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Short waits, happy patients and expert care, moving basic musculoskeletal care from the emergency department to a physiotherapist-led diversion pathway. Emerg Med Australas 2024. [PMID: 38622755 DOI: 10.1111/1742-6723.14416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Patients with musculoskeletal conditions (MSKCs) are highly prevalent in ED. This project explores the impact of the pilot phase of a 'diversion pathway', which directed patients with MSKCs from the ED waiting room to an outpatient clinic led by advanced-scope physiotherapists. METHODS A prospective intervention study comparing care outcomes between patients in the 'diversion pathway' with usual ED care. The characteristics of patients considered eligible and non-eligible are described. RESULTS Between May and December 2022, 1099 patients were diverted. For diverted patients, mean length of stay (LOS) in ED was reduced by 110 (95% confidence interval [CI]: 99-120) min and 4 h rule compliance improved by 19.3% compared to usual ED care. There were fewer patients who 'did not wait' (DNW) with the diversion pathway. The diverted group was young (median age 22 years and 41% paediatric), mostly low urgency, self-referred and arrived by private transport with minor limb trauma. The diversion pathway triage process appropriately identified 182 patients ineligible for diversion. 96.7% of patients reported satisfaction with care received from the diversion pathway. There was no change in ED representation rates for diverted patients. CONCLUSIONS A new pathway resulted in reduced LOS, reduced DNW, high patient satisfaction and more people being discharged within 4 h for diverted patients compared to usual ED care. The pathway increased ED capacity, improved key ED performance metrics and safely expedited care delivery for patients.
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Abstract
Background The relationship between duration of transient neurological events and presence of diffusion-weighted lesions by symptom type is unclear. Methods and Results This was a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment), a multicenter prospective cohort of patients with minor ischemic cerebrovascular events or stroke mimics at academic emergency departments in Canada. For this study we included patients with resolved symptoms and determined the presence of diffusion-weighted imaging (DWI) lesion on magnetic resonance imaging within 7 days. Using logistic regression, we evaluated the association between symptom duration and DWI lesion, assessing for interaction with symptom type (focal only versus nonfocal/mixed), and adjusting for age, sex, education, comorbidities, and systolic blood pressure. Of 658 patients included, a DWI lesion was present in 232 (35.1%). There was a significant interaction between symptom duration and symptom type. For those with focal-only symptoms, there was a continuous increase in DWI probability up to 24 hours in duration (ranging from ≈40% to 80% probability). In stratified analyses, the increase in probability of DWI lesion with increased duration of focal symptoms was seen in women but not men. For those with nonfocal or mixed symptoms, predicted probability of DWI lesion was ≈35% and was greater in men, but did not increase with longer duration. Conclusions Increased duration of neurological deficits is associated with greater probability of DWI lesion in those with focal symptoms only. For individuals with nonfocal or mixed symptoms, about one-third had DWI lesions, but the probability did not increase with duration. These results may be important to improve risk stratification of transient neurological events.
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‘I thought they would do it on the spot’: why do people with non-traumatic musculoskeletal pain present to emergency departments? AUST HEALTH REV 2023:AH22274. [DOI: 10.1071/ah22274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/03/2023] [Indexed: 03/29/2023]
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Evaluation of the Humoral Response to Adeno-Associated Virus-Based Gene Therapy Modalities Using Total Antibody Assays. AAPS J 2021; 23:108. [PMID: 34529177 PMCID: PMC8445016 DOI: 10.1208/s12248-021-00628-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 02/06/2023] Open
Abstract
The number of viral vector-based gene therapies (GTx) continues to grow with two products (Zolgensma® and Luxturna®) approved in the USA as of March 2021. To date, the most commonly used vectors are adeno-associated virus-based (AAV). The pre-existing humoral immunity against AAV (anti-AAV antibodies) has been well described and is expected as a consequence of prior AAV exposure. Anti-AAV antibodies may present an immune barrier to successful AAV transduction and hence negatively impact clinical efficacy and may also result in adverse events (AEs) due to the formation of large immune complexes. Patients may be screened for the presence of anti-AAV antibodies, including neutralizing (NAb) and total binding antibodies (TAb) prior to treatment with the GTx. Recommendations for the development and validation of anti-AAV NAb detection methods have been presented elsewhere. This manuscript covers considerations related to anti-AAV TAb-detecting protocols, including the advantages of the use of TAb methods, selection of assay controls and reagents, and parameters critical to monitoring assay performance. This manuscript was authored by a group of scientists involved in GTx development representing eleven organizations. It is our intent to provide recommendations and guidance to industry sponsors, academic laboratories, and regulatory agencies working on AAV-based GTx viral vector modalities with the goal of achieving a more consistent approach to anti-AAV TAb assessment. Graphical abstract ![]()
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WS14.2 Potential factors influencing reduced requirements for intravenous antibiotics during the COVID-19 pandemic. J Cyst Fibros 2021. [PMCID: PMC8192164 DOI: 10.1016/s1569-1993(21)00994-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Landspreading with co-digested cattle slurry, with or without pasteurisation, as a mitigation strategy against pathogen, nutrient and metal contamination associated with untreated slurry. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 744:140841. [PMID: 32755776 DOI: 10.1016/j.scitotenv.2020.140841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 06/11/2023]
Abstract
North Atlantic European grassland systems have a low nutrient use efficiency and high rainfall. This grassland is typically amended with unprocessed slurry, which counteracts soil organic matter depletion and provides essential plant micronutrients but can be mobilised during rainfall events thereby contributing to pathogen, nutrient and metal incidental losses. Co-digesting slurry with waste from food processing mitigates agriculture-associated environmental impacts but may alter microbial, nutrient and metal profiles and their transmission to watercourses, and/or soil persistence, grass yield and uptake. The impact of EU and alternative pasteurisation regimes on transmission potential of these various pollutants is not clearly understood, particularly in pasture-based agricultural systems. This study utilized simulated rainfall (Amsterdam drip-type) at a high intensity indicative of a worst-case scenario of ~11 mm hr-1 applied to plots 1, 2, 15 and 30 days after grassland application of slurry, unpasteurised digestate, pasteurised digestate (two conditions) and untreated controls. Runoff and soil samples were collected and analysed for a suite of potential pollutants including bacteria, nutrients and metals following rainfall simulation. Grass samples were collected for three months following application to assess yield as well as nutrient and metal uptake. For each environmental parameter tested: microbial, nutrient and metal runoff losses; accumulation in soil and uptake in grass, digestate from anaerobic co-digestion of slurry with food processing waste resulted in lower pollution potential than traditional landspreading of slurry without treatment. Reduced microbial runoff from digestate was the most prominent advantage of digestate application. Pasteurisation of the digestate further augmented those environmental benefits, without impacting grass output. Anaerobic co-digestion of slurry is therefore a multi-beneficial circular approach to reducing impacts of livestock production on the environment.
