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At least 199 records · Page 11Linked to original sources

PubMed1996

Satisfaction with prescriptive authority protocols.

OBJECTIVES: The use of prescriptive authority protocols by pharmacists and physicians in Washington was described as to: (1) types of decisions made, frequency of use, and nature of working arrangements among participants; (2) their perceived impact on professional practice and care rendered to patients; and (3) their satisfaction with the protocol arrangements. DESIGN: A mail survey of participants currently engaged in prescriptive authority was conducted. RESULTS: Responses were received from participants in 44 of 57 protocols. A total of 135 prescribers and 84 pharmacists responded. On average, 7 pharmacists and 27 prescribers were involved in each protocol, and had been involved for 6 years or more. It was estimated that approximately 10% of all active practitioners participated in protocols. Most protocols involved continuation of drug therapy or authorizing renewals. Modification of therapy (usually involving dosage or dose from changes) was practiced in two-thirds of the protocols, and initiation of therapy in about half of them. Most existed within managed care and group practice settings. Most prescribers (98%) and pharmacists (95%) were satisfied with protocol arrangements. Additionally, they generally agreed that the protocols increase patient convenience and increase the quality of patient care, and they encouraged their colleagues to use prescribing protocols. CONCLUSIONS: Protocol arrangements appear to be working well from the perspective of participants. Based on this experience, the authors encourage the development of similar protocol arrangements in other states.

Clinical Protocols↗

PubMedDate not supplied

Pressure ulcer prevention in homecare: do Dutch homecare agencies have an evidence-based pressure ulcer protocol?

OBJECTIVE: The purpose of this study was to gain insight into the availability and quality of protocols for pressure ulcer prevention in homecare agencies in the Netherlands. DESIGN: A descriptive study was completed. SETTING AND SUBJECTS: Forty-one homecare agencies in the Netherlands that provide nursing care were queried. INSTRUMENTS: Three instruments were used to collect data: (1) a structured questionnaire containing 46 closed and open-ended questions, (2) a checklist used by experts to analyze the protocols for conformity to guidelines, and (3) a tool used to generate a numerical score for each protocol based on the experts' reviews. METHODS: A questionnaire was mailed to all homecare agencies in the Netherlands that provided nursing care. The quality of each protocol was judged and scored by 3 pressure ulcer prevention experts. The scores were analyzed using descriptive statistics. RESULTS: A pressure ulcer protocol was available in 78% of the agencies. Seventy-five percent had at least 1 wound care nurse who spent an average of 10 hours per week on pressure ulcer prevention. In 20% of the agencies, no introduction or instruction was given to the nurses when the protocol was implemented. In 25% of the agencies, nurses did not participate in the revision of the protocol. At the end of 2003, only 13% of the agencies had executed 1 or more revisions of their protocol since 2002, when the last Dutch pressure ulcer guideline was introduced. The 26 pressure ulcer prevention protocols had a mean score of 47 points out of a maximum of 100 points (range 9 to 82; SD, 18). CONCLUSIONS: Although the use of protocols is considered an important adjunct in the prevention of pressure ulcers, 22% of the participating agencies did not have a pressure ulcer prevention protocol and 25% did not have wound care nurses, indicating a need for further promotion of standardized pressure ulcer prevention strategies. In addition, the available protocols were frequently of low quality or outdated, reflecting a need for increased attention to current and accurate tools to guide nursing practice.

Causality↗

PubMed2007

A review of the use of insulin protocols to maintain normoglycaemia in high dependency patients.

