Immunotherapy in Prostate Cancer: Teaching an Old Dog New Tricks

Abstract

Immunotherapy is rapidly transforming cancer care across a range of tumor types. Although Sipuleucel-T represented the first successful vaccine for the treatment of established cancer, other immunotherapeutic approaches for prostate cancer such as checkpoint inhibitors have been relatively disappointing to date. However, significant promise is on the horizon as there is a wide array trials evaluating immunotherapy in prostate cancer patients. These include both immune checkpoint inhibitors and antigen-specific approaches including vaccines, antibody-drug conjugates, and antitumor antibodies. Furthermore, a better understanding of the key mechanisms that promote the immunosuppressive microenvironment of prostate cancer is emerging. These insights may eventually make it possible to determine which patients will benefit from immunotherapy. This review will discuss the successes and failures of immunotherapy in prostate cancer. We will also present key lessons learned from completed trials and highlight important ongoing studies.

https://ift.tt/2MB0NaU

Management of Brain Metastases in the New Era of Checkpoint Inhibition

Abstract

Purpose of the Review

Brain metastasis is a common complication of advanced malignancies, especially, lung cancer, breast cancer, renal cell carcinoma, and melanoma. Traditionally surgery, when indicated, and radiation therapy, either as whole-brain radiation therapy or stereotactic radiosurgery, constituted the major treatment options for brain metastases. Until recently, most of the systemic chemotherapy agents had limited activity for brain metastases. However, with the advent of small molecule tyrosine kinase inhibitors and immunotherapy agents, there has been renewed interest in using these agents in the management of brain metastases.

Recent Findings

Immune checkpoint inhibitors have revolutionized the treatment of metastatic melanoma, lung cancer, kidney cancer, and bladder cancer among others. They modulate the immune system to recognize tumor antigens as "non-self" antigens and mount an immune response against them.

Summary

Initial studies of using immune checkpoint inhibitors in brain metastases have shown promising activity, and several clinical trials are currently underway. Studies are also assessing the combination of radiation therapy and immunotherapy in brain metastases. The results of these ongoing clinical trials have the potential to change the therapeutic paradigm in patients with brain metastases.

https://ift.tt/2OKIJZk

Combined Effect of NF-κB Inhibitor and β2-Adrenoreceptor Agonist on Mouse Mortality and Blood Concentration of Proinflammatory Cytokines in Sepsis

Experiments on random-bred albino mice showed that NF-κB inhibitor (BAY 11-7082) and β2-adrenoreceptor agonist (dexmedetomidine hydrochloride) significantly reduced mouse mortality in 4 and 24 h after sepsis modeling (intraperitoneal administration of E. coli) by reducing blood levels of proinflammatory cytokines TNFα, IL-1β, and IL-6. The combined administration of NF-κB inhibitor and β2-adrenoreceptors agonist have an additive effect.

https://ift.tt/2PhQAyP

Correction to: A Method of Measuring Glutathione Peroxidase Activity in Murine Brain: Application in Pharmacological Experiment

A method of measuring of glutathione peroxidase activity using H₂O₂ was adapted for homogenates of murine brains.

https://ift.tt/2MXpdII

Aflibercept plus FOLFIRI in Asian patients with pretreated metastatic colorectal cancer: a randomized Phase III study

Future Oncology, Ahead of Print.


https://ift.tt/2MTWJja

Utilisation of primary care before a childhood cancer diagnosis: do socioeconomic factors matter?: A Danish nationwide population-based matched cohort study

Objectives

Early diagnosis of childhood cancer is critical. Nevertheless, little is known about the potential role of inequality. This study aims to describe the use of primary care 2 years before a childhood cancer diagnosis and to investigate whether socioeconomic factors influence the use of consultations and diagnostic tests in primary care.

Design

A national population-based matched cohort study.

Setting and participants

This study uses observational data from four Danish nationwide registers. All children aged 0–15 diagnosed with cancer during 2008–2015 were included (n=1386). Each case was matched based on gender and age with 10 references (n=13 860).

Primary and secondary outcome measures

The primary outcome was additional rates for consultations and for invoiced diagnostic tests for children with cancer according to parental socioeconomic factors. Furthermore, we estimated the association between socioeconomic factors and frequent use of consultations, defined as at least four consultations, and the odds of receiving a diagnostic test within 3 months of diagnosis.

Results

Children with cancer from families with high income had 1.46 (95% CI 1.23 to 1.69) additional consultations 3 months before diagnosis, whereas children from families with low income had 1.85 (95% CI 1.60 to 2.11) additional consultations. The highest odds of frequent use of consultations was observed among children from low-income families (OR: 1.94, 95% CI 1.24 to 3.03). A higher odds of receiving an invoiced diagnostic test was seen for children from families with mid-educational level (OR: 1.46, 95% CI 1.09 to 1.95).

Conclusion

We found a socioeconomic gradient in the use of general practice before a childhood cancer diagnosis. This suggests that social inequalities exist in the pattern of healthcare utilisation in general practice.

https://ift.tt/2L5wncl

Reuse of intermittent catheters: a qualitative study of IC users perspectives

Objectives

To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters.

Design

Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically.

Setting

Participant's own homes in Hampshire and Dorset, UK.

Participants

A convenience sample of 39 IC users, aged 23–86 years, using IC for at least 3 months.

Results

The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were advantages. Always having a catheter without fear of 'running out' was considered an advantage of reuse. Some participants were concerned about environmental impact (waste) and cost of single-use catheters. The potential for reuse was usually dependent on location. The analysis showed that often the disadvantages of single-use could be off-set by the advantages of reuse and vice versa, for example, the need to take many single-use catheters on holiday could be addressed by reuse, while the burden of cleaning would be obviated by single-use.

Conclusions

If shown to be safe with a practical cleaning method, some participants would find reuse an acceptable option, alongside their current single-use method. The choice to use a mixture of single-use and reuse of catheters for different activities (at home, work or holiday) could optimise the perceived advantages and disadvantages of both. The safety and acceptability of such an approach would require testing in a clinical trial.

https://ift.tt/2vT2AP4

Enhancing peer support experience for patients discharged from acute psychiatric care: protocol for a randomised controlled pilot trial

Introduction

This study will evaluate the effectiveness of an innovative peer support programme. The programme incorporates leadership training, mentorship, recognition and reward systems for peer support workers, and supportive/reminder text messaging for patients discharged from acute (hospital) care. We hypothesise that patients enrolled in the peer support system plus daily supportive/reminder text messages condition will achieve superior outcomes in comparison to other groups.

Methods and analysis

This is a prospective, rater-blinded, four-arm randomised controlled trial. 180 patients discharged from acute psychiatric care in Edmonton, Alberta, Canada will be randomised to one of four conditions: (1) enrolment in a peer support system; (2) enrolment in a peer support system plus automated daily supportive/reminder text messages; (3) enrolment in automated daily supportive/reminder text messages alone; or (4) treatment as usual follow-up care. Patients in each group will complete evaluation measures (eg, recovery, general symptomatology and functional outcomes) at baseline, 6 months and 12months. Patient service utilisation data and clinician-rated measures will also be used to gauge patient progress. Patient data will be analysed with descriptive statistics, repeated measures and correlational analyses. The peer support worker experience will be captured using qualitative methods.

Ethics and dissemination

The study will be conducted in accordance with the Declaration of Helsinki (Hong Kong Amendment) and Good Clinical Practice (Canadian Guidelines). The study has received ethical clearance from the Health Ethics Research Board of the University of Alberta (Ref # Pro00078427) and operational approval from our regional health authority (AHS- (PRJ) #35293). All participants will provide informed consent prior to study inclusion. The results will be disseminated at several levels, including patients/peer supports, practitioners, academics/researchers, and healthcare organisations.

Trial registration number

NCT03404882; Pre-results.

https://ift.tt/2L5vW1H

Is time to progression associated with post-progression survival in previously treated metastatic non-small cell lung cancer with BRAF V600E mutation? A secondary analysis of phase II clinical trial data

Objective

Longer time to progression (TTP) is associated with prolonged post-progression survival (PPS) in anaplastic lymphoma kinase+non-small cell lung cancer (NSCLC). This study evaluated whether TTP is associated with PPS among previously treated patients with metastatic v-Raf murine sarcoma viral oncogene homolog B V600E NSCLC receiving dabrafenib as monotherapy or in combination with trametinib.

Design

Secondary analysis of phase II clinical trial data.

Setting

Patients who experienced disease progression treated with dabrafenib monotherapy or in combination with trametinib as second line or later in an open-label, non-randomised, phase II study.

Primary outcome measures

The primary outcome was the TTP–PPS association. PPS was assessed with Kaplan-Meier analysis among patients with shorter versus longer TTP (< or ≥6 months). The TTP–PPS association was quantified in the Cox models adjusting for clinical covariates.

Results

Of the 84 included patients who progressed on dabrafenib monotherapy (n=57) or combination therapy (n=27), 60 (71%) died during post-progression follow-up. Patients with TTP ≥6 months experienced significantly longer PPS compared with those with TTP <6 months (median PPS: 9.5 vs 2.7 months, log-rank p<0.001). Each 3 months of longer TTP was associated with a 32% lower hazard of death following progression (HR 0.68, 95% CI 0.52 to 0.88) in the multivariable Cox model. Similar associations were seen in each treatment arm.