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0438 Automatic Nighttime Agitation and Sleep Disruption Detection Using a Wearable Ankle Device and Machine Learning. Sleep 2020. [DOI: 10.1093/sleep/zsaa056.435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Nighttime agitation behavior such as wandering and restlessness during awake and sleep in people with Alzheimer’s disease (AD) is expensive to manage and adversely affects sleep. Nighttime agitation is mostly noted by subjective caregiver reports. An automated process for this assessment would improve clinical management. Here we report on the RestEaZeTM system that uses an ankle band and machine learning to automatically classify sleep status and nighttime agitation behaviors in older adults with AD.
Methods
We collected data on 7 adults (mean: 81 years, SD: 10.6) with AD. They wore the RestEaZeTM ankle band with a 3-axis accelerometer, a 3-axis gyroscope, and three textile capacitive sensors. A trained Research Assistant (RA) continuously observed for wandering, restlessness, wake, and sleep between 5pm and 7am using the Cohen Mansfield Agitation Inventory (CMAI). We merged, and band-pass filtered the data and divided it into 10-second non-overlapping windows. CMAI labels and time-series features (scaled using StandardScaler) extracted from the RestEaZeTM data were used to train a Random Forest binary classifier. The significant features were extracted based on the impact on the p-value for the classifier. We used the Synthetic Minority Oversampling Technique (SMOTE) to balance the dataset and performed 5-fold cross-validation with a 67-33 train-test split.
Results
We report the sensitivity, specificity, accuracy, and Area-under-the Curve (AUC) for the ROC curve for the classifiers: (1) Sleep/Awake: sensitivity=0.95, specificity=0.87, accuracy=0.92, AUC=0.97; (2) Wandering/Non-Wandering: sensitivity=0.85, specificity=0.99, accuracy=0.98, AUC=0.99; and (3) Restless/Non-Restless: sensitivity=0.84, specificity=0.84, accuracy=0.84, AUC=0.92. The significant features were related to the intensity of movements.
Conclusion
Our preliminary results show the feasibility of using RestEaZeTM for quantitatively measuring nighttime agitation. These can provide clinically useful objective measures of agitation that can be automatically transmitted to clinical or research records with minimal staff time requirements.
Support
The authors acknowledge the funding support from the National Institute on Aging under award R01AG051588 and Arbor Pharmaceuticals for support for Horizant and the matching placebo.
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30 The Role of A Virtual Clinic in Reducing Waiting Times for Out-Patient Follow-Up. Age Ageing 2020. [DOI: 10.1093/ageing/afz183.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Topic
Hospital admissions for older people are increasing with subsequent pressure on out-patient (OP) clinics. By early 2018, 350 patients were waiting up to 6 months for follow-up, with limited capacity in existing clinics. There were concerns regarding potential harm to patients from delayed review of significant results.
Intervention
A working group considered options for managing the OP waiting list. We decided to pilot a fortnightly virtual clinic (VC) where cases were reviewed without the patient present. All patients awaiting results were listed for the VC rather than routine OP. Each VC had 50 patients listed. Patient’s GP received a clear action plan. Clinic rules were modified as issues were identified. Links with other specialities evolved reducing the number of missing results. Data was analysed for 50% of consultations between January 2018 and March 2019.
Improvement
311 VC appointments were reviewed: 207 in 2018 and 104 up to March 2019. Maximum 25 cases could be completed per clinic, additional sessions cleared initial backlog within 3 months. Completion time/case ranged from 2-15 minutes depending on complexity. Main reason for VC was test results: 82% in 2018, increasing to 93% in 2019. 61% in 2018, 80% in 2019 were discharged directly from VC. 20% required a 2nd VC for outstanding results. OP review post-VC fell from 16% in 2018 to just 2% in 2019. General OP requirements fell from 24hrs to 10 hours/ week as a result of VCs, releasing consultants for other clinical areas.
Discussion
VCs are an effective means of reviewing outstanding results from recent admissions and OP consultations. Routine listing of patients with outstanding investigations provides a safety net. Most results are normal and do not require follow-up. Repeat CXRs at 6 weeks continue to be requested for severely frail people who are unlikely to benefit.
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Description of the larva of Catadromus lacordairei Boisduval, 1835 (Coleoptera: Carabidae), a threatened carabid, from Tasmania, Australia. Zootaxa 2019; 4664:zootaxa.4664.4.6. [PMID: 31716656 DOI: 10.11646/zootaxa.4664.4.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Indexed: 11/04/2022]
Abstract
The carabid beetle genus Catadromus MacLeay (Coleoptera: Carabidae) is endemic to the Australasian region. Of the five currently recognised species, only one, C. lacordairei Boisduval, 1835 occurs in Tasmania, Australia, where it is listed as a threatened species on the Tasmanian Threatened Species Protection Act 1995. In the present paper, we describe and illustrate the larva of C. lacordairei, providing the first detailed larval description of a member of this genus.
