth of data generated by J-CaP and CaPSURE. As a newly-developed database, K-CaP has also provided a valuable 'template' for other countries, such as China and Indonesia, planning to establish their own national databases and this will ultimately allow greater opportunities for international data comparisons. A range of topics was discussed at this Seventh Joint Meeting including comparison of outcomes following androgen deprivation therapy or radical prostatectomy in patients with localized prostate cancer, the use of active surveillance as a treatment option and the triggers for intervention when employing this regimen, patient quality of life during treatment, the impact of comorbidities on outcomes, and a comparison of recent outcomes data between J-CaP and CaPSURE. The participants recognized that prostate cancer was now a global disease and therefore major insights into understanding and improving the management of this condition would arise from global interactions such as this joint initiative.

The Importance of Quality in Ventilation-Perfusion Imaging.

PubMed

Mann, April; DiDea, Mario; Fournier, France; Tempesta, Daniel; Williams, Jessica; LaFrance, Norman

2018-06-01

As the health care environment continues to change and morph into a system focusing on increased quality and evidence-based outcomes, nuclear medicine technologists must be reminded that they play a critical role in achieving high-quality, interpretable images used to drive patient care, treatment, and best possible outcomes. A survey performed by the Quality Committee of the Society of Nuclear Medicine and Molecular Imaging Technologist Section demonstrated that a clear knowledge gap exists among technologists regarding their understanding of quality, how it is measured, and how it should be achieved by all practicing technologists regardless of role and education level. Understanding of these areas within health care, in conjunction with the growing emphasis on evidence-based outcomes, quality measures, and patient satisfaction, will ultimately elevate the role of nuclear medicine technologists today and into the future. The nuclear medicine role now requires technologists to demonstrate patient assessment skills, practice safety procedures with regard to staff and patients, provide patient education and instruction, and provide physicians with information to assist with the interpretation and outcome of the study. In addition, the technologist must be able to evaluate images by performing technical analysis, knowing the demonstrated anatomy and pathophysiology, and assessing overall quality. Technologists must also be able to triage and understand the disease processes being evaluated and how nuclear medicine diagnostic studies may drive care and treatment. Therefore, it is imperative that nuclear medicine technologists understand their role in the achievement of a high-quality, interpretable study by applying quality principles and understanding and using imaging techniques beyond just basic protocols for every type of disease or system being imaged. This article focuses on quality considerations related to ventilation-perfusion imaging. It provides insight on appropriate imaging techniques and protocols, true imaging variants and tracer distributions versus artifacts that may result in a lower-quality or misinterpreted study, and the use of SPECT and SPECT/CT as an alternative providing a high-quality, interpretable study with better diagnostic accuracy and fewer nondiagnostic procedures than historical planar imaging. © 2018 by the Society of Nuclear Medicine and Molecular Imaging.

Neural correlates of the divergence of instrumental probability distributions.

PubMed

Liljeholm, Mimi; Wang, Shuo; Zhang, June; O'Doherty, John P

2013-07-24

Flexible action selection requires knowledge about how alternative actions impact the environment: a "cognitive map" of instrumental contingencies. Reinforcement learning theories formalize this map as a set of stochastic relationships between actions and states, such that for any given action considered in a current state, a probability distribution is specified over possible outcome states. Here, we show that activity in the human inferior parietal lobule correlates with the divergence of such outcome distributions-a measure that reflects whether discrimination between alternative actions increases the controllability of the future-and, further, that this effect is dissociable from those of other information theoretic and motivational variables, such as outcome entropy, action values, and outcome utilities. Our results suggest that, although ultimately combined with reward estimates to generate action values, outcome probability distributions associated with alternative actions may be contrasted independently of valence computations, to narrow the scope of the action selection problem.

Neural Correlates of the Divergence of Instrumental Probability Distributions

PubMed Central

Wang, Shuo; Zhang, June; O'Doherty, John P.

2013-01-01

Flexible action selection requires knowledge about how alternative actions impact the environment: a “cognitive map” of instrumental contingencies. Reinforcement learning theories formalize this map as a set of stochastic relationships between actions and states, such that for any given action considered in a current state, a probability distribution is specified over possible outcome states. Here, we show that activity in the human inferior parietal lobule correlates with the divergence of such outcome distributions–a measure that reflects whether discrimination between alternative actions increases the controllability of the future–and, further, that this effect is dissociable from those of other information theoretic and motivational variables, such as outcome entropy, action values, and outcome utilities. Our results suggest that, although ultimately combined with reward estimates to generate action values, outcome probability distributions associated with alternative actions may be contrasted independently of valence computations, to narrow the scope of the action selection problem. PMID:23884955

Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: a systematic review and meta-analysis.

PubMed

Xue, Xing-He; Yan, Shi-Gui; Cai, Xun-Zi; Shi, Ming-Min; Lin, Tiao

2014-04-01

With development in the techniques of reduction and fixation, there has been a controversy in comparison between intramedullary nailing (IMN) and plating for the treatment of distal tibial metaphyseal fracture (DTF). The study aimed to investigate: (1) which fixation, IMN or plating, was better in the clinical outcomes and in the complications for the treatment of DTF and (2) which modifying variables affected the comparative results between the two modalities. PubMed, EMBASE, OVID, Scopus, ISI Web of Science, the Cochrane Library, Google Scholar and specific orthopaedic journals were searched from inception to July 2013, using the search strategy of '('Fracture Fixation, Intramedullary' [MeSH]) AND ('Tibial Fractures' [MeSH]) AND (plate OR plating)'. All prospective and retrospective controlled trials comparing function, pain, bone union and complications between IMN and plating for DTF were identified. Our analysis had no limitation of the language or the publication year. The primary outcome measurements were complication rate, union time, operation time and hospital stays, while the secondary outcome measurements were functional score and pain score. Fourteen of 6620 studies with 842 patients were included. IMN was probably preferential to plating for DTF given its higher functional score (p=0.01), lower risk of infection (p=0.02) and comparable pain score (p=0.33), total complication rate (p=0.53) and time to union (p=0.86). However, plating had a lower malunion rate than IMN (p<0.0001). All the results were based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence of moderate quality. With a satisfying alignment obtained, IMN may be preferential to plating for fixation of DTF with better function and lower risk of infection. However, IMN showed higher malunion rate for fixation of DTF. With the biases in our meta-analysis, it will ultimately require a rigorous and adequately powered randomised controlled trial (RCT) to prove. Level III, therapeutic study (systematic review). Copyright © 2014 Elsevier Ltd. All rights reserved.

Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism.

PubMed

Pasrija, Chetan; Shah, Aakash; George, Praveen; Kronfli, Anthony; Raithel, Maxwell; Boulos, Francesca; Ghoreishi, Mehrdad; Bittle, Gregory J; Mazzeffi, Michael A; Rubinson, Lewis; Gammie, James S; Griffith, Bartley P; Kon, Zachary N

2018-04-07

Massive pulmonary embolism (PE) remains a highly fatal condition. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical pulmonary embolectomy in the management of massive PE have been reported previously, the outcomes remain less than ideal. We hypothesized that the institution of a protocolized approach of triage and optimization using VA-ECMO would result in improved outcomes compared with historical surgical management. All patients with a massive PE referred to the cardiac surgery service between 2010 and 2017 were retrospectively reviewed. Patients were stratified by treatment strategy: historical control versus the protocolized approach. In the historical control group, the primary intervention was surgical pulmonary embolectomy. In the protocol approach group, patients were treated based on an algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. A total of 56 patients (control, n = 27; protocol, n = 29) were identified. All 27 patients in the historical control group underwent surgical pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 patients were treated with anticoagulation alone and 14 patients ultimately required surgical pulmonary embolectomy. One-year survival was significantly lower in the historical control group compared with the protocol approach group (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary embolectomy in the protocol approach group. A protocolized strategy involving the aggressive institution of VA-ECMO appears to be an effective method to triage and optimize patients with massive PE to recovery or intervention. Implementation of this strategy rather than an aggressive surgical approach may reduce the mortality associated with massive PE. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Evaluating perceived benefits of ecoregional assessments.

PubMed

Bottrill, Madeleine C; Mills, Morena; Pressey, Robert L; Game, Edward T; Groves, Craig

2012-10-01

The outcomes of systematic conservation planning (process of assessing, implementing, and managing conservation areas) are rarely reported or measured formally. A lack of consistent or rigorous evaluation in conservation planning has fueled debate about the extent to which conservation assessment (identification, design, and prioritization of potential conservation areas) ultimately influences actions on the ground. We interviewed staff members of a nongovernmental organization, who were involved in 5 ecoregional assessments across North and South America and the Asia-Pacific region. We conducted 17 semistructured interviews with open and closed questions about the perceived purpose, outputs, and outcomes of the ecoregional assessments in which respondents were involved. Using qualitative data collected from those interviews, we investigated the types and frequency of benefits perceived to have emerged from the ecoregional assessments and explored factors that might facilitate or constrain the flow of benefits. Some benefits reflected the intended purpose of ecoregional assessments. Other benefits included improvements in social interactions, attitudes, and institutional knowledge. Our results suggest the latter types of benefits enable ultimate benefits of assessments, such as guiding investments by institutional partners. Our results also showed a clear divergence between the respondents' expectations and perceived outcomes of implementation of conservation actions arising from ecoregional assessments. Our findings suggest the need for both a broader perspective on the contribution of assessments to planning goals and further evaluation of conservation assessments. ©2012 Society for Conservation Biology.

Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain.

PubMed

Jessep, Sally A; Walsh, Nicola E; Ratcliffe, Julie; Hurley, Michael V

2009-06-01

Chronic knee pain is a major cause of disability in the elderly. Management guidelines recommend exercise and self-management interventions as effective treatments. The authors previously described a rehabilitation programme integrating exercise and self-management [Enabling Self-management and Coping with Arthritic knee Pain through Exercise (ESCAPE-knee pain)] that produced short-term improvements in pain and physical function, but sustaining these improvements is difficult. Moreover, the programme is untried in clinical environments, where it would ultimately be delivered. To establish the feasibility of ESCAPE-knee pain and compare its clinical effectiveness and costs with outpatient physiotherapy. Pragmatic, randomised controlled trial. Outpatient physiotherapy department and community centre. Sixty-four people with chronic knee pain. Outpatient physiotherapy compared with ESCAPE-knee pain. The primary outcome was physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index. Secondary outcomes included pain, objective functional performance, anxiety, depression, exercise-related health beliefs and healthcare utilisation. All outcomes were assessed at baseline and 12 months after completing the interventions (primary endpoint). ANCOVA investigated between-group differences. Both groups demonstrated similar improvements in clinical outcomes. Outpatient physiotherapy cost pound 130 per person and the healthcare utilisation costs of participants over 1 year were pound 583. The ESCAPE-knee pain programme cost pound 64 per person and the healthcare utilisation costs of participants over 1 year were pound 320. ESCAPE-knee pain can be delivered as a community-based integrated rehabilitation programme for people with chronic knee pain. Both ESCAPE-knee pain and outpatient physiotherapy produced sustained physical and psychosocial benefits, but ESCAPE-knee pain cost less and was more cost-effective.

Failed back surgery syndrome: what's in a name? A proposal to replace "FBSS" by "POPS"….