Conclusion

A longer TTP duration after treatment with dabrafenib monotherapy or combination therapy was associated with significantly longer PPS duration.

Trial registration number

NCT01336634; Post-results.

https://ift.tt/2vNmXNJ

Process evaluation of a randomised controlled trial of a pharmacological strategy to improve hypertension control: protocol for a qualitative study

Introduction

Globally, the prevalence of uncontrolled hypertension is high, particularly in low- and middle-income countries. There is a critical need for strategies to improve hypertension control. The early use of a fixed low-dose combination of three antihypertensive drugs (triple pill) has the potential to significantly improve hypertension control. The TRI ple Pill vs. U sual care M anagement for P atients with mild-to- moderate H ypertension (TRIUMPH) randomised controlled trial (RCT) is designed to test the effects of this strategy compared with usual care in patients with mild-to-moderate hypertension. This paper reports the protocol of a process evaluation of the TRIUMPH RCT. The objectives are to understand factors related to implementation of the intervention, mechanisms of effect, contextual factors that underpin the effectiveness of the triple pill strategy and the potential barriers and facilitators to implementing the strategy in clinical practice.

Methods and analysis

Face-to-face semistructured in-depth interviews with a purposive sample of TRIUMPH RCT participants and healthcare professionals in Sri Lanka will be conducted. Healthcare professionals will include physicians and their staff who were involved in conducting the TRIUMPH RCT. Interviewees will be recruited sequentially until thematic saturation is achieved. Interviews will be audio recorded, transcribed verbatim and analysed in NVivo using framework analysis methods.

Ethics and dissemination

The TRIUMPH RCT and process evaluation have received approval from the relevant Ethics Review Committee. All participants will be asked to provide written consent before participation. Findings from the study will be disseminated through publications and conference presentations.

Trial registration number

ACTRN12612001120864 , SLCTR/2015/020 ; Pre-results.

https://ift.tt/2OKmnap

Ginkgo biloba extract for prevention of acute mountain sickness: a systematic review and meta-analysis of randomised controlled trials

Objective

Trials of ginkgo biloba extract (GBE) for the prevention of acute mountain sickness (AMS) have been published since 1996. Because of their conflicting results, the efficacy of GBE remains unclear. We performed a systematic review and meta-analysis to assess whether GBE prevents AMS.

Methods

The Cochrane Library, EMBASE, Google Scholar and PubMed databases were searched for articles published up to 20 May 2017. Only randomised controlled trials were included. AMS was defined as an Environmental Symptom Questionnaire Acute Mountain Sickness-Cerebral score ≥0.7 or Lake Louise Score ≥3 with headache. The main outcome measure was the relative risk (RR) of AMS in participants receiving GBE for prophylaxis. Meta-analyses were conducted using random-effects models. Sensitivity analyses, subgroup analyses and tests for publication bias were conducted.

Results

Seven study groups in six published articles met all eligibility criteria, including the article published by Leadbetter et al, where two randomised controlled trials were conducted. Overall, 451 participants were enrolled. In the primary meta-analysis of all seven study groups, GBE showed trend of AMS prophylaxis, but it is not statistically significant (RR=0.68; 95% CI 0.45 to 1.04; p=0.08). The I² statistic was 58.7% (p=0.02), indicating substantial heterogeneity. The pooled risk difference (RD) revealed a significant risk reduction in participants who use GBE (RD=–25%; 95% CI, from a reduction of 45% to 6%; p=0.011) The results of subgroup analyses of studies with low risk of bias, low starting altitude (<2500 m), number of treatment days before ascending and dosage of GBE are not statistically significant.

Conclusion

The currently available data suggest that although GBE may tend towards AMS prophylaxis, there are not enough data to show the statistically significant effect of GBE on preventing AMS. Further large randomised controlled studies are warranted.

https://ift.tt/2vUgtfX

Small volume plasma exchange for Guillain-Barre syndrome in resource-limited settings: a phase II safety and feasibility study

Objective

To assess the safety and feasibility of small volume plasma exchange (SVPE) for patients with Guillain-Barré syndrome (GBS).

Design

Non-randomised, single-arm, interventional trial.

Setting

National Institute of Neurosciences and Hospital, Dhaka, Bangladesh.

Participants

Twenty adult (>18 years) patients with GBS presented within 2 weeks of onset of weakness who were unable to walk unaided for more than 10 m.

Interventions

SVPE involves blood cell sedimentation in a blood bag and removal of supernatant plasma after blood cells are retransfused. This procedure was repeated three to six times a day, for eight consecutive days. Fresh frozen plasma (FFP) and normal saline were used as replacement fluid.

Outcome measures

Serious adverse events (SAEs) were defined as severe sepsis and deep venous thrombosis related to the central venous catheter (CVC) used during SVPE. SVPE was considered safe if less than 5/20 patients experienced an SAE, and feasible if 8 L plasma could be removed within 8 days in at least 15/20 patients.

Results

Median patient age 33 years (IQR 23–46; range 18–55); 13 (65%) were male. Median Medical Research Council (MRC) sum score was 20 (IQR 0–29; range 0–36); three (15%) patients required mechanical ventilation. One patient developed SAE (severe sepsis, possibly related to CVC). The median plasma volume exchanged was 140 mL/kg (range 110–175) and removal of 8 L plasma was possible in 15 (75%) patients. Patients received a median 1 g/kg IgG via FFP although a substantial proportion of IgG was probably removed again by the SVPE sessions. GBS disability score improved by at least one grade in 14 (70%) patients 4 weeks after SVPE started. No patients died.

Conclusion

SVPE seems a safe and feasible alternative treatment to standard plasma exchange (PE) or intravenous immunoglobulin (IVIg) for GBS; further studies of clinical efficacy in low-income and middle-income countries are warranted.

Trial registration number

NCT02780570.

https://ift.tt/2L2Qis8

Escalation-related decision making in acute deterioration: a retrospective case note review

Aim

To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility.

Design and methods

A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation.

Sample

45 cases, age range 38–96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days.

Results

Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty.

Conclusions

The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities, often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.

https://ift.tt/2nOSnyW

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

Objective

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

Design

Systematic review and Delphi study.

Methods

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

Results

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

Conclusions

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO registration number

CRD42015027351.

https://ift.tt/2OHQaAM

Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing

Introduction

Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures.

Methods and analysis

This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents ≥60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model.

Ethics and dissemination

The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.

https://ift.tt/2nLrFXH

Utilisation willingness for institutional care by the elderly: a comparative study of empty nesters and non-empty nesters in Shandong, China

Introduction

Institutional care has been strongly promoted in China to meet seniors' long-term care needs. Empty-nest elderly, in comparison with their counterparts, have less social support and fewer caring networks. This study aimed to compare the utilisation willingness for institutional care and its predictors between empty-nest and non-empty-nest seniors.

Methods

A total of 3923 seniors were included in the analysis. Binary logistic regression models were used to understand the association between the living arrangements of the elderly households and willingness for institutional care and to identify the predictors of the utilisation willingness for institutional care among empty nesters and non-empty nesters.

Results

Our study found that approximately 8.5% of the seniors had a willingness for institutional care in Shandong, China. Empty-nest singles (OR 5.301; 95% CI 2.838 to 9.904) and empty-nest couples (OR 1.547; 95% CI 1.135 to 2.107) were found to be more willing to receive institutional care. Our results also showed that residence was a key determinant for institutionalisation willingness in empty-nest and non-empty-nest elderly. Among empty-nest singles, psychological stress was a positive determinant for institutional care. Factors, including education attainment, relationship with adult children, household income and per capita living space, were determinants for empty-nest couple willingness for institutionalisation. Age, number of children and self-reported health status were found to be associated factors for willingness among non-empty nesters.

Conclusions

The government should pay more attention to institutional care in rural areas where there is still a gap in elder care compared with that in urban areas. Targeted policies should be made for different types of seniors to offer appropriate institutional care.

https://ift.tt/2OKmbrH

'Adding another spinning plate to an already busy life. Benefits and risks in patient partner-researcher relationships: a qualitative study of patient partners experiences in a Canadian health research setting

Objective

To better understand, based on patient partners' experiences, benefits and risks in patient partner–researcher relationships in a health research setting.

Design

Qualitative interviews with thematic analysis informed by a relational ethics lens.

Setting

A multidisciplinary health research centre in Vancouver, Canada. This study was codeveloped by patient partners and researchers at the centre.

Participants

22 people living with arthritis, with experience as members of a patient advisory board at the research centre from 1 month to 10 years.

Results

We identified three main themes: (1) Being Heard: Participants had experienced uncomfortable emotions (eg, feelings of insecurity) in their relationships with researchers. The discomfort, however, was minimised by the demonstration of mutual respect in their interactions. Specifically, participants valued environments without a hierarchy between patient partners and researchers, where contributions of each party were considered equally important, and where patients' voices were heard; (2) Cobuilding social relations: Participants valued building social relations with researchers beyond their expected interactions as partners in research and (3) Adding another spinning plate to an already busy life: Participants valued relationships with researchers who had cocreated environments that minimised the risks of physical and emotional impacts (eg, fatigue, stress, guilt) on them while juggling multiple obligations, priorities and their health.