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Abstract
OBJECTIVE This report describes the instructional design and development process, learner feedback, and factors associated with course completion in the Academy of Peer Services (APS), an online educational platform for partial fulfillment of peer specialist state certification. METHOD From January 2014 to August 2017, 4,064 individuals in the APS completed online courses and provided demographic information and course evaluation feedback. This report analyzed the relationship between demographic data (work role, experience with online training, level of education) and posttest performance. Course evaluation data on quality, perceived difficulty, and learner satisfaction were also analyzed. RESULTS Overall, participants passed posttests 70.6% of the time. The effect size of work role was very small, η2 = .006. Level of education attainment was associated with differences on posttest scores, F(5, 3903) = 20.22, p < 001, but the effect size was, again, very modest, η2 = .025. Previous experience with online learning slightly influenced posttest scores, F(2, 4053) = 3.95, p < .02, η2 = .002. The great majority of students (88.2%) agreed or strongly agreed that the content was relevant to their everyday work. Similarly, 89% agreed or strongly agreed that the content contained practical tools, which they intend to use in their work. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE The feedback collected from more than 4000 learners suggests that the application of instructional design principles and techniques succeeded in translating the practical knowledge of peer-provided services to an easily accessible web-based platform for persons of varying education and life experiences. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Non-traumatic musculoskeletal pain in Western Australian hospital emergency departments: A clinical audit of the prevalence, management practices and evidence-to-practice gaps. Emerg Med Australas 2019; 31:1037-1044. [PMID: 31090200 DOI: 10.1111/1742-6723.13305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Musculoskeletal pain (MSP) conditions are a leading cause of morbidity worldwide and a common reason for ED presentation. Little is currently known about non-traumatic MSP (NTMSP) presenting to EDs. The present study described the prevalence and management practices of NTMSP in EDs. METHODS The design was a retrospective clinical audit in two hospital EDs in Western Australia covering 3 months beginning 1 January 2016. We defined NTMSP as pain of musculoskeletal origin occurring in the absence of external force or excessive physical loading. The outcomes measured included: patient, condition and hospital-episode characteristics, as well as management practices. Management practices were compared to recommended care derived from guideline recommendations. These included: assessment for red flags and psychosocial risk factors, appropriate use of diagnostic imaging, provision of patient education, administration and prescription of analgesic medication, and assessment of risk factors for opioid-related harm. RESULTS Eight hundred and eighty-eight patients were included in the present study. NTMSP accounted for 3.0% of all ED presentations. According to clinician documentation, red flag and psychosocial assessments were recorded in 73.3 and 10.5% of patients. Forty-one percent of patients were referred for imaging, of which 39.7% were inconsistent with guideline recommendations. Education was recorded 52.0% of the time. At least one opioid medication was administered to 55.3% of patients and there was no documented assessment of risk factors for opioid-related harm. CONCLUSIONS NTMSP is a relatively common reason for ED presentation. Documented management practices are discordant with guideline recommendations. Strategies to improve the concordance between management and guideline recommendations are needed.
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Phalangeal fracture leading to digital amputation, sustained during manipulation for Dupuytren's disease as part of clostridial collagenase treatment. Ann R Coll Surg Engl 2019; 101:e102-e104. [PMID: 30855178 DOI: 10.1308/rcsann.2019.0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Collagenase injection was approved in Europe for use in the treatment of Dupuytren's disease in 2011. Reported adverse effects include skin tears, swelling, pain and complex regional pain syndrome. Here, we present a case of a rare complication of phalangeal fracture following treatment with collagenase clostridium and the resultant digital amputation. An 81-year-old man was treated for a 25-year history of progressively disabling Dupuytren's disease of his left middle and ring fingers. Nine days post-manipulation he presented with persistent pain and swelling and was diagnosed with a displaced fracture of the proximal phalanx of his ring finger. Following discussion of surgical options and potential outcome, he elected to undergo amputation of the digit. He has experienced good treatment results in his middle finger and has no significant functional impairment as a result of this complication. Those offering collagenase injection in the management of Dupuytren's disease should be aware of this potential complication and it should be included in the consent process.
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13THE FRAILTY FLYING SQUAD HOTLINE: DIRECT REFERRAL FROM PARAMEDICS TO THE ACUTE HOSPITAL FRAILTY SERVICE. REPORT OF AN INITIAL PDSA CYCLE. Age Ageing 2019. [DOI: 10.1093/ageing/afy211.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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100DEVELOPMENT OF RECREATIONAL THERAPY ROLE WITHIN THE ELDERLY CARE DEPARTMENT. Age Ageing 2018. [DOI: 10.1093/ageing/afy126.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Environmental peanut exposure increases the risk of peanut sensitization in high-risk children. Clin Exp Allergy 2018; 48:586-593. [DOI: 10.1111/cea.13111] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 12/14/2022]
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Abstract
Stromatolites are the oldest evidence for life on Earth, but modern living examples are rare and predominantly occur in shallow marine or (hyper-) saline lacustrine environments, subject to exotic physico-chemical conditions. Here we report the discovery of living freshwater stromatolites in cool-temperate karstic wetlands in the Giblin River catchment of the UNESCO-listed Tasmanian Wilderness World Heritage Area, Australia. These stromatolites colonize the slopes of karstic spring mounds which create mildly alkaline (pH of 7.0-7.9) enclaves within an otherwise uniformly acidic organosol terrain. The freshwater emerging from the springs is Ca-HCO3 dominated and water temperatures show no evidence of geothermal heating. Using 16 S rRNA gene clone library analysis we revealed that the bacterial community is dominated by Cyanobacteria, Alphaproteobacteria and an unusually high proportion of Chloroflexi, followed by Armatimonadetes and Planctomycetes, and is therefore unique compared to other living examples. Macroinvertebrates are sparse and snails in particular are disadvantaged by the development of debilitating accumulations of carbonate on their shells, corroborating evidence that stromatolites flourish under conditions where predation by metazoans is suppressed. Our findings constitute a novel habitat for stromatolites because cool-temperate freshwater wetlands are not a conventional stromatolite niche, suggesting that stromatolites may be more common than previously thought.