AIM: This paper critically examines the evidence base for and issues involved in the introduction of an insulin protocol to maintain normoglycaemia in patients within a medical/surgical high dependency ward. BACKGROUND: A growing body of evidence has linked hyperglycaemia to worsened clinical outcomes. This has led to intravenous insulin protocols becoming a new standard of care in intensive care units. However, the use and benefits of insulin protocols within high dependency units have not yet been addressed in the literature. METHODS: The literature was examined for the 10-year period up to January 2005. The databases searched were MEDLINE, OVID, CINHAL, the British Nursing Index, the EBSCO collection, the COCHRANE library, the Department of Health, and guidelines within the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence using the key words insulin, protocol, hyperglycaemia, critical care, intensive care and high dependency. RESULTS: The literature reports that both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. Resulting hypoglycaemic episodes were limited with no incidence of patient deterioration. A review of published intravenous insulin protocols used in intensive care settings revealed their safe and effective use in nurse to patient ratios similar to those present in high dependency units. CONCLUSIONS: In the light of this evidence, it would seem safe and ethically correct to enable high dependency patients to benefit from this cheap intervention. An insulin protocol tailored for the glycaemic control of high dependency patients has been suggested, although it may have to be commenced in conjunction with other fluid and nutrition protocols to safeguard the risk of hypoglycaemic events. Further research into the safety and benefit of insulin protocols in high dependency populations is required. RELEVANCE TO CLINICAL PRACTICE: The stress of critical illness often leads to hyperglycaemia, which is linked to worsened clinical outcomes. Both medical and surgical intensive care patients treated with intravenous insulin protocols to maintain normoglycaemia experienced significantly reduced mortality and morbidity. This paper identifies that, to date, no research into the benefits of glycaemic control in high dependency populations has been published. The case for the introduction of insulin protocols into high dependency units is therefore examined and an insulin protocol suggested.

Clinical Protocols↗

PubMed1992

Comparison of same-day protocols using technetium-99m-sestamibi myocardial imaging.

Two same-day protocols (rest/exercise [Protocol 1] and exercise/rest [Protocol 2]) with sestamibi (hexakis 2-methoxy-2-isobutyl-isonitrile) were performed within 2 to 14 days of each other after randomization. The initial study in each protocol was done using a dose of 185-296 MBq of 99mTc-sestamibi. The second study in each protocol used a dose of 555-925 MBq. SPECT imaging was started 30 to 60 min after injection using a 180 degrees anterior arc. Segmental analysis was interpreted as normal, scar or ischemia (20 segments/patient). Among the protocols, there was concordance in 93% of the segments (593/640 segments). In the 11 patients with coronary artery disease and no prior myocardial infarction who had ischemic abnormality, count densities from abnormal and normal zones were compared between the two protocols. Protocol 1 showed greater count differences between abnormal and normal zones on exercise images with better normalization of abnormality on rest images than Protocol 2 (p less than 0.05). Technetium-99m-sestamibi provides high quality images using either of the two same-day protocols. However, the rest/exercise protocol provides better image contrast and ability to detect reversibility of perfusion defects, and is the preferred same-day protocol.

Ambulatory Care↗

PubMed1996

Technetium-99m tetrofosmin myocardial perfusion scan: comparison of 1-day and 2-day protocols.

Nineteen patients with angina were recruited in this study for comparison of two 1-day protocols (stress-4h rest and rest-4-h stress) and a 2-day protocol of technetium-99m tetrofosmin single-photon emission tomography (SPET). All of them underwent coronary angiography before or after the study. Exercise stress-rest study and rest-stress study were performed on two consecutive days. Delayed imaging was performed before the rest injection on the 2nd day. The stress study on the 1st day and rest study on the 2nd day were considered as a 2-day protocol. The 1-day stress-rest protocol had a sensitivity of 100% (18/18) and an accuracy of 100% (19/19) in diagnosing ischaemic heart disease. The 1-day rest-stress protocol had a sensitivity of 94.4% (17/18) and an accuracy of 94.7% (18/19). These differences were not statistically significant (P=0.5 for sensitivity and accuracy). There was also no statistically significant difference between the two protocols in the diagnosis of ischaemic heart disease in individual artery territories. For the left descending artery, sensitivity was 88.2% (15/17) vs 76.5% (13/17) (P=0.48) for the stress-rest and rest-stress studies respectively. For the left circumflex artery, sensitivity was 90% (9/10) vs 80% (8/10) (P=1) and specificity was 66.7% (6/9) vs 77.8% (7/9) (P=1) respectively. For the right coronary artery, the sensitivity was 100% (16/16) vs 94% (15/16) (P=1) respectively, while the specificity was 33.3% (1/3) in both studies. Three hundred and forty-two myocardial segments were analysed. The stress-rest and 2-day protocols showed no statistically significant difference in the overall identification of segments with reversible ischaemia (48/141 segments vs 48/141 segments) or in respect of individual artery territories. There was also no significant difference in the identification of reversible ischaemic segments between the rest-stress and 2-day protocols (48/141 segments vs 34/135 segments, P=0.14). Abdominal activity was seen in 36 studies and interpretation was affected in five of them. Five patients with 24-h delayed images were evaluated and 24 segments with washout were identified. It is concluded that 99mTc-tetrofosmin is a valuable new tracer in the investigation of ischaemic heart disease. The 1-day stress-rest protocol is as good as the 1-day rest-stress protocol in diagnosing coronary heart disease. The 1-day protocols and the 2-day protocol display no difference in identifying segments with reversible ischaemia.