Conclusions

Findings provide valuable insights to guide relationship building between patient partners and researchers. Informed by a relational ethics lens, these findings are a critical step in supporting an ethically sound practice of patient engagement in research that prioritises patients' perspectives.

https://ift.tt/2nNXq2m

Impact of adverse media reporting on public perceptions of the doctor-patient relationship in China: an analysis with propensity score matching method

Objectives

Numerous studies indicate that the doctor–patient relationship in China is facing serious challenges. This study examined the impact of China Central Television's negative coverage of high medicines prices on both doctors' and patients' opinions of the doctor–patient relationship.

Setting

Data were collected in a national survey conducted during 19 December 2016 to 11 January 2017 which targeted 136 public tertiary hospitals across the country.

Participants

All patients and doctors who submitted completed questionnaire were retrieved from the survey database.

Intervention

The study used propensity score matching method to match the respondents before and after China Central Television's news report about high medicines prices which was given at 00:00 hours on 24 December 2016.

Outcome measure

Perception scores were calculated based on the five-point Likert scales to measure the opinions of the doctor–patient relationship.

Results

The perception scores of the doctor–patient relationship were significantly affected by the negative media coverage for hospitalised patients, who scored 1.18 lower on the doctor–patient relationship following the report (p=0.006, 95% CI 0.34 to 2.02), and doctors who scored 5.96 points lower on the same scale (p<0.001, 95% CI 4.11 to 7.82). Score for the ambulatory patients was unaffected by exposure to the adverse news report (p=0.05).

Conclusion

Chinese national media's reporting of adverse news negatively affected the perceptions of the doctor–patient relationship among both inpatients and doctors. A better understanding of the role of mass media in the formation of opinion and trust between doctors and patients may permit strategies for managing the media, in order to improve public perceptions of the doctor–patient relationship.

https://ift.tt/2OHQ4sU

Psychiatry as a career choice among medical students: a cross-sectional study examining school-related and non-school factors

Objectives

Given the low recruitment to psychiatry worldwide, the current study aimed to examine how premedical and intramedical school factors, perception of career aspects, attitudes towards psychiatry, stigma towards mental illness and personality traits may affect the likelihood of psychiatry as a career choice.

Design

Cross-sectional online study.

Participants

502 medical students from two public medical institutions in Singapore.

Methods

We critically examined existing literature for factors identified to influence psychiatry as a career choice and explored their effects in a group of medical students in Singapore. To avoid overloading the regression model, this analysis only included variables shown to have significant association (p<0.05) with the outcome variable from the initial X² test and independent t-test analyses.

Results

A considerable number of non-medical school factors such as preschool influence and interest, personality traits and importance of a high status specialty in medicine were found to affect students' choice of psychiatry as a career. Among medical school factors, attending a psychiatry/mental health club was the only influential factor. Negative attitudes towards psychiatry, but not stigma towards people with mental illness, significantly predicted the likelihood of not choosing psychiatry as a career.

Conclusions

Improving educational environment or teaching practice in psychiatric training may aid in future recruitment for psychiatrists. While the changing of premedical school influences or personality factors may be infeasible, medical schools and psychiatry institutes could play a more critical role by enhancing enrichment activities or clerkship experience to bring about a more positive attitudinal change towards psychiatry among students who did consider a career in psychiatry.

https://ift.tt/2nLFqG3

Digital health app development standards: a systematic review protocol

Introduction

There is currently a lack of clear and accepted standards for the development (planning, requirement analysis and research, design and application testing) of apps for medical and healthcare use which poses different risks to developers, providers, patients and the public. The aim of this work is to provide an overview of the current standards, frameworks, best practices and guidelines for the development of digital health apps. This review is a critical 'stepping stone' for further work on producing appropriate standards that can help mitigate risks (eg, clinical, privacy and economic risks).

Methods and analysis

A systematic review identifying criteria from applicable standards, guidelines, frameworks and best practices for the development of health apps. We will draw from standards for software for medical devices, clinical information systems and medicine because of their relatedness and hope to apply lessons learnt to apps. We will exclude other types of publications, and those published in languages other than English. We will search websites of relevant regulatory and professional organisations. For health apps, we will also search electronic research databases (eg, MEDLINE, Embase, SCOPUS, ProQuest Technology Collection and Engineering Index) because relevant publications may not be found on other websites. We will hand-search reference lists of included publications. The review will focus on international, USA, European and UK standards because these are the markets of primary interest to the majority of app developers currently. We will provide a narrative overview of findings and tabular summaries of extracted data. Also, we will examine the relationship between different standards and compare USA and European Union standards.

Ethics and dissemination

No ethics approval is required. The review will be disseminated through peer-reviewed publications, conference presentations and inform efforts that aim to improve the quality of health apps through existing links with relevant organisations.

https://ift.tt/2OKmYZH

An exploration of how women in the UK perceive the provision of care received in an early pregnancy assessment unit: an interpretive phenomenological analysis

Objective

The objective of the study was to explore how women experience care within an early pregnancy assessment unit (EPAU) and how they are helped to understand, reconcile and make sense of their loss and make informed decisions about how their care will be managed following a first trimester miscarriage.

Design

This was a single centre, prospective qualitative study. An interpretive phenomenological analysis approach was used to interpret the participants' meanings of their experiences. It is an ideographic approach that focuses in depth on a small set of cases to explore how individuals make sense of a similar experience.

Setting

An EPAU in a large teaching hospital in the Midlands that provides care to women in their early pregnancy, including those experiencing pregnancy loss.

Participants

A purposive sample of 10 women were recruited to this study. All of the women were either miscarrying at the time of this study or had miscarried within the previous few weeks.

Results

Six superordinate themes in relation to women's experiences of miscarriage were identified: (1) the waiting game, (2) searching for information, (3) management of miscarriage: no real choice, (4) the EPAU environment, (5) communication: some room for improvement and (6) moving on.

Conclusions

This study found that improvements are required to ensure women and their partners receive a streamlined, informative, supportive and continuous package of care from the point they first see their general practitioner or midwife for support to being discharged from the EPAU. The provision of individualised care, respect for women's opinions and appropriate clinical information is imperative to those experiencing miscarriage to help them gain a degree of agency within an unfamiliar situation and one in which they feel is out of their control.

https://ift.tt/2MZvd3x

Correction: Patent foramen ovale closure, antiplatelet therapy or anticoagulation in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence

Mir H, Siemieniuk RAC, Ge LC, et al. Patent foramen ovale closure, antiplatelet therapy or anticoagulation in patients with patent foramen ovale and cryptogenic stroke: a systematic review and network meta-analysis incorporating complementary external evidence BMJ Open 2018;8:e023761. doi: 10.1136/bmjopen-2018-023761

The previous version of this manuscript contains an error in the author list. Author "Long Ge" was previously incorrectly listed as "Long Cruz Ge".

https://ift.tt/2MzXOPW

Factors contributing to practitioner choice when declining involvement in legally available care: A scoping protocol

Introduction

As legislation addressing medical treatments continues to evolve, there are several circumstances (eg, abortion, assisted dying) in which health practitioners may choose to not provide legally available care options. It is not always clear what underlies practitioner choice, as some research has suggested non-participation in care provision is not always due to an ethical abstention but may represent other factors. This results in tension between a practitioner's right to refrain from practices deemed morally objectionable by the practitioner, and the care recipient's right to access legally available treatments. The aim of this systematic scoping review is to identify the current knowledge regarding all the factors influencing practitioner's choices when declining involvement in legally available healthcare options.

Methods and analysis

Arksey and O'Malley's scoping framework in concert with Levac et al's enhancements will guide the systematic scoping review methodological processes. English language documents from 1 January 1998 to current will be sought using Medline, CINAHL, JSTOR, EMBASE, ProQuest Dissertations and Theses Global, PsychINFO and Sociological Abstracts. MeSH headings, keywords and synonyms will be adjusted using an iterative search process. Theses and dissertations will be included in the search protocol; however, other grey literature will be accessed only as required. Two research team members will screen the abstracts and full articles against inclusion criteria. Article information will be extracted via a data collection tool and undergo thematic analysis. Descriptive summary (visual summary and study contextual information) and a presentation of analytical themes will align findings back to the research question.

Ethics and dissemination

Ethics approval is not required. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist will be used to support transparency and guide translation of findings. Findings will be disseminated through professional networks, in peer-reviewed journals and conferences via abstract and presentation.

https://ift.tt/2OL3ZhF

Clinical and cost-effectiveness of one-session treatment (OST) versus multisession cognitive-behavioural therapy (CBT) for specific phobias in children: protocol for a non-inferiority randomised controlled trial

Introduction

Specific phobias (intense, enduring fears of an object or situation that lead to avoidance and severe distress) are highly prevalent among children and young people. Cognitive–behavioural therapy (CBT) is a well-established, effective intervention, but it can be time consuming and costly because it is routinely delivered over multiple sessions during several months. Alternative methods of treating severe and debilitating phobias in children are needed, like one-session treatment (OST), to reduce time and cost, and to prevent therapeutic drift and help children recover quickly. Our study explores whether (1) outcomes with OST are 'no worse' than outcomes with multisession CBT, (2) OST is acceptable to children, their parents and the practitioners who use it and (3) OST offers good value for money to the National Health Service (NHS) and to society.

Method

A pragmatic, non-inferiority, randomised controlled trial will compare OST with multisession CBT-based therapy on their clinical and cost-effectiveness. The primary clinical outcome is a standardised behavioural task of approaching the feared stimulus at 6 months postrandomisation. The outcomes for the within-trial cost-effectiveness analysis are quality-adjusted life years based on EQ-5D-Y, and individual-level costs based of the intervention and use of health and social service care. A nested qualitative evaluation will explore children's, parents' and practitioners' perceptions and experiences of OST. A total of 286 children, 7–16 years old, with DSM-IV diagnoses of specific phobia will be recruited via gatekeepers in the NHS, schools and voluntary youth services, and via public adverts.