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15THE PICTURE OF FRAILTY AT MID YORKSHIRE. Age Ageing 2017. [DOI: 10.1093/ageing/afx115.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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32IMPLEMENTATION OF A MEDICAL CHECKLIST TOOL TO IMPROVE THE QUALITY OF ELDERLY PATIENT CARE: A QUALITY IMPROVEMENT PROJECT. Age Ageing 2017. [DOI: 10.1093/ageing/afx055.32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Increasing Access to Cost Effective Home-Based Rehabilitation for Rural Veteran Stroke Survivors. AUSTIN JOURNAL OF CEREBROVASCULAR DISEASE & STROKE 2016; 3:1-11. [PMID: 28018979 PMCID: PMC5175468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION An estimated 750,000 Americans experience a stroke annually. Most stroke survivors require rehabilitation. Limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robotic devices deliver reproducible therapy without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor: HM and FM) to improve functional ability and reduce depression symptoms, while improving access and cost savings associated with rehabilitation. METHODS Twenty stroke survivors performed three months of home-based rehabilitation using a robotic device, while a therapist remotely monitored progress. Baseline and end of treatment function and depression symptoms were assessed. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy. RESULTS Compared to baseline, significant improvement in upper extremity function (30.06%, p= 0.046), clinically significant benefits in gait speed (29.03%), moderate improvement in depressive symptoms (28.44%) and modest improvement in distance walked (30.2%) were observed. Participants indicated satisfaction with the device. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the people no longer receiving formal services and increased daily access for the remaining 65%, with a cost savings of $2,352 (64.97%) compared to clinic-based therapy. CONCLUSION Stroke survivors made significant clinically meaningful improvements in the use of their impaired extremities using a robotic device in the home. Home-based, robotic therapy reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care.
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25PATIENT SURVEY INVESTIGATING CATERING CHOICES ON ‘CARE FOR THE ELDERLY’ WARDS. Age Ageing 2015. [DOI: 10.1093/ageing/afv106.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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30REDUCING PRESCRIBING ERRORS THROUGH PERSONALISED FEEDBACK. Age Ageing 2015. [DOI: 10.1093/ageing/afv106.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pre-operative thrombotic complications of neoadjuvant chemotherapy for breast cancer: Implications for immediate breast reconstruction. Ann Med Surg (Lond) 2015; 4:80-4. [PMID: 25834732 PMCID: PMC4372642 DOI: 10.1016/j.amsu.2014.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/01/2014] [Accepted: 11/04/2014] [Indexed: 01/05/2023] Open
Abstract
UNLABELLED Thrombotic complications arising during the treatment of breast cancer can impact the breast reconstruction pathway. We set out to review the details of cases of thromboembolism occurring during neoadjuvant chemotherapy and peri-operatively to study the impact of the event and its management on subsequent breast reconstruction. METHODS We retrospectively reviewed the medical records of seven patients who had experienced a thrombotic event during their treatment of breast cancer between 2008 and 2012, who then proceeded to breast reconstruction. We recorded size and grade of tumour, neoadjuvant chemotherapeutic regimen, details of port insertion, planned reconstruction, thrombotic event and its management and the surgery performed and outcome. RESULTS All patients received chemotherapy via central venous access and went on to present with local symptomatic thrombosis. They were managed with anticoagulant regimens at the time of mastectomy and reconstruction, which were unique for each patient. The results revealed delays to surgery and modifications to planned reconstruction. DISCUSSION The majority of patients developing thrombotic complications go on to achieve successful reconstruction. There is significant variation in the anticoagulation management in this patient group. Identification of optimal anticoagulant regimes and the possibilities for prophylaxis may prove key in informing surgeons when planning the reconstructive process. CONCLUSION An awareness of the effects of thrombotic events in this patient group is important in terms of developing an understanding of its impact on the performance of reconstruction, on the management of anticoagulation peri-operatively and on monitoring for post-operative complications.
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163 Interrogation of pharmacogenes in cancer patients using targeted DNA sequencing. Eur J Cancer 2014. [DOI: 10.1016/s0959-8049(14)70289-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Pharmacogenetic Evaluation of Targeted Dna Sequencing in Cancer Patients. Ann Oncol 2014. [DOI: 10.1093/annonc/mdu358.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Progression to insulin for patients with diabetes mellitus on dual oral antidiabetic therapy using the US Department of Defense Database. Diabetes Obes Metab 2013; 15:901-5. [PMID: 23531154 DOI: 10.1111/dom.12103] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 01/14/2013] [Accepted: 02/14/2013] [Indexed: 11/29/2022]
Abstract
AIM To compare 'progression to insulin' for three cohorts on oral antidiabetic medication combinations: metformin/sulphonylurea (Met/SU), metformin/thiazolidinedione (Met/TZD) and sulphonylurea/thiazolidinedione (SU/TZD). METHODS Retrospective cohort analysis design was used. The subjects were US nationwide members of military and their families. A total of 5608 patients who were on antidiabetic monotherapy for at least 1 year before adding a second agent to their medication regimen between October 2001 and September 2008 participated in this study. Mean age ranged from 64 to 71 years among the cohorts. Cox regression compared the progression to insulin, adjusting for demographics, months of follow-up and co-morbidities [measured with Chronic Disease Score (CDS)]. RESULTS By the end of the 2- to 6-year follow-up period, 14.3% of the Met/TZD cohort, 23.6% of the Met/SU cohort and 28.2% of the SU/TZD cohort had insulin added to their regimen. Those in the Met/SU cohort had a 1.8 times higher probability of progression to insulin than those in the Met/TZD cohort [odds ratio (OR) = 1.80, 95% confidence interval (CI) = 1.51-2.14), and those in the SU/TZD cohort had a 2.5 times higher probability of progression to insulin than those in the Met/TZD cohort (OR = 2.51, 95% CI = 2.04-3.08). CONCLUSION When sensitizers were paired (Met/TZD), a lower percentage of patients progressed to insulin during the study period, as opposed to patients who used a combination of a secretagogue with a sensitizer (SU/TZD or Met/SU).