Adult↗

PubMed1993

The influence of field size and other treatment factors on pulmonary toxicity following hyperfractionated irradiation for inoperable non-small cell lung cancer (NSCLC)--analysis of a Radiation Therapy Oncology Group (RTOG) protocol.

PURPOSE: The risk of pulmonary toxicity, observed in an Radiation Therapy Oncology Group Phase I/II randomized dose escalation trial of hyperfractionated irradiation for nonsmall cell lung cancer, was analyzed with regard to custom vs. hand blocking and compliance to protocol specified treatment field parameters. MATERIALS AND METHODS: There were 832 evaluable cases analyzed. The protocol required field margins 2 cm beyond primary tumor and involved nodes. In 674, the field margins were considered "per protocol" or as having minor protocol variations. In 94, margins exceeded protocol specification ("excessive margin" group). In this group, the area (cm2) of the effective (blocked) field and the portion including lung was measured from simulator films with a computer scanning device. Based on size and location of the primary and nodal disease, "per protocol" fields were constructed and the area (cm2) of lung included beyond these margins was estimated. Patients from both groups who received less than 30 Gy to normal lung were excluded from analysis of pulmonary toxicity. RESULTS: Grade 1 acute lung toxicity was higher (p = .009) in the "excessive margin" group compared to the "per protocol" group, whereas late lung toxicity was not significantly different (p = .94). The risk of Grade 2 or greater acute toxicity increased as area of excess irradiated lung increased. Overall lung toxicity, defined as the greater of either acute or late toxicity, was evaluated by multivariate analysis, in relation to assigned dose, effective treated field area, and type of shielding. Overall maximum lung toxicity (> or = Grade 2) was significantly greater in the "excessive margin" group, when lung treated beyond protocol margins exceeded an area of 35 cm2, than in the "per protocol" group, but only when the effective treated field size was > or = 180 cm2 (68% vs. 37%; p = .02). This effect was independent of assigned total dose or type of shielding. CONCLUSION: For nonsmall cell lung cancer treated with hyperfractionated irradiation, the risk of overall pulmonary toxicity was increased for patients treated with field sizes in excess of protocol specified margins of tumor coverage in comparison to patients treated with protocol specified margins. This effect was seen only when the area of lung treated beyond protocol margins exceeded 35 cm2 and when the overall field size was below 180 cm2.

Carcinoma, Non-Small-Cell Lung↗

PubMed2005

Importance of protocol target definition on the ability to spare normal tissue: an IMRT and 3D-CRT planning comparison for intraorbital tumors.