Ethics and dissemination

The trial received ethical approval from North East and York Research Ethics Committee (Reference: 17/NE/0012). Dissemination plans include publications in peer-reviewed journals, presentations in relevant research conferences, local research symposia and seminars for children and their families, and for professionals and service managers.

Trial registration number

ISRCTN19883421;Pre-results.

https://ift.tt/2PhnuiZ

Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial

Objectives

No intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke.

Design

Assessor-blinded randomised controlled trial.

Setting

Two academic hospitals in an urban area.

Interventions

Participants were allocated using stratified blocked randomisation to either 'traditional' balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 'booster' training sessions during the follow-up.

Participants

Eighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis.

Primary and secondary outcome measures

The primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration.

Results

PBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects.

Conclusions

The results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits.

Trial registration number

ISRCTN05434601; Results.

https://ift.tt/2OJeYbm

Memory impairment during a climbing traverse: implications for search and rescue climbing

Abstract

Cognitive resource limitations can impair one's ability to multitask. Previous research has shown that climbing is a particularly demanding task, and does not neatly fit into existing cognitive resource models. Climbing is a task relevant to firefighting and search and rescue, and operators often must also handle communication and navigation tasks in tandem. We present the results of a study where a naturalistic narrative memory task was paired with a climbing traverse. As hypothesized, both climbing and memory performance significantly declined in the dual-compared to each single-task condition. The specific cognitive demands of climbing should be explored further using non-verbal secondary tasks, to determine whether an executive resource bottleneck, verbal resource demand, or something else entirely can better explain the dual-task interference. A more thorough understanding of the mental demand in concurrent operational tasks can be used to tailor the modality and timing or diversion of certain tasks for minimal interference.

https://ift.tt/2vVAXVy

Influence of Apoptotic Bodies and Apoptotic Microvesicles on NO Production in Macrophages

We studied the effect of extracellular vesicular particles generated during apoptosis by macrophages of M0, M1 and M2 phenotypes on spontaneous and LPS-stimulated production of NO. The fractions of apoptotic bodies and apoptotic microvesicles were obtained in the primary cultures of peritoneal macrophages undergoing apoptosis. The effect of these microparticles on LPS-induced proinflammatory response of recipient macrophages critically depends on the initial phenotype of "donor" macrophages. Microvesicles and especially apoptotic bodies from M1 macrophages stimulate basal NO production. LPS stimulation of these macrophages preincubated with apoptotic bodies was not followed by further growth of NO production; in macrophages preincubated with microvesicles, LPS even suppressed NO production. Apoptotic microparticles obtained from M2 macrophages produced little effect on the basal production of NO. LPS stimulation of macrophages-recipients preincubated with microparticles from M2 macrophages did not enhance NO production. Incubation of macrophages with apoptotic microparticles induces the formation of endotoxic tolerance.

https://ift.tt/2BlZbNW

Collagen Hydrolysis Products Reduce the Formation of Stress-Induced Ulcers by Regulating Stress-Associated Activation of the Neuroendocrine and Immune Systems

We studied the effect of collagen fragments (PGP and AcPGP) on serum content of epinephrine, corticosterone, and IL-1β in rats subjected to water-immersion stress. The degree of local inflammation accompanying ulceration was assessed by IL-1β production by ln. gastricus caudalis cells. In 1 h, the sharp increase in hormone concentrations in the blood of stressed animals reflected the high stress intensity. Intranasal administration of PGP reduced the area of stress-induced ulcers by 63%, prevented the increase in the levels of stress hormones and the main proinflammatory cytokine in rat blood. The concentrations of IL-1β in cell culture from regional lymph node of experimental animals returned to normal in 24 and 48 h after the stress. Acetylation of PGP prevents with gastroprotection, but does not abrogate other properties of the peptide.

https://ift.tt/2vRhxRO

Does Racial Bias Affect NCI-Funded PIs’ Willingness to Mentor Prospective Graduate Students?

Audit studies suggest that racial discrimination disadvantages black individuals in educational/professional advancement. We hypothesized that prospective black male doctoral students would experience greater disparity in responses when seeking access to National Cancer Institute (NCI)-funded principal investigators (PI) compared with prospective white males. Primary aim was to explore response and acceptance rates for black versus white men seeking cancer research mentorship. Identical e-mails were sent to 1,028 randomly selected PIs affiliated with 65 NCI-designated cancer centers from "Lamar Washington" (black; n = 515) or "Brad Anderson" (white; n = 513). Primary outcomes: (i) responses within one week; and (ii) type of response. We used logistic regression to examine effects of condition (black/white) on primary outcomes. Approximately 48.3% and 50.0% of the sample responded to "Lamar" and "Brad," respectively. For responders, 40.9% and 43.7% and "agreed" to meet with Lamar and Brad, respectively. This design did not detect bias by PIs against black prospective male students. Cancer Res; 78(17); 1–3. ©2018 AACR.

https://ift.tt/2nOf3PI

The Effects of Cholesterol-Derived Oncometabolites on Nuclear Receptor Function in Cancer

Epidemiologic studies are controversial concerning the roles played by cholesterol in cancer risk and development, possibly as it is not cholesterol per se that is pathologic in cancers. Indeed, recent data reveal that the cholesterol metabolism in cancer cells can generate endogenous oncopromoter metabolites at higher levels compared with normal tissues and/or can be deregulated in the production of endogenous oncosuppressor metabolites in an opposite way. These metabolites are oxysterols, which are cholesterol oxygenation products generated by enzymatic and/or autoxidation processes. All these oxysterols are new classes of estrogen, glucocorticoid, or liver X nuclear receptor ligands, and their protumor action on their cognate receptors could explain some drug resistance, while treatment with antitumor metabolites could complement their deficiency in cancers and restore their action on their nuclear receptor. Given that hypercholesterolemia and high intakes of cholesterol-rich foods or processed foods can generate these oxysterols, their importance in cancer risk or development in overweight and obese people is to be considered. The discovery of these cholesterol-derived metabolites and the identification of the nuclear receptors mediating their pro- or antitumor activities are important findings, which should have major implications in the diagnosis, prevention, and treatment of different cancers and open new areas of research. Cancer Res; 78(17); 1–6. ©2018 AACR.

https://ift.tt/2OGHsT8

Promoting scientist-advocate collaborations in cancer research: why and how

Advocates bring unique and important viewpoints to the cancer research process, ensuring that scientific and medical advances are patient-centered and relevant. In this article, we discuss the benefits of engaging advocates in cancer research and underscore ways in which both the scientific and patient communities can facilitate this mutually beneficial collaboration. We discuss how to establish and nurture successful scientist-advocate relationships throughout the research process. We review opportunities that are available to advocates who want to obtain training in the evaluation of cancer research. We also suggest practical solutions that can strengthen communication between scientists and advocates, such as introducing scientist-advocate interactions at the trainee level. Finally, we highlight the essential role social media can play in disseminating patient-supported cancer research findings to the patient community and in raising awareness of the importance of promoting cancer research. Our perspective offers a model that Georgetown Breast Cancer Advocates have found effective and which could be one option for those interested in developing productive, successful, and sustainable collaborations between advocates and scientists in cancer research.

https://ift.tt/2wb1wFC

Gastric Cancer Organoids Reveal a Wnt Inhibitor Sensitive Subset [Research Watch]

Gastric cancers gain R-spondin independence by multiple mechanisms including CDH1/TP53 comutations.

https://ift.tt/2MVQxHm

Distinct Splicing Factor Mutations Converge on NF-{kappa}B Signaling [Research Watch]

Mutations in SF3B1 and SRSF2 common in myelodysplastic syndrome (MDS) are synthetic lethal.

https://ift.tt/2MVQzPu

Dysregulated Urea Cycle-Associated Signatures Are Tumor Biomarkers [Research Watch]

Urea cycle dysregulation is linked to both poor prognosis and improved response to immunotherapy.

https://ift.tt/2Pgz6To

The Nucleoporin POM121 Enhances Prostate Cancer Aggressiveness [Research Watch]

POM121 is upregulated in aggressive and lethal prostate cancers and promotes tumor growth in vivo.

https://ift.tt/2Pgz3aa

Radiotherapeutic Approved for Neuroendocrine Tumors [News in Brief]

Iobenguane I 131 eases symptoms, reduces need for antihypertensive medication.

https://ift.tt/2MVQE5K

Single-Cell RNA Sequencing Uncovers Kidney Tumor Cells of Origin [Research Watch]

Wilms tumors arise from fetal cells whereas adult tumors arise from proximal convoluted tubular cells.

https://ift.tt/2Pl2EPZ

EHR Review Can Measure Diagnostic Uncertainty

FRIDAY, Aug. 17, 2018 -- Retrospective review of clinician documentation in the electronic health record (EHR) can help identify diagnostic uncertainty with moderate reliability, according to a study published in the June issue of the Journal of...

https://ift.tt/2PhtWGP

U.S. Measles Outbreak Hits 107 Cases in 21 States, D.C.