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Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg 2013; 217:336-46.e1. [PMID: 23628227 DOI: 10.1016/j.jamcollsurg.2013.02.027] [Citation(s) in RCA: 415] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 02/26/2013] [Indexed: 12/17/2022]
Abstract
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) collects detailed clinical data from participating hospitals using standardized data definitions, analyzes these data, and provides participating hospitals with reports that permit risk-adjusted comparisons with a surgical quality standard. Since its inception, the ACS NSQIP has worked to refine surgical outcomes measurements and enhance statistical methods to improve the reliability and validity of this hospital profiling. From an original focus on controlling for between-hospital differences in patient risk factors with logistic regression, ACS NSQIP has added a variable to better adjust for the complexity and risk profile of surgical procedures (procedure mix adjustment) and stabilized estimates derived from small samples by using a hierarchical model with shrinkage adjustment. New models have been developed focusing on specific surgical procedures (eg, "Procedure Targeted" models), which provide opportunities to incorporate indication and other procedure-specific variables and outcomes to improve risk adjustment. In addition, comparative benchmark reports given to participating hospitals have been expanded considerably to allow more detailed evaluations of performance. Finally, procedures have been developed to estimate surgical risk for individual patients. This article describes the development of, and justification for, these new statistical methods and reporting strategies in ACS NSQIP.
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Development of physical activity components for a peer delivered intervention to reduce obesity: Team up for healthy living. J Sci Med Sport 2012. [DOI: 10.1016/j.jsams.2012.11.417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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A Novel Anti-CD22 Immunotoxin, Moxetumomab Pasudotox (HA22, CAT-8015): Activity in Pediatric Patients with Relapsed Acute Lymphoblastic Leukemia (ALL) After Allogeneic Hematopoietic Stem Cell Transplantation (SCT). Biol Blood Marrow Transplant 2012. [DOI: 10.1016/j.bbmt.2011.12.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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A Pilot Trial of WT1 Peptide-Loaded Allogeneic Dendritic Cell (DC) Vaccination and Donor Lymphocyte Infusion (DLI) for WT1-Expressing Hematologic Malignancies and Post-Transplant Relapse. Biol Blood Marrow Transplant 2012. [DOI: 10.1016/j.bbmt.2011.12.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Olive versus mineral oil. COMMUNITY PRACTITIONER : THE JOURNAL OF THE COMMUNITY PRACTITIONERS' & HEALTH VISITORS' ASSOCIATION 2011; 84:40-42. [PMID: 21388045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Do cancer centers need to assess quality and outcomes? Introducing a customized ACS-NSQIP for oncology (Onc-NSQIP). J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.4_suppl.475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
475 Background: To identify quality improvement opportunities, hospitals can use ACS NSQIP to compare their risk-adjusted performance to other hospitals. However, Cancer Centers have few opportunities to compare their outcomes to similar hospitals for oncologic operations. Our objective was to develop an oncology-specific version of ACS NSQIP (Onc-NSQIP) and determine whether it could be useful for Cancer Centers. Methods: From ACS-NSQIP (2006-2009), patients undergoing major colorectal (n=34,858; 221 hospitals) and pancreatic (n=7,667; 65 hospitals) as well as esophageal, gastric, and soft tissue operations for malignancy were identified. Risk-adjusted postoperative outcomes were assessed with regression models adjusting for demographics, comorbidities, and operative procedure. Relative rankings of NCI-designated Comprehensive Cancer Centers in ACS NSQIP among the other ACS NSQIP hospitals were compared. Results: Cancer Center outcomes varied widely for colorectal and pancreas. For overall colorectal morbidity, Cancer Centers were ranked in the top third (n=4), middle third (n=7), and bottom third (n=10). For colorectal 30-day mortality, Cancer Centers were ranked in the top (n=14), middle (n=3), and bottom third (n=4). For overall pancreatic morbidity, Cancer Centers were ranked in the top (n=5), middle (n=7), and bottom third (n=7). For pancreatic 30-day mortality, Cancer Centers were ranked in the top (n=5), middle (n=6), and bottom third (n=8). Similar results were observed for colorectal and pancreas for DVT/PE, SSI, reoperation, and length of stay. Onc-NSQIP models were comparable to standard ACS NSQIP models. At least some Cancer Centers were statistical outliers for most outcomes (P<0.05). Results were similar for other malignancies. Conclusions: Cancer Center outcomes varied as much as other ACS NSQIP hospitals, demonstrating need for quality assessment. Without standardized risk-adjusted outcomes comparisons, Cancer Centers cannot accurately assess their outcomes to identify quality improvement targets. ACS NSQIP's new platform allows customization so hospitals can compare surgical oncology-specific risk-adjusted processes and outcomes. No significant financial relationships to disclose.