PURPOSE: We selected five intraorbital tumor sites that are frequently found in clinical practice in children diagnosed with orbital rhabdomyosarcoma and performed three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated photon radiotherapy (IMRT) planning. Results of target coverage and doses to critical structures were compared. The goal of this study was to evaluate and to document realistic expectations as to organ-sparing capabilities of modern radiation therapy planning technologies with a focus on lens-sparing irradiation. Furthermore, we investigated potential added benefits of IMRT compared with 3D-CRT and the influence of protocol volume criteria definitions on the ability to obtain normal tissue dose sparing using the orbit as an example of a complex anatomic site. METHODS AND MATERIALS: The five intraorbital tumor sites were placed retrobulbar, temporal, nasal, in the upper inner and upper outer quadrant, the latter two more complex in shape. Gross tumor volume (GTV), clinical target volume (CTV), and planning target volume (PTV) were defined in image-fused computed tomography and magnetic resonance data sets. 3D-CRT and IMRT photon plans, using equal beam angles and collimation for direct comparison, were designed to 45 Gy prescription dose according to Intergroup Rhabdomyosarcoma Study Group-D9602 (IRSG-D9602) protocol (Intergroup Rhabdomyosarcoma Study V [IRS-V] protocol) for Stage I, Clinical Group 3 orbital rhabdomyosarcoma. To compare the impact of changed target definitions in IMRT planning, additional IMRT plans were generated using modified volume and dose coverage criteria. The minimum dose constraint (95%) of the PTV was substituted by a required minimum volume coverage (95%) with the prescribed dose. Dose-volume histograms (DVHs) were obtained, including target volumes, lens, optic nerves, optic chiasm, lacrimal gland, bony orbit, pituitary gland, frontal and temporal lobes. RESULTS: Protocol target volume coverage criteria were fulfilled in all cases (5/5) with 3D-CRT and IMRT. Using the protocol criteria, lens sparing was achieved only for two tumor sites (retrobulbar and lateral position) with either planning technique. Mean lens doses were 8.5 and 10.4 Gy for 3D-CRT and 7.5 and 13.2 Gy for IMRT, respectively. The mean lens doses for the other three tumor locations averaged 26.8 Gy. IMRT plans reduced the lens dose in four of five cases by an average of 2.6 Gy compared with 3D-CRT. Modified target protocol prescription markedly reduced mean lens doses by 23-50% and by as much as 18 Gy. Recorded mean lens doses after protocol modification were 26% lower using IMRT plans compared with 3D-CRT. The cold spot as a result of the relaxed volume coverage requirements was within 2% of the original protocol criteria and located at the edge of the PTV, outside the CTV. Compared with 3D-CRT, IMRT resulted in an increase of brain volume receiving 10% (V10) and 20% (V20) of the prescribed dose. CONCLUSION: Strict adherence to IRS-V protocol criteria prohibits at present lens sparing within compliance criteria for the majority of intraorbital tumor locations because of protocol-specific CTV and PTV target definitions. Changing protocol definitions by prescribing to the volume rather than to a dose constraint, IMRT planning significantly reduced lens doses. This was not accomplished to the same degree with 3D-CRT. Our study underlines the importance of appropriate selection of planning objectives to maximize the specific capabilities and advantages of IMRT in terms of sufficient target coverage and simultaneous sparing of critical structures. Our results can add to the ongoing discussion in the design of future 3D-CRT/IMRT protocols.

Child↗

PubMed1977

New practical treadmill protocol for clinical use.

A new continuous treadmill protocol (USAFSAM) has been designed using a constant treadmill speed (3.3 miles/hour) and regular equal increments in treadmill grade (5%/3min). The constant treadmill speed requires only initial adaptation in patient stride, reduces technician adjustments and produces less electrocardiographic motion artifact than do protocols using multiple or higher treadmill speeds, or both. The regular equal increments in treadmill grade are easy to implement and provide a larger number of work loads than do protocols that are discontinuous or require larger changes in work load. The USAFSAM protocol was compared with the older Balke-Ware protocol in 26 healthy men (aged 30 to 59 years). Each fasting subject completed two maximal treadmill tests from each protocol. Measurements included minute heart rate from the electrocardiogram, auscultatory blood pressures and oxygen consumption obtained with standard techniques. Similarities in between-protocol measurements for submaximal and maximal treadmill efforts were impressive; differences were small and unimportant. Further, both protocols showed equal reproducibility for the measurements noted. Importantly, time to maximal effort was reduced by 24% with the USAFSAM protocol. The USAFSAM treadmill protocol has since been used in more than 500 clinical and screening examinations, thus confirming its advantages and practicality for routine clinical stress testing. Normal reference values previously established for the Balke-Ware protocol are shown to apply to the new USAFSAM protocol as well.

Adult↗

PubMed1994

Long-term survival and prognostic factors in advanced epithelial ovarian cancer with special emphasis upon the effects of protocol inclusion.