PubMed

Rigoard, P; Desai, M J; Taylor, R S

2015-03-01

The current definition of Failed Back Surgery Syndrome (FBSS) has a pejorative and restrictive connotation of blame and failure. Optimally, the evaluation of FBSS patients might be based on a multidimensional approach, involving an array of practitioners including spine surgeons, pain physicians, physiotherapists and behavioural specialists. Even though these clinical interactions should lead to a unique approach, one main problem comes from the fact that FBSS definition has varied over time and remains extremely controversial. There is now a need for global consensus about what we call FBSS, why, when and how. Discussing the name of this syndrome appears to be a logical starting point. "PostOperative Persistent Syndrome", summarised by the acronym "POPS", could be an appropriate term to not only encapsulate failure but pain, function and psychosocial dysfunction following unsuccessful spine surgery whether from a technical or expectation standpoint. A return to the source might help to identify the real clinical problem, i.e. the pain mechanism: nociceptive, neuropathic pain or mixed. A clinical and radiological spine assessment is key to ensure that no further surgery is required, by distinguishing within the so-called FBSS population, "true" FBSS patients and "potential" FBSS patients, who are actually not FBSS patients, as an aetiological treatment of potential pain generators still remains possible. We propose to replace the FBSS acronym by POPS. The ultimate goal of this redefinition would be to guide the patient towards the future rather than the past and to reach a consensus, based on network discussions, concerning the following items: integrate pain mechanisms into the diagnostic process; implement the notion of a predominant ratio between mechanical/neuropathic pain mechanisms, which defines the potential target for treatment options; create a network supported by a database, to prospectively pool and analyse data, using homogeneous evaluation tools and ultimately define outcome predictors in this population. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Contribution of immunology to implantation failure of euploid embryos.

PubMed

Franasiak, Jason M; Scott, Richard T

2017-06-01

Outcomes in assisted reproduction have seen marked improvement. With increased ability in the embryology laboratory to use extended embryo culture which in turn enables other selective techniques, such as trophectoderm biopsy and comprehensive chromosome screening, the chance of success per embryo transfer is increased. However, even the selection of a euploid blastocyst, which selects out many embryonic factors, does not yield successful implantation and ultimately delivery in all cases. Among the factors that affect implantation failure of apparently reproductively competent embryos, the immune system has been perhaps both the most plausible and the most debated. There are data on T-helper cells, in particular the T H 1-T H 2 balance, peripheral and uterine natural killer cells, and autoantibodies, all of which have been shown to have variable effects on implantation. Many investigators have developed and used a wide range of immune tests and treatments aimed at manipulating the milieu to favor implantation. Although it is certain that the immune system plays a role in implantation, our understanding of the physiology, let alone the pathophysiology, remains incomplete. It is imperative that we gain more clear evidence of causes and test and implement treatment paradigms. In the meantime, immune testing or empirical treatment with the use of immune modulators must be approached with caution. Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Targeted therapies in gastric cancer treatment: where we are and where we are going.

PubMed

Tomasello, Gianluca; Ghidini, Michele; Liguigli, Wanda; Ratti, Margherita; Toppo, Laura; Passalacqua, Rodolfo

2016-06-01

Gastric cancer (GC) is one of the most common malignancies and a major cause of cancer-related deaths worldwide. Its incidence has significantly declined over the last few decades, probably due to the identification of specific etiologic agents such as Helicobacter pylori and other dietary and environmental risk factors. Nevertheless, most of the cases are unfortunately diagnosed at an advanced stage justifying median overall survival rates frequently not exceeding one year. Palliative combination chemotherapy usually represented by a platinum-based doublet is the mainstay of treatment in the metastatic setting. Adding a third drug such as an anthracycline or a taxane has been shown to improve response rate and provide limited survival benefits in fit selected patients. Unlike other tumors, the introduction of molecularly targeted drugs in the medical armamentarium for GC is relatively recent with trastuzumab and ultimately ramucirumab constituting the only agents approved to date. Recent advances in the understanding of GC biology have led to the development of novel targeted therapies holding the promise to further improve treatment outcomes. The aim of this paper is to review the main available data coming from clinical trials of targeted drugs and to describe some of the most interesting molecules in clinical development in GC. These include drugs targeting EGFR, angiogenesis, c-MET, FGFR2, mTOR and immune checkpoints.

Patient Education for Endoscopic Sinus Surgery: Preliminary Experience Using 3D-Printed Clinical Imaging Data.

PubMed

Sander, Ian M; Liepert, Taimi T; Doney, Evan L; Leevy, W Matthew; Liepert, Douglas R

2017-04-07

Within the Ear, Nose, and Throat (ENT) medical space, a relatively small fraction of patients follow through with elective surgeries to fix ailments such as a deviated septum or occluded sinus passage. Patient understanding of their diagnosis and treatment plan is integral to compliance, which ultimately yields improved medical outcomes and better quality of life. Here we report the usage of advanced, polyjet 3D printing methods to develop a multimaterial replica of human nasal sinus anatomy, derived from clinical X-ray computed tomography (CT) data, to be used as an educational aid during physician consultation. The final patient education model was developed over several iterations to optimize material properties, anatomical accuracy and overall display. A two-arm, single-center, randomized, prospective study was then performed in which 50 ENT surgical candidates (and an associated control group, n = 50) were given an explanation of their anatomy, disease state, and treatment options using the education model as an aid. Statistically significant improvements in patient ratings of their physician's explanation of their treatment options ( p = 0.020), self-rated anatomical understanding ( p = 0.043), self-rated understanding of disease state ( p = 0.016), and effectiveness of the visualization ( p = 0.007) were noted from the population that viewed the 3D education model, indicating it is an effective tool which ENT surgeons may use to educate and interact with patients.

Integral pharmacological management of bone mineral disorders in chronic kidney disease (part I): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification.