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Comparison of outlier identification methods in hospital surgical quality improvement programs. J Gastrointest Surg 2010; 14:1600-7. [PMID: 20824379 DOI: 10.1007/s11605-010-1316-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 08/09/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgeons and hospitals are being increasingly assessed by third parties regarding surgical quality and outcomes, and much of this information is reported publicly. Our objective was to compare various methods used to classify hospitals as outliers in established surgical quality assessment programs by applying each approach to a single data set. METHODS Using American College of Surgeons National Surgical Quality Improvement Program data (7/2008-6/2009), hospital risk-adjusted 30-day morbidity and mortality were assessed for general surgery at 231 hospitals (cases = 217,630) and for colorectal surgery at 109 hospitals (cases = 17,251). The number of outliers (poor performers) identified using different methods and criteria were compared. RESULTS The overall morbidity was 10.3% for general surgery and 25.3% for colorectal surgery. The mortality was 1.6% for general surgery and 4.0% for colorectal surgery. Programs used different methods (logistic regression, hierarchical modeling, partitioning) and criteria (P < 0.01, P < 0.05, P < 0.10) to identify outliers. Depending on outlier identification methods and criteria employed, when each approach was applied to this single dataset, the number of outliers ranged from 7 to 57 hospitals for general surgery morbidity, 1 to 57 hospitals for general surgery mortality, 4 to 27 hospitals for colorectal morbidity, and 0 to 27 hospitals for colorectal mortality. CONCLUSIONS There was considerable variation in the number of outliers identified using different detection approaches. Quality programs seem to be utilizing outlier identification methods contrary to what might be expected, thus they should justify their methodology based on the intent of the program (i.e., quality improvement vs. reimbursement). Surgeons and hospitals should be aware of variability in methods used to assess their performance as these outlier designations will likely have referral and reimbursement consequences.
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New approaches to the National Surgical Quality Improvement Program: the American College of Surgeons experience. Am J Surg 2010; 198:S56-62. [PMID: 19874936 DOI: 10.1016/j.amjsurg.2009.07.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 07/21/2009] [Indexed: 11/19/2022]
Abstract
In honor of the seminal contributions of Dr. Shukri Khuri to the foundation and development of the National Surgical Quality Improvement Program (NSQIP), a review of recent work and new directions within the American College of Surgeons (ACS) NSQIP is presented, according to the following outline:
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Risk Adjustment in the American College of Surgeons National Surgical Quality Improvement Program: A Comparison of Logistic Versus Hierarchical Modeling. J Am Coll Surg 2009; 209:687-93. [DOI: 10.1016/j.jamcollsurg.2009.08.020] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 08/12/2009] [Accepted: 08/19/2009] [Indexed: 11/30/2022]
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Variability in Reoperation Rates at 182 Hospitals: A Potential Target for Quality Improvement. J Am Coll Surg 2009; 209:557-64. [DOI: 10.1016/j.jamcollsurg.2009.07.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/08/2009] [Accepted: 07/08/2009] [Indexed: 10/20/2022]
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Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg 2009; 250:363-76. [PMID: 19644350 DOI: 10.1097/sla.0b013e3181b4148f] [Citation(s) in RCA: 569] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE The National Surgical Quality Improvement Program (NSQIP) has demonstrated quality improvement in the VA and pilot study of 14 academic institutions. The objective was to show that American College of Surgeons (ACS)-NSQIP helps all enrolled hospitals. METHODS ACS-NSQIP data was used to evaluate improvement in hospitals longitudinally over 3 years (2005-2007). Improvement was defined as reduction in risk-adjusted "Observed/Expected" (O/E) ratios between periods with risk adjustment held constant. Multivariable logistic regression-based adjustment was performed and included indicators for procedure groups. Additionally, morbidity counts were modeled using a negative binomial model, to estimate the number of avoided complications. RESULTS Multiple perspectives reflected improvement over time. In the analysis of 118 hospitals (2006-2007), 66% of hospitals improved risk-adjusted mortality (mean O/E improvement: 0.174; P < 0.05) and 82% improved risk adjusted complication rates (mean improvement: 0.114; P < 0.05). Correlations between starting O/E and improvement (0.834 for mortality, 0.652 for morbidity), as well as relative risk, revealed that initially worse-performing hospitals had more likelihood of improvement. Nonetheless, well-performing hospitals also improved. Modeling morbidity counts, 183 hospitals (2007), avoided ~9598 potential complications: ~52/hospital. Due to sampling this may represent only 1 of 5 to 1of 10 of the true total. Improvement reflected aggregate performance across all types of hospitals (academic/community, urban/rural). Changes in patient risk over time had important contributions to the effect. CONCLUSIONS ACS-NSQIP indicates that surgical outcomes improve across all participating hospitals in the private sector. Improvement is reflected for both poor- and well-performing facilities. NSQIP hospitals appear to be avoiding substantial numbers of complications- improving care, and reducing costs. Changes in risk over time merit further study.
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Compendium of gene expression profiles comprising a baseline model of the human liver drug metabolism transcriptome. Xenobiotica 2009; 36:938-62. [PMID: 17118915 DOI: 10.1080/00498250600861728] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Oligonucleotide microarrays were used to study the variability of pharmacokinetics and drug metabolism (PKDM)-related gene expression in 75 normal human livers. The objective was to define and use absorption, distribution, metabolism and excretion (ADME) gene expression variability to discern co-regulated genes and potential surrogate biomarkers of inducible gene expression. RNA was prepared from donor tissue and hybridized on Agilent microarrays against an RNA mass balanced pool from all donors. Clustering of PKDM gene sets revealed donors with distinct patterns of gene expression that grouped genes known to be regulated by the nuclear receptor, pregnane X-receptor (PXR). Fold range metrics and frequency distributions from the heterogeneous human population were used to define the variability of individual PKDM genes in the 75 human livers and were placed in context by comparing expression data with basal ADME gene expression variability in an inbred and diet/environment controlled population of 27 Rhesus livers. The most variable genes in the hepatic transcriptome were mainly related to drug metabolism, intermediary metabolism, inflammation and cell cycle control. Unique patterns of expression across 75 individuals of inducible ADME gene expression allowed their expression to be correlated with the expression of many other genes. Correlated genes for AhR, CAR and PXR responsive genes (CYP1A2, CYP2B6 and CYP3A4) were identified that may be co-regulated and, therefore, provide clues to the identity of surrogate gene or protein markers for CYP induction. In conclusion, microarrays were used to define the variable expression of hepatic ADME genes in a diverse human population, the expression variability of ADME genes was compared with the expression variability in an inbred population of Rhesus monkeys, and genes were defined that may be co-regulated with important inducible CYP genes.