The Danish Ovarian Cancer Study Group registered 722 patients in stages III and IV during the period 1981-1986. The material included 85% of all ovarian cancer patients in the catchment area of the group and patients allocated to protocol as well as patients treated outside protocols. Five and 10-year survival were: stage III 17%, and 8%, respectively; and stage IV 4% and 2%. Patients allocated to protocol had a significantly better survival than patients not included in protocols even when only patients younger than 70 years were compared. All non-protocol patients had a poorer prognosis irrespective of the reason for exclusion. Five-year survival for stage III protocol patients was 25% vs. 9%, for non-protocol patients younger than 70 years. The 10-year survival was 11% and 4% for stage III protocol and non-protocol patients, respectively. A multivariate analysis showed that residual tumor, age, stage, and performance status had prognostic value. In non protocol patients histologic grade had an additional marginal prognostic impact. In conclusion the study showed that the statement that long-term survival in advanced ovarian cancer has been increased could not be proven by comparison of survival from randomized studies performed in the early eighties with survival of stage III and IV patients before the introduction of cisplatinum chemotherapy. It is necessary to consider survival of all patients, protocol and non-protocol in a geographically well-defined region for evaluation of survival improvement.

Journal Article↗

PubMed1997

Inhibition of lung tumourigenesis by sulindac: comparison of two experimental protocols.

The tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is a potent lung carcinogen in mice and is most likely involved in the aetiology of tobacco-induced lung cancer. Two protocols using NNK and A/J mice have been developed. In the single-dose protocol, each mouse was injected once with 2 mg of NNK. In the 7-week protocol, each mouse received 9.1 mg of NNK in drinking water during 7 weeks. Mice were killed 16 weeks after NNK treatment. We observed a near-Gaussian distribution in the number of tumours per mouse in the single protocol, but not in the 7-week protocol. In the 7-week protocol, a significant number (8.6%) of mice had more than 20 tumours/mouse. In the single-dose protocol, no mouse had more than 20 tumours. Sulindac at a dose of 123 mg/kg of diet inhibits lung tumourigenesis in the 7-week protocol, but not in the single-dose protocol. We observed that the inhibition of tumourigenesis in the 7-week protocol was proportional to the logarithm of the dose of sulindac between 15 and 123 mg/kg of diet. Treatment of mice for 7 weeks inhibits the primary humoral response to sheep red blood cells by 70%. This observation is particularly significant considering that NNK is present in tobacco smoke and that tobacco smoking suppresses both the specific and non-specific humoral and cellular immunity. Single injections of 2.0, 3.5 or 5.0 mg of NNK had no effect on this response. Our results suggest that the immunosuppressive effects of NNK contribute to its high carcinogenic potency particularly in sustained or life-time exposure models. We hypothesize that sulindac promotes the recovery of immune system from the NNK-mediated suppression observed in the 7-week protocol. This study illustrates the importance of selecting the most appropriate protocol of carcinogen treatment in investigating the efficacies of cancer chemopreventive agents.

Administration, Oral↗

PubMed1997

Myocardial SPET imaging with 99Tcm-tetrofosmin in clinical practice: comparison of a 1 day and a 2 day imaging protocol.

99Tcm-tetrofosmin is a new myocardial perfusion agent with the advantage that it can be reconstituted at room temperature. Because two separate injections are required for rest and stress images, a separate-day imaging protocol with one injection each day would be optimal in terms of image quality. From the logistical point of view, a 1 day protocol may be more convenient for the majority of those referred as outpatients. The main aim of this study was to determine whether the detection of myocardial ischaemia would be impeded by the use of a 1 day protocol instead of a 2 day protocol. A secondary aim was to establish the relative diagnostic accuracy of the two imaging strategies. 99Tcm-tetrofosmin SPET imaging was performed in 157 patients. Sixty-nine (44%) patients were administered 250 MBq (7 mCi) 99Tcm-tetrofosmin at rest followed 4 h later by 750 MBq (21 mCi) during stress (the 1 day protocol), whereas 88 (56%) patients had rest and stress imaging studies on two separate days, receiving a 500 MBq (14 mCi) dose of 99Tcm-tetrofosmin on each occasion (the 2 day protocol). With the 1 day protocol, 135 of 621 (22%) abnormal segments (i.e. both reversible and persistent defects) were observed, compared with 195 of 792 (25%) segments with the 2 day protocol. Also, the occurrence of reversible defects only did not differ between the two protocols (both 9%). The sensitivity for the detection of coronary artery disease was 83 and 90% for the 1 and 2 day protocols respectively. We conclude that the 1 and 2 day protocols provide similar scintigraphic information and are equally sensitive and specific for the detection of coronary artery disease. Therefore, the imaging protocol can be adjusted as appropriate for the patient in question.