PubMed

Bover, J; Ureña-Torres, P; Lloret, M J; Ruiz-García, C; DaSilva, I; Diaz-Encarnacion, M M; Mercado, C; Mateu, S; Fernández, E; Ballarin, J

2016-06-01

Chronic kidney disease-mineral and bone disorders (CKD-MBD), involving a triad of laboratory and bone abnormalities, and tissue calcifications, are associated with dismal hard-outcomes. In two comprehensive articles, we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (this part 1) and hyperparathyroidism (part 2), taking into account CKD-accelerated atheromatosis/atherosclerosis and/or cardiovascular calcification (CVC) processes. Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Individualization of treatment with P-binders and combinations of anti-parathyroid agents may improve biochemical control with lower incidence of undesirable effects. Isolated biochemical parameters do not accurately reflect calcium or P load or bone activity and do not stratify high cardiovascular risk patients with CKD. Initial guidance is provided on reasonable therapeutic strategies which consider the presence of CVC. This part reflects that although there is not an absolute evidence, many studies point to the need to improve P imbalance while trying to, at least, avoid progression of CVC by restriction of Ca-based P-binders if economically feasible. The availability of new drugs (i.e. inhibitors of intestinal transporters), and studies including early CKD should ultimately lead to clearer and more cost/effective clinical targets for CKD-MBD.

Management of hepatitis C virus infection: the basics.

PubMed

Naggie, Susanna

2012-12-01

Chronic hepatitis C virus (HCV) infection affects some 170 million people worldwide, including 3 to 4 million in the United States who are largely unaware of their infection status. HCV has 6 genotypes; genotype 1 is the most common in the United States and genotypes 1 and 4 are less responsive to interferon alfa-based therapy than the other genotypes. Treatment with available direct-acting antiviral (DAA) drugs has increased sustained virologic response (SVR) rates in genotype 1 infection and shortened duration of therapy in many patients, but at this time these agents must still be administered with peginterferon alfa and ribavirin to prevent rapid emergence of resistance. Baseline predictors of response to therapy continue to play a role with triple-drug combination therapy including the pharmacogenetic IL28B genotype, which differs in prevalence throughout the world. The stopping/futility rules are different for triple-drug combination therapy, allowing for earlier decision-making. Ultimately, SVR is the goal of HCV treatment because it dramatically reduces likelihood of poor long-term outcome, even among patients with histologically advanced disease. This article summarizes a basic review presented by Susanna Naggie, MD, at the IAS-USA live management of HCV continuing medical education program held in Atlanta in October 2012. This article is intended for practitioners who are new to HCV management or who are interested in reviewing the basics of HCV treatments.

Human growth hormone may be detrimental when used to accelerate recovery from acute tendon-bone interface injuries.

PubMed

Baumgarten, Keith M; Oliver, Harvey A; Foley, Jack; Chen, Ding-Geng; Autenried, Peter; Duan, Shanzhong; Heiser, Patrick

2013-05-01

There have been few scientific studies that have examined usage of human growth hormone to accelerate recovery from injury. The hypothesis of this study was that human growth hormone would accelerate tendon-to-bone healing compared with control animals treated with placebo in a rat model of acute rotator cuff injury repair. Seventy-two rats underwent repair of acute rotator cuff injuries and were randomized into the following postoperative dosing regimens: placebo, and human growth hormone at 0.1, 1, 2, 5, and 10 mg/kg/day, administered subcutaneously once per day for fourteen days (Protocol 1). An additional twenty-four rats were randomized to receive either (1) placebo or (2) human growth hormone at 5 mg/kg, administered subcutaneously twice per day for seven days preoperatively and twenty-eight days postoperatively (Protocol 2). All rats were killed twenty-eight days postoperatively. Mechanical testing was performed. Ultimate stress, ultimate force, stiffness, energy to failure, and ultimate distension were determined. For Protocol 1, analysis of variance testing showed no significant difference between the groups with regard to ultimate stress, ultimate force, stiffness, energy to failure, or ultimate distension. In Protocol 2, ultimate force to failure was significantly worse in the human growth hormone group compared with the placebo group (21.1 ± 5.85 versus 26.3 ± 5.47 N; p = 0.035). Failure was more likely to occur through the bone than the tendon-bone interface in the human growth hormone group compared with the placebo group (p = 0.001). No significant difference was found for ultimate stress, ultimate force, stiffness, energy to failure, or ultimate distension between the groups in Protocol 2. In this rat model of acute tendon-bone injury repair, daily subcutaneous postoperative human growth hormone treatment for fourteen days failed to demonstrate a significant difference in any biomechanical parameter compared with placebo. Furthermore, subcutaneous administration of 5 mg/kg of human growth hormone twice daily from seven days preoperatively until twenty-eight days postoperatively demonstrated lower loads to ultimate failure and a higher risk of bone fracture failure compared with placebo.

The Aftermath of Remedial Math: Investigating the Low Rate of Certificate Completion among Remedial Math Students

ERIC Educational Resources Information Center

Bahr, Peter Riley

2013-01-01

Nationally, a majority of community college students require remedial assistance with mathematics, but comparatively few students who begin the remedial math sequence ultimately complete it and achieve college-level math competency. The academic outcomes of students who begin the sequence but do not complete it are disproportionately unfavorable:…

Taking Action for Looked after Children in School: A Knowledge Exchange Programme

ERIC Educational Resources Information Center

Carroll, Catherine; Cameron, Claire

2017-01-01

Promoting the Achievement of Looked After Children (PALAC) is a knowledge exchange programme that aims to support the development of practice in schools and to expand the evidence base to ultimately improve outcomes for children in care. Feedback on the first year of PALAC exceeded expectations, with practitioners using their projects to evaluate…

Application of the ToxMiner Database: Network Analysis of Linkage between ToxCast Phase I Chemicals and Thyroid Related Disease Outcomes

EPA Science Inventory

The US EPA ToxCast program is using in vitro HTS (High-Throughput Screening) methods to profile and model bioactivity of environmental chemicals. The main goals of the ToxCast program are to generate predictive signatures of toxicity, and ultimately provide rapid and cost-effecti...