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A phase II study of dexamethasone, ifosfamide, cisplatin and etoposide (DICE) as salvage chemotherapy for patients with relapsed and refractory lymphoma. Leuk Lymphoma 2009; 46:197-206. [PMID: 15621802 DOI: 10.1080/10428190400014884] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The 4-day combination of dexamethasone, ifosfamide, cisplatin, and etoposide (DICE) is a salvage regimen for lymphoma. We report a prospective phase II multi-center trial of a modified DICE regimen in relapsed or refractory Hodgkin (HL) or non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukemia (CLL), constituting a single day of intravenous administration followed by 3 days of oral administration, aimed at reducing inpatient days without losing efficacy. Forty patients (median age 56, range 25 - 79) were included: 28 (70%) NHL, 9 (23%) HL and 3 (8%) CLL. Fifty-three per cent had received 2 prior treatment regimens. International Prognostic Index (IPI) was 2 in 75% of NHL patients. Patients aged 55 and those with previous autologous stem cell transplantation (ASCT) started on a lower-dose regimen, with dose escalation possible in 2 patients. Overall response rate was 41%. Thirty-eight per cent of patients had stable disease. With a median of 3.1 years of follow-up, estimated progression-free survival (PFS) and overall survival (OS) rates at 3 years were 15% and 43% respectively. OS was longer in the < 55 compared to the 55 age cohort (P = 0.0091), longer for HL than NHL (P = 0.59 and 0.039 respectively) and longer for Low/Low-Int IPI than High/High-Int IPI (P = 0.0074 and 0.0009 respectively). Median duration of inpatient stay was 3 days. There were no treatment-related deaths. In conclusion, this modification of DICE is an effective and well tolerated salvage regimen, even in this poor prognosis group of patients. Further clinical studies of DICE in first relapse and in older patients, possibly with the addition of rituximab, are warranted.
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Encopresis: Multi-Disciplinary Management. JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 2009. [DOI: 10.1080/19411240903146400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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An assessment of methods for aligning two-dimensional microscope sections to create image volumes. J Neurosci Methods 2008; 170:332-44. [DOI: 10.1016/j.jneumeth.2008.01.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 01/09/2008] [Accepted: 01/09/2008] [Indexed: 11/29/2022]
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CYP2C75-Involved Autoinduction of Metabolism in Rhesus Monkeys of Methyl 3-Chloro-3′-fluoro-4′-{(1R)-1-[({1-[(trifluoroacetyl)amino]cyclopropyl}carbonyl)amino]ethyl}-1,1′-biphenyl-2-carboxylate (MK-0686), a Bradykinin B1 Receptor Antagonist. J Pharmacol Exp Ther 2008; 325:935-46. [DOI: 10.1124/jpet.107.136044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
OBJECTIVE Actuarial analysis of stoma complications (problematic stomas) is lacking. The objectives of this audit were: to identify the incidence of stoma complications within the UK; to highlight any dissimilarity of incidence from centre to centre; to ascertain if the height of the stoma (distance of stoma lumen from the skin) at the time of fashioning is a predisposing factor to problems; and finally to initiate much needed research. METHOD Commencing 1st January 2005, stoma care services nationwide (256) were invited to audit prospectively their next 50 enteric stomas or for a period of 1 year which ever came first. The definition of a problematic stoma being one, which needed one or more accessories to keep the patient clean and dry for a minimum period of 24 h. The incident is to have happened within 3 weeks of surgery. Factors taken into account were: type of stoma, height of stoma within 48 h of surgery; emergency or elective procedure, problem identified, BMI, gender and underlying diagnosis of the patient. The identities of the participating centres are confidential. RESULTS Of the 256 hospital-based stoma care services within the UK, 93 (36%) participated. A total of 3970 stomas were recorded, of which 1329 (34%) were identified as problematic. Sixty-two centres reported 45-50 stomas with a range of complications 6-96%. The loop ileostomy was found to be the stoma which causes most problems. A stoma of <10 mm is a predisposing factor to complications and problems are more likely to occur following an emergency procedure. More men than women have stomas formed, but have significantly fewer problems and there is no significant difference between underlying diagnoses. CONCLUSION The stoma height, stoma type and gender of the patient are significant risk factors identified in this audit. The BMI of patient did not affect the outcome. Patients undergoing an emergency procedure are more likely to have a problematic stoma. The significant variation of complications from centre to centre indicates surgical technique as being the key factor in stoma formation and subsequent quality of life for the patient.
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In vitro and in vivo CYP3A64 induction and inhibition studies in rhesus monkeys: a preclinical approach for CYP3A-mediated drug interaction studies. Drug Metab Dispos 2006; 34:1546-55. [PMID: 16782766 DOI: 10.1124/dmd.106.009878] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In this study, induction and inhibition of rhesus monkey CYP3A64 versus human CYP3A4 were characterized in vitro, and the corresponding pharmacokinetic consequences were evaluated in rhesus monkeys. In monkey hepatocytes, rifampin markedly induced CYP3A64 mRNA (EC50 = 0.5 microM; Emax = 6-fold) and midazolam (MDZ) 1'-hydroxylase activity (EC50 = 0.2 microM; Emax = 2-fold). Compound A (N-[2(R)-hydroxy-1(S)-indanyl-5-[2(S)-(1,1-dimethylethylaminocarbonyl)-4-[(furo[2,3-b]pyridin-5-yl)-methyl]piperazin-1-yl]-4(S)-hydroxy-2(R)-phenylmethylpentanamide), a known potent and mechanism-based inhibitor of CYP3A4, strongly inhibited the formation of 1'-hydroxy MDZ by recombinant CYP3A64 in a concentration- and time-dependent manner (KI = 0.25 microM; k(inact) = 0.4 min(-1)). Similar corresponding results also were obtained with human CYP3A4 in the presence of rifampin or compound A. In rhesus monkeys, MDZ exhibited a relatively high metabolic clearance (primarily via 1'-hydroxylation followed by glucuronidation) and a low hepatic availability (Fh = 16%). Consistent with the induction of hepatic metabolism of a high-clearance compound, pretreatment with rifampin (18 mg/kg p.o. for 5 days) did not significantly affect the i.v. kinetics of MDZ, but caused a pronounced reduction (approximately 10-fold) in the systemic exposure to MDZ and, consequently, its Fh following intrahepatic portal vein administration (i.pv.) of MDZ. A comparable extent of the pharmacokinetic interaction also was obtained after a 1.8 mg/kg rifampin dose. Also consistent with the in vitro CYP3A64 inhibition finding, compound A (6 mg/kg i.v.) markedly increased (10-fold) the i.pv. administered MDZ exposure. At the doses studied, plasma concentrations of rifampin or compound A reached or exceeded their respective in vitro EC50 or KI values. These findings suggest the potential applicability of the in vitro-in vivo relationship approach in rhesus monkeys for studying CYP3A-mediated interactions in humans.