Adult↗

PubMed1998

A nonpharmacologic sleep protocol for hospitalized older patients.

OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative-hypnotic drug (SHD) use. DESIGN: Prospective cohort study. SETTING: A 34-bed general medical unit in a university-affiliated teaching hospital. PARTICIPANTS: A total of 175 consecutive admissions aged 70 years or older. INTERVENTION: A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD. MEASUREMENTS: The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction. RESULTS: A cohort of 111 patients, mean age 79.3 (+/- 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients-days. The overall adherence rate was 400/539 (74%) patient-days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose-response relationship, with the highest correlation for receiving two to three parts (p = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (p = .75, P = .001) than did SHDs (p = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001). CONCLUSION: The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.

Aged↗

PubMed1998

Aerobic endurance testing of children and adolescents--a comparison of two treadmill-protocols.

Fifty-eight children and adolescents of both sexes, aged 8-16, were tested on a treadmill using two different protocols. The well-known Bruce-protocol has the disadvantages of steep incline and large increments at each step. A new protocol (Oslo-protocol) with less incline and smaller increments was compared to the Bruce-protocol. The results from the two protocols showed no differences with regard to peak oxygen uptake (VO2peak) or peak heart rate (HRpeak). However, the respiratory exchange ratio (R) and blood lactate concentration [La-] showed higher values when the Bruce-protocol was used. The study also indicated that the often used criteria of HRpeak, R and achievement of a plateau in VO2 to estimate VO2peak, were not reliable indicators in either protocol. When time to exhaustion was used as an estimation of aerobic endurance level, the Oslo-protocol discriminated better than the Bruce-protocol. As a conclusion, the results indicate that none of the criteria may be used as a reliable indicator of having achieved VO2peak. An experienced testleader may be essential to define when VO2peak has been reached in children. On the basis of the results from the current study, the Oslo-protocol seems suitable as a test-protocol when testing children and adolescents for VO2peak.

Adolescent↗

PubMed2001

Evaluation of a reduced MR imaging sequencing protocol in adult patients with stroke.

PURPOSE: To compare a reduced (three-sequence) magnetic resonance (MR) imaging protocol with a full (eight- to 10-sequence) MR imaging protocol in adults suspected of having stroke. MATERIALS AND METHODS: Six neuroradiologists interpreted a consecutive sample of 265 MR images in patients suspected of having stroke. Each read reduced-protocol images in a discrete series of 40 patients (one read images in only 15) and corresponding full-protocol images 1 month later (reduced/full protocol). Five of the readers each read images in 10 additional cases, five each as full/full and reduced/reduced protocol controls. kappa values between full and reduced protocols, reader assessment of protocol adequacy, confidence level, and need for additional sequences or examinations were evaluated. RESULTS: In the reduced/full protocol, the kappa value for detecting ischemia was 0.797; and that for detecting any clinically important abnormality, 0.635. Statistically similar kappa values were found with the full/full control design (kappa = 0.802 and 0.715, respectively). The full protocol was judged more adequate than the reduced protocol (2.0 of 5.0 points vs 1.6, P <.001) and generated greater diagnostic confidence (8.6 of 10.0 points vs 8.9, P =.01), less need for additional sequences (2.7 of 6.0 points vs 1.5, P <.001), and more requests for additional examinations (28.4% vs 36.3%). CONCLUSION: Disagreement between interpretations of reduced- and full-protocol images might be attributable to baseline-level intraobserver inconsistency, as demonstrated in control designs. A greater number of sequences did not lead to greater consistency.