A Compendium of Social-Behavioral Research Funded by NCER and NCSER: 2002-2013. NCER 2016-2002

ERIC Educational Resources Information Center

Yamaguchi, Ryoko; Hall, Adam; Stapleton, Katina; Doolittle, Emily; Buckley, Jacquelyn

2016-01-01

The purpose of this compendium is to catalog NCER's and NCSER's contributions to social-behavioral research. Research undertaken as part of these projects is contributing to a knowledge base that ultimately aims to improve academic outcomes for students via improvements in students' social-behavioral competencies, teachers' practices, and the…

Comparing Linguistic Complexity and Efficiency in Conversations from Stimulation and Conversation Therapy in Aphasia

ERIC Educational Resources Information Center

Savage, Meghan C.; Donovan, Neila J.

2017-01-01

Background: Efficacy studies have demonstrated the benefit of group conversation therapy for a person with aphasia (PWA). However, a PWA typically participates in individual therapy prior to group therapy. Stimulation therapy (ST) is the most common type of individual aphasia therapy. Ultimately, the outcome of therapy is to enable the PWA to…

The Role of Academic Preparation and Interest on STEM Success. ACT Research Report Series

ERIC Educational Resources Information Center

Radunzel, Justine; Mattern, Krista; Westrick, Paul

2016-01-01

Research has shown that science, technology, engineering, and mathematics (STEM) majors who are more academically prepared--especially in terms of their mathematics and science test scores--are more likely to be successful across a variety of outcomes: cumulative grade point average (GPA), persistence in a STEM major, and ultimately earning a STEM…

Estimating the Effects of Students' Social Networks: Does Attending a Norm-Enforcing School Pay Off?

ERIC Educational Resources Information Center

Carolan, Brian V.

2010-01-01

In an attempt to forge tighter social relations, small school reformers advocate school designs intended to create smaller, more trusting, and more collaborative settings. These efforts to enhance students' social capital in the form of social closure are ultimately tied to improving academic outcomes. Using data derived from ELS: 2002, this study…

Understanding the Design Context for Australian University Teachers: Implications for the Future of Learning Design

ERIC Educational Resources Information Center

Bennett, Sue; Thomas, Lisa; Agostinho, Shirley; Lockyer, Lori; Jones, Jennifer; Harper, Barry

2011-01-01

Based on the premise that providing support for university teachers in designing for their teaching will ultimately improve the quality of student learning outcomes, recent interest in the development of support tools and strategies has gained momentum. This article reports on a study that examined the context in which Australian university…

Enhancing Understanding of Social Responsibility through Intentional Teacher Education Programming: A Profession's Imperative

ERIC Educational Resources Information Center

Miels, Jill C.

2011-01-01

Universities are central to promoting the idea of civic engagement. As for teacher education programs, the author believes that civic engagement is the ultimate outcome for the profession. She argues that civic engagement should be the responsibility of every individual, but often it rests solely on the shoulders of classroom teachers. In offering…

Transfer of Life Skills in Sport-Based Youth Development Programs: A Conceptual Framework Bridging Learning to Application

ERIC Educational Resources Information Center

Jacobs, Jennifer M.; Wright, Paul M.

2018-01-01

Research has demonstrated that many quality sport-based youth development programs promote life skill acquisition (e.g., leadership, self-control) with the ultimate goal of facilitating positive outcomes in youth participants' social and academic environments. Researchers call this "transfer of life skills" (i.e., the idea that physical,…

Home-Based Crisis Therapy: A Comparative Outcome Study.

ERIC Educational Resources Information Center

Rowland, Charity; And Others

Substitute care for a child at risk has been been associated with psychological distress in the child and his family and a drain on public finances. To investigate the cost effectiveness and ultimate influence on family intactness of home-based family crisis intervention, 77 low income, inner city families with an adolescent child at risk of…

The Provision of a Health Promoting Environment for HIV/AIDS Education: The Case of Namibian Senior Secondary Schools

ERIC Educational Resources Information Center

Campbell, Bob; Lubben, Fred

2003-01-01

HIV/AIDS programmes in schools ultimately intend to decrease high risk sexual behaviour. One factor facilitating this outcome is a strong health promoting environment in the school. This paper reports a study surveying the health promoting environments supporting HIV/AIDS education in Namibian senior secondary schools. It develops a…

Using prognostic models in CLL to personalize approach to clinical care: Are we there yet?

PubMed

Mina, Alain; Sandoval Sus, Jose; Sleiman, Elsa; Pinilla-Ibarz, Javier; Awan, Farrukh T; Kharfan-Dabaja, Mohamed A

2018-03-01

Four decades ago, two staging systems were developed to help stratify CLL into different prognostic categories. These systems, the Rai and the Binet staging, depended entirely on abnormal exam findings and evidence of anemia and thrombocytopenia. Better understanding of biologic, genetic, and molecular characteristics of CLL have contributed to better appreciating its clinical heterogeneity. New prognostic models, the GCLLSG prognostic index and the CLL-IPI, emerged. They incorporate biologic and genetic information related to CLL and are capable of predicting survival outcomes and cases anticipated to need therapy earlier in the disease course. Accordingly, these newer models are helping develop better informed surveillance strategies and ultimately tailor treatment intensity according to presence (or lack thereof) of certain prognostic markers. This represents a step towards personalizing care of CLL patients. We anticipate that as more prognostic factors continue to be identified, the GCLLSG prognostic index and CLL-IPI models will undergo further revisions. Copyright © 2017 Elsevier Ltd. All rights reserved.

Integrative Psychotherapy for Schizophrenia: Its Potential for a Central Role in Recovery Oriented Treatment.

PubMed

Lysaker, Paul H; Roe, David

2016-02-01

Research has affirmed that recovery from serious mental illnesses (SMI), such as schizophrenia, is a common outcome and often involves subjective changes in the experience of self, one's identity, and one's sense of agency in the world. Although many different interventions have been developed and validated, efforts to consider how those interventions should be integrated to assist people to direct their own recovery have been limited. This article considers the 5 case reports of psychotherapy presented in this special issue that have sought to integrate scientifically valid approaches within a recovery frame work. Exploring shared themes, this article suggests that a common set of processes exists between these examples of integrative work. These include therapist acceptance of a vulnerable stance in the face of uncertainty, which rejects stigma and remains open to knowing the person. This ultimately allows the kinds of meaning to be made jointly between the therapist and client that promote recovery. © 2015 Wiley Periodicals, Inc.