FRIDAY, Aug. 17, 2018 -- A measles outbreak that's so far affected 21 states and the District of Columbia is being investigated by U.S. health officials. As of July 14, there had been 107 cases reported since the start of the year, according to the...

https://ift.tt/2Ph6YQ1.

FDA Permits Marketing of Brain Stimulation Device for OCD

FRIDAY, Aug. 17, 2018 -- A brain stimulation device to treat obsessive-compulsive disorder (OCD) has received approval for marketing by the U.S. Food and Drug Administration. Transcranial magnetic stimulation uses magnetic fields to stimulate nerve...

https://ift.tt/2MVNaAc

Psych Screening Beneficial in Pediatric Abdominal Pain

FRIDAY, Aug. 17, 2018 -- Systematic screening for anxiety, disability, and pain can increase psychological referral rates among pediatric patients with abdominal pain, according to a study published in the August issue of Pediatrics. Natoshia R....

https://ift.tt/2MTB5vq

Comments Open on End of NIH Review for Gene Therapy Studies

FRIDAY, Aug. 17, 2018 -- A U.S. National Institutes of Health oversight panel will no longer review all applications for gene therapy experiments. Instead, the panel will assume an advisory role, while the U.S. Food and Drug Administration will...

https://ift.tt/2PhtU1F

Exam 1: Efficacy of Treatments for Opioid-Induced Constipation: Systematic Review and Meta-analysis

https://ift.tt/2Ph77D3

Exam 2: Increased Risk of Acute Myocardial Infarction and Heart Failure in Patients With Inflammatory Bowel Diseases

https://ift.tt/2MWoyHt

Note on the use of different approaches to determine the pore sizes of tissue engineering scaffolds: what do we measure?

Collagen-based scaffolds provide a promising option for the treatment of bone defects. One of the key parameters of such scaffolds consists of porosity, including pore size. However, to date, no agreement has ...

https://ift.tt/2Ml4l1D

Prevalence, intensity and factors associated with soil-transmitted helminths infections among preschool-age children in Hoima district, rural western Uganda

Over 80% of morbidity due to soil-transmitted helminthiasis (STH) occurs in low-income countries. Children under 5 account for 20–30% of the burden in endemic areas. This study assessed the prevalence, intensi...

https://ift.tt/2PklpD0

Manifestation of anaplasmosis as cerebral infarction: a case report

Human granulocytic anaplasmosis is a tick-borne zoonotic disease caused by Anaplasma phagocytophilum, an obligate intracellular granulocytotropic bacterium.

https://ift.tt/2MTs1qo

NOS3 895Ge;T and CBR3 730Ge;A Are Associated with Recurrence Risk in Non-Muscle-Invasive Bladder Cancer with Intravesical Instillations of THP

Objectives: To analyze the correlation between pharmacogenomic biomarkers and the efficacy of pirarubicin (THP, also named 4'-O-tetrahydropyranyl-adriamycin) and to explore potential associations of individual genetic backgrounds with the clinical outcomes of non-muscle-invasive bladder cancer (NMIBC) patients. Methods: Between July 2003 and June 2011, a total of 91 patients were treated with transurethral resection (TUR) of the bladder tumor and were histopathologically confirmed to have NMIBC. Patients received an immediate instillation and maintenance therapy with THP. All patients underwent follow-up for recurrence. We genotyped 13 single nucleotide polymorphisms (SNPs) from blood and saliva DNA samples of all patients. Results: The associations of patients' genotypes with tumor recurrence risks were analyzed by survival analysis. A total of 16 (17.6%) of the 91 patients with NMIBC had tumor recurrences with a median follow-up of 17 months (range, 2–83 months). We confirmed the effect of the European Organization for Research and Treatment of Cancer (EORTC) risk score for predicting tumor recurrence (p = 0.002, log-rank test). We adjusted for the EORTC score and found that 2 SNPs, NOS3 895G#x3e;T (rs1799983) (p = 0.02, HR = 4.32, 95% CI, 1.30–14.39, GT+TT vs. GG) and CBR3 730G#x3e;A (rs1056892) (p = 0.04, HR = 2.57, 95% CI, 1.07–6.18, GA+AA vs. GG), were significantly associated with a higher recurrence risk after TUR and instillations of THP in NMIBC patients. Conclusions: Our results suggest that NOS3 895G#x3e;T and CBR3 730G#x3e;A are genetic markers that can be used to predict tumor recurrence in NMIBC patients receiving intravesical instillations of THP. The effects of those 2 SNPs are independent of the EORTC scores. Further studies with larger sample sizes and longer follow-ups are needed to confirm our results.
Chemotherapy 2018;63:191–197

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Differential Expression of MicroRNAs and miR-206-Mediated Downregulation of BDNF Expression in the Rat Fetal Brain Following Maternal Hypothyroidism

Horm Metab Res
DOI: 10.1055/a-0658-2095

To investigate the mechanism responsible for the neurological alterations, miRNA expression profile and brain-derived neurotrophic factor (BDNF) were evaluated in brain tissues of fetal or neonatal rats and from maternal rats with hypothyroidism. Ninety female Wistar rats were divided into a control and a hypothyroid group, which were mated. Brain samples of the offspring were obtained at maternal embryonic day (E) E13 and E17 as well as postnatal day (P) P0 and P7, and the hippocampus and cortex were separated at P7. BDNF mRNA at E13 was tested by real-time PCR and protein expression by Western blot. Luciferase assays were used to confirm that miR-206 targets the 3′-untranslated region (3′-UTR) of BDNF. In the brain tissues of fetal and neonatal rats from maternal rats with hypothyroidism, differentiation miRNAs profile were found at E13, E17, P0, and P7. Compared with the control group, miR-206 levels in the hypothyroidism group were increased by 3.1-fold by micro-array, and were higher as measured by SYBR green real-time qRT–PCR (p<0.01). There was no significant difference in the BDNF mRNA levels at E13 between the hypothyroidism group and the control group (1.767±0.477 vs. 1.798±0.462, respectively; p>0.05), but pro-BDNF and mature BDNF protein levels in the hypothyroid group at E13 were significantly lower than those in the control group (p<0.05). miR-206 targeted 3′-UTR of BDNF. Our data highlight the role of miR-206 as a post-transcriptional inhibitor of BDNF at E13 in pregnant hypothyroid rats.
[...]

© Georg Thieme Verlag KG Stuttgart · New York

Article in Thieme eJournals:
Table of contents  |  Abstract  |  Full text

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Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature

Publication date: Available online 17 August 2018

Source: Injury

Author(s): Margaux van Maele, Dominique Misselyn, Willem-Jan Metsemakers, An Sermon, Stefaan Nijs, Harm Hoekstra

Abstract

Introduction

Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures.

Methods

Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved.

Results

We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant.

Conclusion

The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.

https://ift.tt/2BtSBoS

Phenotypic variability of Niemann-Pick disease type C including a case with clinically pure schizophrenia: a case report

Niemann-Pick disease type C (NPC) is a lysosomal storage disorder with severe prognosis. Disease-specific therapy is crucial to prevent disease progression; however, diagnosing NPC is quite difficult because o...

https://ift.tt/2MzWvAL

A motivational phone call improves participation to screening colonoscopy for those with a positive FIT in a national screening programme (NCT 03276091)

A large proportion of individuals with a positive faecal immunologic test (FIT) will never undergo the recommended colonoscopy despite a full sequence of reminders.

https://ift.tt/2MzutFi

Hexokinase 2 is dispensable for T cell-dependent immunity

Abstract

Background

T cells and cancer cells utilize glycolysis for proliferation. The hexokinase (1–4) family of enzymes catalyze the first step of glycolysis. Hexokinase 2 (HK2) is one of the most highly upregulated metabolic enzymes in both cancer and activated T cells. HK2 is required for the development and/or growth of cancer in several cancer models, but the necessity of HK2 in T cells is not fully understood. The clinical applicability of HK2 inhibition in cancer may be significantly limited by any potential negative effects of HK2 inhibition on T cells. Therefore, we investigated the necessity of HK2 for T cell function. In order to identify additional therapeutic cancer targets, we performed RNA-seq to compare in vivo proliferating T cells to T cell leukemia.

Methods

HK2 was genetically ablated in mouse T cells using a floxed Hk2 allele crossed to CD4-Cre. CD4+ and CD8+ cells from mice were characterized metabolically and tested in vitro. T cell function in vivo was tested in a mouse model of colitis, Th2-mediated lung inflammation, and viral infection. Treg function was tested by crossing Hk2-floxed mice to FoxP3-Cre mice. Hematopoietic function was tested by deleting HK2 from bone marrow with Vav1-iCre. RNA-seq was used to compare T cells proliferating in response to virus with primary T-ALL leukemia induced with mutant Notch1 expression.

Results

We unexpectedly report that HK2 is largely dispensable for in vitro T cell activation, proliferation, and differentiation. Loss of HK2 does not impair in vivo viral immunity and causes only a small impairment in the development of pathological inflammation. HK2 is not required for Treg function or hematopoiesis in vivo. One hundred sixty-seven metabolic genes were identified as being differentially expressed between T cells and leukemia.