Female↗

PubMed2000

A prospective evaluation of empiric versus protocol-based sedation and analgesia.

STUDY OBJECTIVE: To compare empiric and protocol-based therapies of sedation and analgesia in terms of pharmacologic cost, effects on mechanical ventilation and intensive care unit (ICU) stay, and quality of sedation and analgesia. DESIGN: Prospective study. SETTING: A 24-bed medical-surgical-neurologic ICU. PATIENTS: Seventy-two patients evaluated during empiric therapy and 86 during protocol-based therapy. INTERVENTION: Assessment of data collected for 4 months before and 5 months after an evidence-based sedation and analgesia protocol was implemented. MEASUREMENTS AND MAIN RESULTS: Protocol adherence rate was 83.7%. The hourly cost (Canadian dollars) of sedation was less with protocol-based therapy ($5.68 +/- 4.27 vs $7.69 +/- 5.29, p<0.01) likely due to increased lorazepam use. Pharmacologic cost savings may be negated since sedation duration tended to be longer (122.7 +/- 142.8 vs 88.0 +/- 94.8 hrs, p<0.1) and extubation may have been delayed (61.6 +/- 97.4 vs 39.1 +/- 54.7 hrs, p=0.13) with protocol use. Duration of ICU stay after sedation was discontinued was not significantly different before and after protocol implementation. With the protocol, however, the percentage of modified Ramsay sedation scores representing discomfort decreased from 22.4 to 11% (p<0.001) and the percentage at a score of 4 increased from 17.2% to 29.6% (p<0.01). The percentage of modified visual analog measurements representing pain decreased from 9.6 to 5.9% (p<0.05) with the protocol. When data were stratified according to duration of sedation, the benefits and delayed extubation associated with protocol-based therapy were limited to patients requiring long-term sedation. CONCLUSION: Compliance with this protocol reduced drug costs and enhanced the quality of sedation and analgesia for patients requiring long-term sedation. Protocol-based therapy with lorazepam may have delayed extubation but did not delay ICU discharge.

Analgesia↗

PubMed1996

Multiple-phase helical CT of the liver for detecting small hepatomas in patients with liver cirrhosis: contrast-injection protocol and optimal timing.

OBJECTIVE: Helical CT scanners allow multiple-phase sequential scans of the entire liver to be obtained during a single bolus injection of contrast material. The purpose of this study was to compare two injection protocols and to establish timing that would optimize detection of hepatomas less than 3 cm in diameter. SUBJECTS AND METHODS: Triple-phase helical CT of the liver was evaluated in 217 patients who had liver cirrhosis and were referred for known or suspected hepatomas. Proof of individual neoplasms was based on biopsy results, surgical findings, or findings of other imaging studies. Sixty percent nonionic contrast material, infused at 2 or 4 ml/sec, was followed by sequential arterial-phase, portal-venous phase, and equilibrium-phase helical scans of the liver. Aortic and hepatic enhancement curves were constructed by measuring CT attenuation. The CT attenuation values of individual tumor lesions were also measured. We compared the degree of enhancement of normal structures and tumors obtained with four scan protocols (injection at 2 ml/sec with a 30-sec scan delay [n = 54], injection at 2 ml/sec with a 35-sec scan delay [n = 47], injection at 4 ml/sec with a 20-sec scan delay [n = 56], and injection at 4 ml/sec with a 25-sec scan delay [n = 60] and determined the optimal injection protocol and timing for CT acquisition. RESULTS: Peak aortic and hepatic enhancement was obtained earlier with the 4-ml/sec protocol (at 24 sec and 61 sec versus 36 sec and 90 sec for the 2-ml/sec protocol). The peak attenuation value of the aorta was higher with the 4-ml/sec protocol (330 H versus 186 H for the 2-ml/sec protocol). However, peak hepatic attenuation was similar for both protocols (98 H for the 4-ml/sec protocol versus 92 H for the 2-ml/sec protocol). Liver-tumor contrast was highest in the arterial phase with both protocols. The next highest contrast was obtained during the equilibrium phase. Liver-tumor contrast in the portal-venous phase was significantly lower than that in the other two phases. Tumor enhancement was significantly higher in scans obtained using the 4-ml/sec protocol with a delay time of 25 sec than those obtained with a delay time of 20 sec. In 109 hepatomas, 35 tumors were only seen or were most conspicuous during the arterial phase, four tumors were most conspicuous during the equilibrium phase, and one tumor was most conspicuous during the portal-venous phase. CONCLUSION: Arterial-phase helical CT of the liver after 4-ml/sec injection of contrast material significantly improves detection of hepatomas less than 3 cm in diameter when performed in addition to delayed scanning. Portal-venous phase helical CT is of limited value in detecting small hepatomas.