Apples to committee consensus: the challenge of gender identity classification.

PubMed

Rettew, David C

2012-01-01

The debate surrounding the inclusion of gender dysphoria/gender variant behavior (GD/GV) as a psychiatric diagnosis exposes many of the fundamental shortcomings and inconsistencies of our current diagnostic classification system. Proposals raised by the authors of this special issue, including basing diagnosis on cause rather than overt behavior, reclassifying GD/GV behavior as a physical rather than mental condition, and basing diagnosis on impairment or distress, offer some solutions but have limitations themselves given the available database. In contrast to most accepted psychiatric conditions where emphasis is placed on ultimately changing internal thoughts, feelings, and behaviors, consensus treatment for most GD/GV individuals, at least from adolescence onward, focuses on modifying the external body and external environment to maximize positive outcomes. This series of articles illustrating the diversity of opinions on when and if gender incongruence should be considered pathological reflects the relative lack of scientific indicators of disease in this area, similar to many other domains of mental functioning.

Therapeutic potential of gel-based injectables for vocal fold regeneration

PubMed Central

Bartlett, Rebecca S.; Thibeault, Susan L.; Prestwich, Glenn D.

2012-01-01

Vocal folds are anatomically and biomechanically unique, thus complicating the design and implementation of tissue engineering strategies for repair and regeneration. Integration of an enhanced understanding of tissue biomechanics, wound healing dynamics and innovative gel-based therapeutics has generated enthusiasm for the notion that an efficacious treatment for vocal fold scarring could be clinically attainable within several years. Fibroblast phenotype and gene expression are mediated by the three-dimensional mechanical and chemical microenvironment at an injury site. Thus, therapeutic approaches need to coordinate spatial and temporal aspects of the wound healing response in an injured vocal tissue to achieve an optimal clinical outcome. Successful gel-based injectables for vocal fold scarring will require a keen understanding of how the native inflammatory response sets into motion the later extracellular matrix remodeling, which in turn will determine the ultimate biomechanical properties of the tissue. We present an overview of the challenges associated with this translation as well as the proposed gel-based injectable solutions. PMID:22456756

The metabolic burden of sleep loss.

PubMed

Schmid, Sebastian M; Hallschmid, Manfred; Schultes, Bernd

2015-01-01

In parallel with the increasing prevalence of obesity and type 2 diabetes, sleep loss has become common in modern societies. An increasing number of epidemiological studies show an association between short sleep duration, sleep disturbances, and circadian desynchronisation of sleep with adverse metabolic traits, in particular obesity and type 2 diabetes. Furthermore, experimental studies point to distinct mechanisms by which insufficient sleep adversely affects metabolic health. Changes in the activity of neuroendocrine systems seem to be major mediators of the detrimental metabolic effects of insufficient sleep, through favouring neurobehavioural outcomes such as increased appetite, enhanced sensitivity to food stimuli, and, ultimately, a surplus in energy intake. The effect of curtailed sleep on physical activity and energy expenditure is less clear, but changes are unlikely to outweigh increases in food intake. Although long-term interventional studies proving a cause and effect association are still scarce, sleep loss seems to be an appealing target for the prevention, and probably treatment, of metabolic disease. Copyright © 2015 Elsevier Ltd. All rights reserved.

Diagnosis and Multimodality Management of Cushing's Disease: A Practical Review

PubMed Central

Zada, Gabriel

2013-01-01

Cushing's Disease is caused by oversecretion of ACTH from a pituitary adenoma and results in subsequent elevations of systemic cortisol, ultimately contributing to reduced patient survival. The diagnosis of Cushing's Disease frequently involves a stepwise approach including clinical, laboratory, neuroimaging, and sometimes interventional radiology techniques, often mandating multidisciplinary collaboration from numerous specialty practitioners. Pituitary microadenomas that do not appear on designated pituitary MRI or dynamic contrast protocols may pose a particularly challenging subset of this disease. The treatment of Cushing's Disease typically involves transsphenoidal surgical resection of the pituitary adenoma as a first-line option, yet may require the addition of adjunctive measures such as stereotactic radiosurgery or medical management to achieve normalization of serum cortisol levels. Vigilant long-term serial endocrine monitoring of patients is imperative in order to detect any recurrence that may occur, even years following initial remission. In this paper, a stepwise approach to the diagnosis, and various management strategies and associated outcomes in patients with Cushing's Disease are discussed. PMID:23401686

Engineering 3D Models of Tumors and Bone to Understand Tumor-Induced Bone Disease and Improve Treatments

PubMed Central

Kwakwa, Kristin A.; Vanderburgh, Joseph P.; Guelcher, Scott A.

2018-01-01

Purpose of Review Bone is a structurally unique microenvironment that presents many challenges for the development of 3D models for studying bone physiology and diseases, including cancer. As researchers continue to investigate the interactions within the bone microenvironment, the development of 3D models of bone has become critical. Recent Findings 3D models have been developed that replicate some properties of bone, but have not fully reproduced the complex structural and cellular composition of the bone microenvironment. This review will discuss 3D models including polyurethane, silk, and collagen scaffolds that have been developed to study tumor-induced bone disease. In addition, we discuss 3D printing techniques used to better replicate the structure of bone. Summary 3D models that better replicate the bone microenvironment will help researchers better understand the dynamic interactions between tumors and the bone microenvironment, ultimately leading to better models for testing therapeutics and predicting patient outcomes. PMID:28646444

A Method for Achieving Reciprocity of Funding in Community-Based Participatory Research

PubMed Central

Gehlert, Sarah; Fayanju, Oluwadamilola M.; Jackson, Sherrill; Kenkel, Sandi; McCullough, Isaac C.; Oliver, Cheryl; Sanford, Mark

2015-01-01

Background The St. Louis Komen Project was conceived to address disparities in breast cancer treatment and outcomes between African-American and White women in St. Louis, Missouri. Our goal was to apportion tasks and funding through a process to which all researcher partners had input and to which all could agree, thus eliminating institutionalized inequalities. Methods This paper describes the collaborative process and resulting division of responsibilities, determination of costs, and ultimate allocation of funds and resources, as well as the documentation employed to achieve funding reciprocity and equal accountability. Results Both communication and documentation are critical. Although the Memoranda of Understanding employed are not a panacea, they codify roles and expectations and promote trust. The process of developing financial transparency set the tone for subsequent steps in the research process. Conclusions The exhaustive planning process and project-specific procedures developed by its partners have helped the project foster reciprocity, facilitate participation, and equitably distribute resources. PMID:25727989

Identifying Medical Diagnoses and Treatable Diseases by Image-Based Deep Learning.