Conclusions

HK2 is a highly upregulated enzyme in cancer and in T cells. The requirement for HK2 in various cancer models has been described previously. Our finding that T cells are able to withstand the loss of HK2 indicates that HK2 may be a promising candidate for cancer therapy. Furthermore, we identify several other potential metabolic targets in T-ALL leukemia that could spare T cell function.

https://ift.tt/2OOmv99

A systematic post-QUANTEC review of tolerance doses for late toxicity after prostate cancer radiotherapy

The aim of this study was to systematically review tolerance doses for late distinct gastrointestinal, genitourinary, and sexual dysfunction (GI/GU/SD) symptoms following external-beam RT (EBRT) alone and treatments involving brachytherapy (BT±EBRT) for prostate cancer post-QUANTEC, and to ultimately perform quantitative syntheses of identified dose/volume tolerances represented by dose-volume histogram (DVH) thresholds, i.e., statistically significant (p≤0.05) cutoff points between symptomatic and asymptomatic patients in a certain study.

https://ift.tt/2MZY9c0

Simethicone is retained in endoscopes despite reprocessing: impact of its use on working channel fluid retention and adenosine triphosphate bioluminescence values (with video)

Studies from our group and others demonstrate residual fluid in 42% to 95% of endoscope working channels despite high-level disinfection (HLD) and drying. Additionally, persistent simethicone has been reported in endoscope channels despite reprocessing.

https://ift.tt/2MYj92y

ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up

Abstract

The European Society for Medical Oncology (ESMO) consensus conference on testicular cancer was held on 3–5 November 2016 in Paris, France. The conference included a multidisciplinary panel of 36 leading experts in the diagnosis and treatment of testicular cancer (34 panel members attended the conference; an additional two panel members [CB and K-PD] participated in all preparatory work and subsequent manuscript development). The aim of the conference was to develop detailed recommendations on topics relating to testicular cancer that are not covered in detail in the current ESMO Clinical Practice Guidelines (CPGs) and where the available level of evidence is insufficient. The main topics identified for discussion related to: (1) diagnostic work-up and patient assessment; (2) stage I disease; (3) stage II-III disease; (4) post-chemotherapy surgery, salvage chemotherapy, salvage and desperation surgery and special topics; and (5) survivorship and follow-up schemes. The experts addressed questions relating to one of the five topics within five working groups. Relevant scientific literature was reviewed in advance. Recommendations were developed by the working groups and then presented to the entire panel. A consensus vote was obtained following whole-panel discussions, and the consensus recommendations were then further developed in post-meeting discussions in written form. This manuscript presents the results of the expert panel discussions, including the consensus recommendations and a summary of evidence supporting each recommendation. All participants approved the final manuscript.

https://ift.tt/2MvSMEh

Understanding patterns of pathologic response following neoadjuvant immunotherapy for solid tumors

The widespread use of immunotherapeutics in oncology [immune-oncology (IO)] today represents a fundamental shift in the clinical approach to elimination of cancer cells. In contrast to the directly cytotoxic and/or cytostatic effects of conventional chemotherapy, radiotherapy, and targeted therapies, drugs directed at immune checkpoints, including PD-1/PD-L1 and CTLA4, harness the patient's immune system to effect tumor cell killing [1]. IO approaches have shown particular promise in solid tumors with a high burden of immunogenic neoantigens, such as non-small-cell lung cancer (NSCLC) and melanoma, and currently represent standard of care treatment of at least a subset of patients with these tumor types [2]. Radiographic studies of tumors undergoing immunotherapy have identified some distinctive patterns of tumor response, such as pseudoprogression and development of new lesions despite shrinking of the baseline tumor, triggering proposals for revised approaches to radiographic response evaluation in IO-treated patients [3, 4]. These unique radiographic patterns are thought to represent tumor infiltration by immune cells, however, the actual reasons for dynamic changes in radiographic tumor appearance can only be inferred from imaging studies.

https://ift.tt/2BkZ9FZ

4th ESO–ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 4)†

breast cancermetastaticadvancedguidelinesABCESO-ESMO

https://ift.tt/2MvSNIl

Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial

We hypothesize that clinical failure rates will be lower in patients treated with point-of-care ultrasonography and incision and drainage compared with those who undergo incision and drainage after physical examination alone.

https://ift.tt/2PcbTSp

Erratum Regarding “Risk of Venous Thromboembolism in Patients by Albuminuria and Estimated GFR” (Am J Kidney Dis. 2017;70[6]:826-833)

In the Original Investigation article entitled "Risk of Venous Thromboembolism in Patients by Albuminuria and Estimated GFR" that appeared in the December 2017 issue of AJKD (Massicotte-Azarniouch et al, volume 70, issue 6, pages 826-833), the name of one of the authors was spelled incorrectly. The name Alejandro LazoLanger should have appeared as Alejandro Lazo-Langner.

https://ift.tt/2MjzUZU

Novel nanoparticle-based approach detects and treats oral plaque without drugs

When the good and bad bacteria in our mouth become imbalanced, the bad bacteria form a biofilm (aka plaque), which can cause cavities, and if left untreated over time, can lead to cardiovascular and other inflammatory diseases like diabetes and bacterial pneumonia. A team of researchers has recently devised a practical nanotechnology-based method for detecting and treating the harmful bacteria that cause plaque and lead to tooth decay and other detrimental conditions.

https://ift.tt/2BfXqlr

Kodiak Emergency Vehicles joins the fast-growing distribution network of Technimount System

Technimount System keeps adding new players to its distribution network

https://ift.tt/2nNyzfm

Case Report of Frostbite with Delay in Evacuation: Field Use of Iloprost Might Have Improved the Outcome

High Altitude Medicine &Biology, Ahead of Print.


https://ift.tt/2vRVTge

Comparison of Echocardiographic Parameters Between Healthy Highlanders in Tibet and Lowlanders in Beijing

High Altitude Medicine &Biology, Ahead of Print.


https://ift.tt/2MWz2H1

The Statistical Curriculum Within Randomized Controlled Trials in Critical Illness

Objectives: Incomplete biostatistical knowledge among clinicians is widely described. This study aimed to categorize and summarize the statistical methodology within recent critical care randomized controlled trials. Design: Descriptive analysis, with comparison of findings to previous work. Setting: Ten high-impact clinical journals publishing trials in critical illness. Subjects: Randomized controlled trials published between 2011 and 2015 inclusive. Interventions: Data extraction from published reports. Measurements and Main Results: The frequency and overall proportion of each statistical method encountered, grouped according to those used to generate each trial's primary outcome and separately according to underlying statistical methodology. Subsequent analysis compared these proportions with previously published reports. A total of 580 statistical tests or methods were identified within 116 original randomized controlled trials published between 2011 and 2015. Overall, the chi-square test was the most commonly encountered (70/116; 60%), followed by the Cox proportional hazards model (63/116; 54%) and logistic regression (53/116; 46%). When classified according to underlying statistical assumptions, the most common types of analyses were tests of 2 × 2 contingency tables and nonparametric tests of rank order. A greater proportion of more complex methodology was observed compared with trial reports from previous work. Conclusions: Physicians assessing recent randomized controlled trials in critical illness encounter results derived from a substantial and potentially expanding range of biostatistical methods. In-depth training in the assumptions and limitations of these current and emerging biostatistical methods may not be practically achievable for most clinicians, making accessible specialist biostatistical support an asset to evidence-based clinical practice. This work was performed while the first author was employed at the ICU of the Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: jeffrey.presneill@mh.org.au; intensive@fastmail.com.au Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

https://ift.tt/2MVg0jY

Preventing Posttraumatic Stress in ICU Survivors: A Single-Center Pilot Randomized Controlled Trial of ICU Diaries and Psychoeducation

Objectives: Critical illness can have a significant psychological impact on patients and their families. To inform the design of a larger trial, we assessed feasibility of ICU diaries and psychoeducation to prevent posttraumatic stress disorder, depression, and anxiety following ICU stays. Design: Four-arm pilot randomized controlled trial. Setting: A 10-bed tertiary ICU in Winnipeg, MB, Canada. Patients: Critically ill patients greater than 17 years old with predicted ICU stays greater than 72 hours and mechanical ventilation duration greater than 24 hours. Interventions: Patients were randomized to usual care, ICU diary, psychoeducation, or both ICU diary and psychoeducation. Measurements and Main Results: Our primary objective was to determine feasibility measured by enrollment/mo. Secondary outcomes included acceptability of the ICU diary intervention and psychological distress, including patients' memories 1 week post ICU using the ICU Memory Tool, posttraumatic stress disorder (Impact of Events Scale-Revised), depression, and anxiety symptoms (Hospital Anxiety and Depression Scale) 30 and 90 days post ICU. Over 3.5 years, we enrolled 58 patients, an average of 1.9 participants/mo. Families and healthcare providers wrote a mean of 3.2 diary entries/d (SD, 2.9) and indicated positive attitudes and low perceived burden toward ICU diary participation. A majority of patients reported distressing memories of their ICU stay. Those who received the diary intervention had significantly lower median Hospital Anxiety and Depression Scale anxiety (3.0 [interquartile range, 2–6.25] vs 8.0 [interquartile range, 7–10]; p = 0.01) and depression (3.0 [interquartile range, 1.75–5.25] vs 5.0 [interquartile range, 4–9]; p = 0.04) symptom scores at 90 days than patients who did not receive a diary. Conclusions: ICU diaries are a feasible intervention in a tertiary Canadian ICU context. Preliminary evidence supports the efficacy of ICU diaries to reduce psychological morbidity following discharge. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Clinical Trials Registration: Registration Number NCT02067559. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by a grant from the Manitoba Medical Service Foundation (grant number 8-2014-07) to Dr. Blouw. Supported, in part, by Canadian Institutes of Health Research Foundation grant number 333252 (to Dr. Sareen). Ms. Kredentser has received doctoral research awards from the Canadian Institutes of Health Research and the University of Manitoba Centre on Aging and Wu Scholarship. Dr. Blouw, Ms. Kredentser, and Drs. Sareen, Bienvenu, Ryu, Logsetty, and Olafson received funding from Manitoba Medical Services Foundation. Drs. Blouw, Sareen, Graff, Logsetty, and Olafson received support for article research from the Canadian Institutes of Health Research. Dr. Sareen disclosed that he was a consultant for UpToDate and has previously held Johnson and Johnson stock. Ms. Beatie has received doctoral research awards from the Social Sciences and Humanities Research Council of Canada and the University of Manitoba Centre on Aging. Drs. Ryu, Sweatman, and Debroni received a research stipend from the University of Manitoba for completing the Med II Summer Research Program while working on this article. Dr. Arora has received an unrestricted educational grant from Pfizer Canada Inc and honoraria from Mallickrodt Pharmaceuticals for work unrelated to this article. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: umkreden@myumanitoba.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Risk Factors on Hospital Arrival for Acute Respiratory Distress Syndrome Following Pediatric Trauma