Carcinoma, Hepatocellular↗

PubMed2001

Lymphoscintigraphy and sentinel node localization in breast cancer patients: a comparison between 1-day and 2-day protocols.

UNLABELLED: The purpose of this study was to compare the results of isotope injection the morning of surgery (1-d protocol) with isotope injection the day before surgery (2-d protocol) in patients having sentinel lymph node (SLN) biopsy for breast cancer. METHODS: The 1-d (protocol 1) and 2-d (protocol 2) protocols included 514 and 152 patients, respectively, treated contemporaneously by surgeons experienced with the SLN biopsy technique. All had preoperative lymphoscintigraphy (LSG) and SLN biopsy using both blue dye and (99m)Tc-sulfur colloid. All patients had a single-site intradermal injection of unfiltered (99m)Tc-sulfur colloid in 0.05 mL normal saline: 3.7 MBq (0.1 mCi) on the morning of surgery for protocol 1 and 18.5 MBq (0.5 mCi) on the afternoon before surgery for protocol 2. RESULTS: The patients in protocols 1 and 2 were comparable in terms of age, tumor size, tumor location, histologic type, node positivity, and frequency of a previous surgical biopsy. Comparing protocols 1 and 2, early (30 min) LSG images found the SLN equally often (69% vs. 68%). Isotope identified the SLN equally often at surgery (93% vs. 97%) as did isotope plus dye (98% vs. 99%). A comparable number of SLNs was found (2.5 vs. 2.8 per axilla), and the concordance between isotope and dye in the SLN was also comparable (97% vs. 95%). Late LSG images (at 2 h, possible only for protocol 2) identified the SLN in significantly more patients compared with early images (86% vs. 68%). CONCLUSION: With unfiltered (99m)Tc-sulfur colloid injected intradermally, the results of SLN biopsy under the 1-d and 2-d protocols are virtually identical. A 2-d protocol allows increased efficiency in scheduling, both for nuclear medicine physicians and for the operating room, with no compromise in the effectiveness of SLN mapping.

Adult↗

PubMed2003

[Evaluation of two injection protocols by time-density curves for possible application to hepatic dynamic and upper abdominal CT angiography in MDCT: high concentration (350 mgI/ml) with conventional volume (100 ml) vs. conventional concentration (300 mgI/ml) with larger volume (150 ml) and higher injection rate].

The purpose of this study was to compare two different injection protocols for possible application to hepatic dynamic CT and CT angiography of the upper abdomen. Single-level dynamic CT scans through the level of the porta heapatis were performed with an MDCT unit every 3 sec in 32 patients using protocol A (350 mgI/ml iodine contrast medium, total volume 100 ml, injection rate 3.0 ml/sec), and in 39 patients using protocol B (300 mgI/ml, 150 ml, 4.5 ml/sec). Injection duration was kept the same in the two protocols. Time-density curves of the abdominal aorta (Ao), liver (L), and portal vein (PV) were created and compared. Peak enhancements were significantly higher in protocol B than in protocol A, in all of Ao, L, and PV. Time to peak enhancement was shorter in protocol B than in protocol A, reaching statistical significance in Ao and PV, but not in L. The duration of the arterial phase was shorter in protocol B than in protocol A, but the difference was not statistically significant. Our data suggest the superiority of protocol B over protocol A, for possible application to hepatic dynamic CT and CT angiography of the upper abdomen in MDCT.

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