PubMed

Kermany, Daniel S; Goldbaum, Michael; Cai, Wenjia; Valentim, Carolina C S; Liang, Huiying; Baxter, Sally L; McKeown, Alex; Yang, Ge; Wu, Xiaokang; Yan, Fangbing; Dong, Justin; Prasadha, Made K; Pei, Jacqueline; Ting, Magdalene Y L; Zhu, Jie; Li, Christina; Hewett, Sierra; Dong, Jason; Ziyar, Ian; Shi, Alexander; Zhang, Runze; Zheng, Lianghong; Hou, Rui; Shi, William; Fu, Xin; Duan, Yaou; Huu, Viet A N; Wen, Cindy; Zhang, Edward D; Zhang, Charlotte L; Li, Oulan; Wang, Xiaobo; Singer, Michael A; Sun, Xiaodong; Xu, Jie; Tafreshi, Ali; Lewis, M Anthony; Xia, Huimin; Zhang, Kang

2018-02-22

The implementation of clinical-decision support algorithms for medical imaging faces challenges with reliability and interpretability. Here, we establish a diagnostic tool based on a deep-learning framework for the screening of patients with common treatable blinding retinal diseases. Our framework utilizes transfer learning, which trains a neural network with a fraction of the data of conventional approaches. Applying this approach to a dataset of optical coherence tomography images, we demonstrate performance comparable to that of human experts in classifying age-related macular degeneration and diabetic macular edema. We also provide a more transparent and interpretable diagnosis by highlighting the regions recognized by the neural network. We further demonstrate the general applicability of our AI system for diagnosis of pediatric pneumonia using chest X-ray images. This tool may ultimately aid in expediting the diagnosis and referral of these treatable conditions, thereby facilitating earlier treatment, resulting in improved clinical outcomes. VIDEO ABSTRACT. Copyright © 2018 Elsevier Inc. All rights reserved.

Dental Caries Progression Among U.S. Marine Corps Personnel Following Operational Deployment

DTIC Science & Technology

2012-06-01

86 dental faculty members at 16 French universities, Tubert- Jeannin and colleagues37 found wide variation in restorative treatment thresholds...lesions, assessment of restorations, and treatment decisions, which ultimately led to variation in their 27     students’ treatment modalities...almost one-third of all teeth. This substantial variation among practitioners is most likely due to differences in individual practitioners’ criteria

Biochemical methane potential, biodegradability, alkali treatment and influence of chemical composition on methane yield of yard wastes.

PubMed

Gunaseelan, Victor Nallathambi

2016-03-01

In this study, the biochemical CH4 potential, rate, biodegradability, NaOH treatment and the influence of chemical composition on CH4 yield of yard wastes generated from seven trees were examined. All the plant parts were sampled for their chemical composition and subjected to the biochemical CH4 potential assay. The component parts exhibited significant variation in biochemical CH4 potential, which was reflected in their ultimate CH4 yields that ranged from 109 to 382 ml g(-1) volatile solids added and their rate constants that ranged from 0.042 to 0.173 d(-1). The biodegradability of the yard wastes ranged from 0.26 to 0.86. Variation in the biochemical CH4 potential of the yard wastes could be attributed to variation in the chemical composition of the different fractions. In the Thespesia yellow withered leaf, Tamarindus fruit pericarp and Albizia pod husk, NaOH treatment enhanced the ultimate CH4 yields by 17%, 77% and 63%, respectively, and biodegradability by 15%, 77% and 61%, respectively, compared with the untreated samples. The effectiveness of NaOH treatment varied for different yard wastes, depending on the amounts of acid detergent fibre content. Gliricidia petals, Prosopis leaf, inflorescence and immature pod, Tamarindus seeds, Albizia seeds, Cassia seeds and Delonix seeds exhibited CH4 yields higher than 300 ml g(-1) volatile solids added. Multiple linear regression models for predicting the ultimate CH4 yield and biodegradability of yard wastes were designed from the results of this work. © The Author(s) 2016.

Impact of Obesity on Heart and Lung Transplantation: Does Pre-Transplant Obesity Affect Outcomes?

PubMed

Bozso, S J; Nagendran, Je; Gill, R S; Freed, D H; Nagendran, Ja

2017-03-01

Increasing prevalence of obesity has led to a rise in the number of prospective obese heart and lung transplant recipients. The optimal management strategy of obese patients with end-stage heart and lung failure remains controversial. This review article discusses and provides a summary of the literature surrounding the impact of obesity on outcomes in heart and lung transplantation. Studies on transplant obesity demonstrate controversy in terms of morbidity and mortality outcomes and obesity pre-transplantation. However, the impact of obesity on outcomes seems to be more consistently demonstrated in lung rather than heart transplantation. The ultimate goal in heart and lung transplantation in the obese patient is to identify those at highest risk of complication that may warrant therapies to mitigate risk by addressing comorbid conditions. Copyright © 2016 Elsevier Inc. All rights reserved.

How to Diagnose Solutions to a Quality of Care Problem

PubMed Central

Silver, Samuel A.; McQuillan, Rory F.; Weizman, Adam V.; Thomas, Alison; Chertow, Glenn M.; Nesrallah, Gihad; Chan, Christopher T.; Bell, Chaim M.