Objectives: To determine risk factors identifiable at hospital arrival associated with acute respiratory distress syndrome development among critically injured children. Design: Retrospective cohort study. Setting: Level I or II adult or pediatric trauma centers contributing to the National Trauma Data Bank from 2007 to 2016. Patients: Patients less than 18 years admitted to an ICU with traumatic injury. Interventions: None. Measurements and Main Results: We determined associations between patient, injury, and clinical characteristics present at hospital arrival with development of acute respiratory distress syndrome recorded as a hospital complication. Acute respiratory distress syndrome occurred in 1.8% of 146,058 critically injured children (n = 2,590). The only demographic factor associated with higher risk of developing acute respiratory distress syndrome on multivariable analysis was African American race (relative risk, 1.42 vs white; 95% CI, 1.13–1.78). Injury characteristics included firearm injuries (relative risk 1.93; 1.50–2.48) and motor vehicle crashes (relative risk, 1.91; 1.57–2.31) relative to falls; spine (relative risk, 1.39; 1.20–1.60), chest (relative risk, 1.36; 1.22–1.52), or lower extremity injuries (relative risk, 1.26; 1.10–1.44); amputations (relative risk, 2.10; 1.51–2.91); and more severe injury (relative risk, 3.69 for Injury Severity Score 40–75 vs 1–8; 2.50–5.44). Clinical variables included abnormal respiratory status (intubated relative risk, 1.67; 1.23–2.26 and hypopnea relative risk, 1.23; 1.05–1.45 and tachypnea relative risk, 1.26; 1.10–1.44) and lower Glasgow Coma Scale score (relative risk, 5.61 for Glasgow Coma Scale score 3 vs 15; 4.44–7.07). Conclusions: We provide the first description of the incidence of and risk factors for acute respiratory distress syndrome among pediatric trauma patients. Improved understanding of the risk factors associated with acute respiratory distress syndrome following pediatric trauma may help providers anticipate its development and intervene early to improve outcomes for severely injured children. This work was performed at Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by National Institute of Child Health and Human Development grant 5 T32 HD057822-08. Drs. Killien's and Rivara's institutions received funding from National Institute of Child Health and Human Development. Drs. Killien, Vavilala, and Rivara received support for article research from the National Institutes of Health. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: elizabeth.killien@seattlechildrens.org Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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Intracranial Pressure Trajectories: A Novel Approach to Informing Severe Traumatic Brain Injury Phenotypes

Objectives: Intracranial pressure in traumatic brain injury is dynamic and influenced by factors like injury patterns, treatments, and genetics. Existing studies use time invariant summary intracranial pressure measures thus potentially losing critical information about temporal trends. We identified longitudinal intracranial pressure trajectories in severe traumatic brain injury and evaluated whether they predicted outcome. We further interrogated the model to explore whether ABCC8 polymorphisms (a known cerebraledema regulator) differed across trajectory groups. Design: Prospective observational cohort. Setting: Single-center academic medical center. Patients: Four-hundred four severe traumatic brain injury patients. Interventions: None. Measurements and Main Results: We used group-based trajectory modeling to identify hourly intracranial pressure trajectories in days 0–5 post traumatic brain injury incorporating risk factor adjustment (age, sex, Glasgow Coma Scale 6score, craniectomy, primary hemorrhage pattern). We compared 6-month outcomes (Glasgow Outcome Scale, Disability Rating Scale, mortality) and ABCC8 tag-single-nucleotide polymorphisms associated with cerebral edema (rs2237982, rs7105832) across groups. Regression models determined whether trajectory groups predicted outcome. A six trajectory group model best fit the data, identifying cohorts differing in initial intracranial pressure, evolution, and number/proportion of spikes greater than 20 mm Hg. There were pattern differences in age, hemorrhage type, and craniectomy rates. ABCC8 polymorphisms differed across groups. GOS (p = 0.006), Disability Rating Scale (p = 0.001), mortality (p

https://ift.tt/2MTj7ZL

Transplantation of human induced pluripotent stem cell-derived cardiomyocytes is superior to somatic stem cell therapy for restoring cardiac function and oxygen consumption in a porcine model of myocardial infarction

Background Somatic stem cell (SC) therapy can improve cardiac performance following ischemic injury. In this study, we investigated whether induced pluripotent SC-derived cardiomyocytes (iPS-CMs) are more effective than somatic SCs, such as skeletal myoblasts (SM) and mesenchymal (M)SCs, in promoting functional recovery upon transplantation in a porcine model of myocardial infarction (MI). Methods Myocardial injury was induced by ameroid ring placement in immunosuppressed female mini-pigs; after 1 month, epicardial cell transplantation was performed with iPS-CMs (n = 7), SMs (n = 7), and MSCs (n = 7). Control pigs underwent sham operation (n = 8). Results Cell therapy improved functional recovery 2 months after MI, as evidenced by increased ejection fraction (iPS-CM, +7.3% ± 2.2% and SM, +5.8% ± 5.4% vs. Control: -4.4% ± 3.8%; P

https://ift.tt/2PiJqdG

Sonographically Detected Transligamentous Median Nerve Branch

No abstract available

https://ift.tt/2Btx8wi

Second-Order Peer Reviews of Clinically Relevant Articles for the Physiatrist: Is Pregabalin Effective in the Treatment of Radiating Low Back Pain Into the Leg?

No abstract available

https://ift.tt/2MVSQKk

Evidence-Based Physiatry: Key Role of Rehabilitation in New CDC Guidelines for the Management of Duchenne Muscular Dystrophy

No abstract available

https://ift.tt/2MTq7WF

Discharge Patterns for Ischemic and Hemorrhagic Stroke Patients Going From Acute Care Hospitals to Inpatient and Skilled Nursing Rehabilitation

Objective The aim of the study was to explore variation in acute care use of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation after ischemic and hemorrhagic stroke. Design A secondary analysis of Medicare claims data linked to inpatient rehabilitation facilities and skilled nursing facilities assessment files (2013–2014) was performed. Results The sample included 122,084 stroke patients discharged to inpatient or skilled nursing facilities from 3677 acute hospitals. Of the acute hospitals, 3649 discharged patients with an ischemic stroke (range = 1–402 patients/hospital, median = 15) compared with 1832 acute hospitals that discharged patients with hemorrhagic events (range = 1–73 patients/hospital, median = 4). The intraclass correlation coefficient examined variation in discharge settings attributed to acute hospitals (ischemic intraclass correlation coefficient = 0.318, hemorrhagic intraclass correlation coefficient = 0.176). Patients older than 85 yrs and those with greater numbers of co-morbid conditions were more likely to discharge to skilled nursing facilities. Comparison of self-care and mobility across stroke type suggests that patients with ischemic stroke have higher functional abilities at admission. Conclusions This study suggests demographic and clinical differences among stroke patients admitted for postacute rehabilitation at inpatient rehabilitation facilities and skilled nursing facilities settings. Furthermore, examination of variation in ischemic and hemorrhagic stroke discharges suggests acute facility-level differences and indicates a need for careful consideration of patient and facility factors when comparing the effectiveness of inpatient rehabilitation facilities and skilled nursing facilities rehabilitation.

https://ift.tt/2MzgG1u

Gait Variability and Energy Cost of Oveground Walking in Persons With Multiple Sclerosis: A Cross-Sectional Study

Objective This study examined the associations between gait variability based on common spatiotemporal parameters and energetic cost of walking in persons with multiple sclerosis. Design Eighty-six persons with multiple sclerosis underwent the 6-min walk while wearing a portable metabolic unit. The cost of walking was generated by dividing the net steady-state VO2 (milliliter per kilogram per minute) by walking speed during the 6-min walk. Participants further completed two trials of walking on the GAITRite mat at a self-selected pace for measuring spatiotemporal parameters. Variability of step length, step time, stride length, swing time, stance time, stride velocity, and single- and double-support time was indexed by the coefficient of variation. Results Variability in the spatiotemporal variables and Expanded Disability Status Scale scores were significantly correlated with cost of walking (i.e., ρ = 0.25–0.36). Multivariate analysis revealed that disability (Expanded Disability Status Scale: β = 0.186), stance time variability (β = 1.446), and step length variability (β = −1.216) explained significant variance (R2 = 0.38, P

https://ift.tt/2MzgvmQ

Long-Term Course of Shoulders After Ultrasound Therapy for Calcific Tendinitis: Results of the 10-Year Follow-Up of a Randomized Controlled Trial