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Abstract
Evidence-based medicine came into focus in 1992 when scholars recognized the need for valid information required for optimal patient care. Because of the increasing volume and uncertain quality of new knowledge, traditional sources of information such as books and journals failed to meet the needs of busy practitioners.Evidence-based medicine promoted strategies for identifying and appraising relevant information and making it readily available. Surgeons face unique challenges in the recognition and application of best evidence. Evidence-based surgery requires careful appraisal of the existing evidence, expanding the pool of level 1 evidence,and improving the availability of best evidence. Ultimately, the organization of systems will incorporate best evidence into the processes of care and will document the outcomes of care.
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Subcellular localization of the Triple Gene Block movement proteins of Beet necrotic yellow vein virus by electron microscopy. Virology 2005; 340:155-66. [PMID: 16023167 DOI: 10.1016/j.virol.2005.06.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 06/01/2005] [Accepted: 06/07/2005] [Indexed: 11/16/2022]
Abstract
The Triple Gene Block proteins TGBp1, TGBp2, and TGBp3 of Beet necrotic yellow vein virus (BNYVV) are required for efficient cell-to-cell spread of the infection. The TGB proteins can drive cell-to-cell movement of BNYVV in trans when expressed from a co-inoculated BNYVV RNA 3-based 'replicon'. TGBp2 and TGBp3 expressed from the replicon were nonfunctional in this assay if they were fused to the green fluorescent protein (GFP), but addition of a hemagglutinin (HA) tag to their C-termini did not incapacitate movement. Immunogold labeling of ultrathin sections treated with HA-specific antibodies localized TGBp2-HA and TGBp3-HA to what are probably structurally modified plasmodesmata (Pd) in infected cells. A similar subcellular localization was observed for TGBp1. Large gold-decorated membrane-rich bodies containing what appear to be short fragments of endoplasmic reticulum were observed near the cell periphery. The modified gold-decorated Pd and the membrane-rich bodies were not observed when the TGB proteins were produced individually in infections using the Tobacco mosaic virus P30 protein to drive cell-to-cell movement, indicating that these modifications are specific for TGB-mediated movement.
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Induction of CYP1A in the beagle dog by an inhibitor of kinase insert domain-containing receptor: differential effects in vitro and in vivo on mRNA and functional activity. Drug Metab Dispos 2005; 33:1044-51. [PMID: 15833927 DOI: 10.1124/dmd.105.003913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Compound I [3-[5-(4-methanesulfonyl-piperazin-1-ylmethyl)-1H-indol-2-yl]-1H-quinolin-2-one] is a potent inhibitor of human kinase insert domain-containing receptor (KDR kinase), which is under investigation for the treatment of cancer. Bile duct-cannulated male beagle dogs were administered 6 mg/kg compound I q.d. for 14 days. There was an approximately 2.5-fold decrease in the mean plasma area under the curve of I on days 7 and 14 (approximately 11.3 microM . h), relative to day 1 (28.2 microM . h). In the dog, compound I was eliminated by metabolism, with a major pathway being aromatic hydroxylation and subsequent sulfation to form the metabolite M3. Metabolic profiling suggested that the pathway leading to the formation of the sulfated conjugate M3 was induced upon multiple dosing of I. Studies conducted in vitro suggested that CYP1A1/2 was responsible for the formation of the hydroxylated metabolite, which is sulfated to yield M3. Additional studies confirmed induction of CYP1A protein and activity in the livers of dogs treated with I. However, studies in a dog hepatocyte model of induction showed a surprising decrease both in CYP1A mRNA and enzymatic activity in the presence of I, emphasizing the need to consider the results from a variety of in vitro and in vivo studies in deriving an understanding of the metabolic fate of a drug candidate. It is concluded that the autoinduction observed after multiple treatments with compound I occurs since compound I is both an inducer and a substrate for dog CYP1A.
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Nonregulated expression of TGBp3 of hordei-like viruses but not of potex-like viruses inhibits beet necrotic yellow vein virus cell-to-cell movement. Arch Virol 2005; 150:1459-67. [PMID: 15770352 DOI: 10.1007/s00705-005-0516-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
Plant viruses containing a Triple Gene Block (TGB) movement protein gene cassette fall into two classes. We have shown previously that the third TGB protein (TGBp3) of beet necrotic yellow vein virus (BNYVV; Class 1) and peanut clump virus (Class 1) inhibit BNYVV intercellular movement when expressed from a co-inoculated BNYVV RNA 3-based replicon. Here we show that autonomous expression of TGBp3's of four other Class 1 viruses of various genera also inhibits BNYVV movement. No such effect was observed for four Class 2 virus TGBp3's, suggesting that the roles of Class 1 and 2 TGBp3's in movement differ significantly.
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