2016-01-01

To change a particular quality of care outcome within a system, quality improvement initiatives must first understand the causes contributing to the outcome. After the causes of a particular outcome are known, changes can be made to address these causes and change the outcome. Using the example of home dialysis (home hemodialysis and peritoneal dialysis), this article within this Moving Points feature on quality improvement will provide health care professionals with the tools necessary to analyze the steps contributing to certain outcomes in health care quality and develop ideas that will ultimately lead to their resolution. The tools used to identify the main contributors to a quality of care outcome will be described, including cause and effect diagrams, Pareto analysis, and process mapping. We will also review common change concepts and brainstorming activities to identify effective change ideas. These methods will be applied to our home dialysis quality improvement project, providing a practical example that other kidney health care professionals can replicate at their local centers. PMID:27016495

Brief Strategic Family Therapy for Young People in Treatment for Drug Use

ERIC Educational Resources Information Center

Lindstrøm, Maia; Filges, Trine; Jørgensen, Anne-Marie Klint

2015-01-01

Purpose: This review evaluates the evidence on the effects of brief strategic family therapy (BSFT) on drug use reduction for young people in treatment for nonopioid drug use. Method: We followed Campbell Collaboration guidelines to prepare this review and ultimately located three studies for final analysis and interpretation. Results: The results…

A Diagnostic/Prescriptive System to Aid in the Treatment of Behavioral Disorders.

ERIC Educational Resources Information Center

Cunningham, William G.; And Others

Described is the development of a diagnostic/prescriptive system--developed as part of the Pendleton Project--which would aid in the understanding of causes and ultimate treatment of dysfunctional behavior in 6- through 12-year-old children. Reported are the objectives and rationale of the Pendleton Project, an interdisciplinary, community based…

Framework for Energy Neutral Treatment for the 21st Century Through Energy Efficient Aeration (WERF Report INFR2R12)

EPA Science Inventory

Aeration is commonly identified as the most significant energy use in the treatment of wastewater and therefore garners significant focus in reducing energy use in the ultimate aspirational goal of achieving net energy neutrality for water resource recovery. This research establi...

Potentiation of omega-3 fatty acid antidepressant-like effects with low non-antidepressant doses of fluoxetine and mirtazapine.

PubMed

Laino, Carlos Horacio; Fonseca, Cristina; Sterin-Speziale, Norma; Slobodianik, Nora; Reinés, Analía

2010-12-01

Despite the advances in psychopharmacology, the treatment of depressive disorders is still not satisfactory. Side effects and resistance to antidepressant drugs are the greatest complications during treatment. Based on recent evidence, omega-3 fatty acids may influence vulnerability and outcome in depressive disorders. The aim of this study was to further characterize the omega-3 antidepressant-like effect in rats in terms of its behavioral features in the depression model forced swimming test either alone or in combination with antidepressants fluoxetine or mirtazapine. Ultimately, we prompted to determine the lowest dose at which omega-3 fatty acids and antidepressant drugs may still represent a pharmacological advantage when employed in combined treatments. Chronic diet supplementation with omega-3 fatty acids produced concentration-dependent antidepressant-like effects in the forced swimming test displaying a behavioral profile similar to fluoxetine but different from mirtazapine. Fluoxetine or mirtazapine at antidepressant doses (10 and 20 mg/kg/day, respectively) rendered additive effects in combination with omega-3 fatty acid supplementation (720 mg/kg/day). Beneficial effects of combined treatment were also observed at sub-effective doses (1 mg/kg/day) of fluoxetine or mirtazapine, since in combination with omega-3 fatty acids (720 mg/kg/day), antidepressants potentiated omega-3 antidepressant-like effects. The antidepressant-like effects occurred in the absence of changes in brain phospholipid classes. The therapeutic approach of combining omega-3 fatty acids with low ineffective doses of antidepressants might represent benefits in the treatment of depression, especially in patients with depression resistant to conventional treatments and even may contribute to patient compliance by decreasing the magnitude of some antidepressant dose-dependent side effects. Copyright © 2010 Elsevier B.V. All rights reserved.

A values-based Motivational Interviewing (MI) intervention for pediatric obesity: study design and methods for MI Values.

PubMed

Bean, Melanie K; Mazzeo, Suzanne E; Stern, Marilyn; Bowen, Deborah; Ingersoll, Karen

2011-09-01

To reduce pediatric obesity in clinical settings, multidisciplinary behaviorally-based treatment programs are recommended. High attrition and poor compliance are two difficulties frequently encountered in such programs. A brief, empathic and directive clinical intervention, Motivational Interviewing (MI), might help address these motivational and behavioral issues, ultimately resulting in more positive health outcomes. The efficacy of MI as an adjunct in the treatment of pediatric obesity remains relatively understudied. MI Values was developed to implement within an existing multidisciplinary treatment program for obese, ethnically diverse adolescents, the T.E.E.N.S. Program (Teaching, Encouragement, Exercise, Nutrition, Support). T.E.E.N.S. participants who consent to MI Values are randomized to either MI or an education control condition. At weeks 1 and 10 of T.E.E.N.S. participation, the subset of participants assigned to the MI condition engages in individual MI sessions and control participants view health education videos. All MI sessions are audiotaped and coded to monitor treatment fidelity, which has been satisfactory thus far. Participants complete comprehensive assessments at baseline, 3- and 6-month follow-ups. We hypothesize that MI participants will demonstrate greater reductions in Body Mass Index (BMI) percentile, improved diet and physical activity behaviors, better compliance with T.E.E.N.S., and lower attrition than participants in the control group. We present study design and methods for MI Values as well as data on feasibility of recruitment methods and treatment integrity. At study completion, findings will contribute to the emerging literature examining the efficacy of MI in the treatment of pediatric obesity. Copyright © 2011 Elsevier Inc. All rights reserved.