Objective The aim of the study was to follow both the structure- and function-related long-term course of shoulders that had been treated with therapeutic ultrasound for symptomatic calcific tendinitis. Design This is a long-term follow-up of 45 shoulders (37 patients) that had been treated for symptomatic calcific tendinitis with either a series of ultrasound or sham ultrasound 10 yrs ago. The main outcome variables were presence of calcium deposits and subacromial impingement on standardized x-ray imaging, shoulder symptoms (Binder score), and function (Constant score). Results At 10 yrs, a similar proportion of calcium deposits had resolved in 78% of the originally ultrasound treated compared with 83% of sham-treated shoulders, whereas at 9 mos, significantly more calcium deposits had been resolved in the ultrasound group (P = 0.045). Relative to baseline, shoulder symptoms and function had significantly improved at both the 10-yr and 9-mo follow-up examinations with no significant differences between groups. Regular sports performance at baseline predicted a favorable long-term outcome. Conclusions Symptomatic calcific tendinitis of the shoulder has a good likelihood to completely resolve in the long term. Treating the calcium deposit effectively, however, may not be causal to the recovery from symptoms and function in calcific tendinitis.

https://ift.tt/2PkJWbc

Association of Academic Physiatrists Women’s Task Force Report

The Association of Academic Physiatrists (AAP) convened a women's task force in 2016, and the members agreed on a list of metrics that would permit retrospective data review pertaining to the representation and inclusion of women physicians in the society. Examples of categories examined included leadership positions (i.e., board membership, board presidents, committee membership, committee chairs, and resident fellow physician chairs), conference presentations (i.e., annual meeting session proposals, annual meeting faculty, annual meeting plenary speakers), and recognition awards (i.e., recognition award nominations and recipients). The findings highlight areas in which the Association of Academic Physiatrists has been successful in supporting gender equity and other areas in which women physiatrists have been underrepresented. The task force worked with the Board of Trustees to construct an action plan, asking the respective committees to address areas of underrepresentation. A volunteer from each committee was deemed a "diversity steward" and going forward will work directly with the task force as a liaison to document an action plan and collect data. The board plans to transparently report progress to members and other stakeholders, and the task force aims to publish a follow-up report within the next 5 years.

https://ift.tt/2BtwL4S

New Swallowing Method to Improve Pharyngeal Passage of a Bolus by Creating Negative Pressure in the Esophagus—Vacuum Swallowing

Herein, we present a case of a patient with Wallenberg syndrome with severe bulbar dysphagia who discovered a unique swallowing method: creating strong negative pressure in the esophagus to improve pharyngeal passage of a bolus. A 47-yr-old man presented with a subarachnoid hemorrhage secondary to a ruptured aneurysm in the right vertebral artery. After coil embolization, he experienced severe dysphagia due to Wallenberg syndrome and required tube feeding. Eighty-one days after the onset of the stroke, a videofluoroscopic swallowing evaluation revealed that the bolus was rapidly sucked into the esophagus. High-resolution manometry showed weak constriction of the pharynx simultaneous with forced, voluntary constriction of the diaphragm before swallowing; this created negative pressure in the esophagus. The authors named this unique swallowing method "vacuum swallowing." Ultimately, the patient was able to eat an ordinary diet via the use of this technique. Vacuum swallowing is a unique method of improving pharyngeal passage of a bolus by creating strong negative pressure in the esophagus. Additional studies are necessary to determine whether vacuum swallowing can be successfully used for other forms of dysphagia.

https://ift.tt/2MVmDD5

Hamstring Co-Contraction in the Early Stage of Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Longitudinal Study

Objective Hamstring co-contraction may affect recovery from anterior cruciate ligament reconstruction. The aim of the study was to evaluate the changes in hamstring co-contraction during the early postoperative stages. Design Twenty-five patients with anterior cruciate ligament reconstruction were followed up for 1–3 mos postoperatively, during which the Lysholm and International Knee Documentation Committee questionnaires were completed and surface electromyograms were assessed during terminal knee extension maximum voluntary contraction and step-up tests. The integrated electromyogram of the tested muscles and co-contraction ratio were analyzed. Results Co-contraction ratio during terminal knee extension maximum voluntary contraction at 3 mos postoperatively was significantly less than that at 1 mo postoperatively (P

https://ift.tt/2MuY8zv

Quality Improvement Education in Residency Training: A Review

Hospitals and healthcare institutions have strong external and internal pressures to improve patient safety and healthcare quality. Quality improvement education has been mandated for resident physicians by the Accreditation Council for Graduate Medical Education. This review describes didactic and experiential curricula for residents in quality improvement interventions as well as factors that create challenges to implementing such a curriculum and those that foster it. Resident attitudes, faculty capacity, institutional resources, and dedicated time are critical elements influencing the success of quality improvement curricula. Faculty interest in quality improvement could be enhanced by academic recognition of their work. Recommendations to facilitate publication of quality improvement efforts are described.

https://ift.tt/2PjSIWT

Intersection Syndrome Revisited: Let’s Talk Much More About It Using Ultrasound

No abstract available

https://ift.tt/2BkQC5V

Fibrinogen Concentrate: Is It Standard Currency or Bitcoin in Bleeding Management?

No abstract available

https://ift.tt/2vOStLa

Survival Analysis and Interpretation of Time-to-Event Data: The Tortoise and the Hare

Survival analysis, or more generally, time-to-event analysis, refers to a set of methods for analyzing the length of time until the occurrence of a well-defined end point of interest. A unique feature of survival data is that typically not all patients experience the event (eg, death) by the end of the observation period, so the actual survival times for some patients are unknown. This phenomenon, referred to as censoring, must be accounted for in the analysis to allow for valid inferences. Moreover, survival times are usually skewed, limiting the usefulness of analysis methods that assume a normal data distribution. As part of the ongoing series in Anesthesia & Analgesia, this tutorial reviews statistical methods for the appropriate analysis of time-to-event data, including nonparametric and semiparametric methods—specifically the Kaplan-Meier estimator, log-rank test, and Cox proportional hazards model. These methods are by far the most commonly used techniques for such data in medical literature. Illustrative examples from studies published in Anesthesia & Analgesia demonstrate how these techniques are used in practice. Full parametric models and models to deal with special circumstances, such as recurrent events models, competing risks models, and frailty models, are briefly discussed.

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Critically Ill, Then Chronically Painful: Pain and Interference With Everyday Life

No abstract available

https://ift.tt/2PkITIi

Informed Consent for Sugammadex and Oral Contraceptives: Through the Looking Glass

No abstract available

https://ift.tt/2MVKv9H

Another Win for Lidocaine, Another Loss for Magnesium?

No abstract available

https://ift.tt/2vSWTkm

Dyeing to Find Out How an “AWEsim” Bundle Can Impact Anesthesia Work Environment Contamination

No abstract available

https://ift.tt/2vSWKgO

Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks: A Randomized Controlled Trial Comparing Spinal and General Anesthesia as Supplements to Nerve Blocks

BACKGROUND: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks). METHODS: All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1–3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm–Bonferroni step-down procedure. RESULTS: General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2–75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0–3.2]; P

https://ift.tt/2MVKa6S

Intraoperative Transfusion Guidelines: Promoting Clinician Adherence in the Operating Room

No abstract available

https://ift.tt/2vSWDSq

Pediatric Intensive Care, 1st ed

No abstract available

https://ift.tt/2MUHJBA

Cardiac Arrest in the Operating Room: Resuscitation and Management for the Anesthesiologist Part 1

No abstract available

https://ift.tt/2L1RUSQ

Local Anesthetics as…Cancer Therapy?

No abstract available

https://ift.tt/2PhSmQg

Promoting a Restrictive Intraoperative Transfusion Strategy: The Influence of a Transfusion Guideline and a Novel Software Tool

BACKGROUND: The effect of neither transfusion guidelines nor decision support tools on intraoperative transfusion has been previously evaluated. The University of Michigan introduced a transfusion guideline in 2009, and in 2011, the Department of Anesthesiology developed a transfusion decision support tool. The primary aim of this study was to assess the associations of the transfusion guideline and the optional use of the software transfusion tool with intraoperative behaviors; pretransfusion hematocrit assessment (whether or not a hematocrit was checked before each red cell unit) and restrictive red cell use (withholding transfusion unless the hematocrit was ≤21%). METHODS: This was a before–after retrospective study without a concurrent control group of patients transfused 1–3 units of red cells intraoperatively. Three phases were studied to provide data both before and after the implementation of the transfusion guideline and the intraoperative software tool. Within each phase, trends of checking hematocrits before transfusion and restrictive transfusion were charted against time. F tests were used to measure differences of slopes. The difference between means of each phase was measured using Mann-Whitney U tests. Independent associations were measured using mixed-effects multivariable logistic regression. A secondary outcome analysis was conducted for 30-day mortality, myocardial infarction, renal injury, and their combination. RESULTS: The transfusion guideline was associated with increased pretransfusion hematocrit evaluation (67.4%, standard deviation [SD] 3.9 vs 76.5%, SD 2.7; P

https://ift.tt/2L1ROdW