SEARCH · PubMed Health

Results for “Complex intervention”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 415 records · Page 23Linked to original sources

PubMed2002

Analysis of pathogenetic mechanisms of common bile duct iatrogenic lesion during laparoscopic cholecystectomy. A review of the literature.

BACKGROUND: Laparoscopic cholecystectomy as the new gold standard for gallstone treatment has reopened the chapter of complications due to cholecystectomy. METHODS: The present work refers to the period between 1988-2001 and analyses 277,121 cholecystectomies, carried out in some European and extra-European Countries. 1,353 CBD lesions with an incidence rate of 0.48%, that almost doubles that of the laparotomic cholecystectomies, were found. Transection of CBD within <2 cm of bifurcation was the most frequent lesion. RESULTS: The mechanism and extension of CBD lesions is different when compared to that of laparotomic intervention. Actual damage is caused by a failure to recognise the anatomical structures, and also by errors in the surgical technique, learning curve and different visualisation of the operative field. CONCLUSIONS: Once the lesion has been diagnosed it is always necessary to define its type and extension accurately. A therapeutic approach that fails to take this aspect into account will expose the patient to repeated and increasingly complex surgical interventions, recurrent cholangitis episodes and a higher risk of suffering a secondary biliary cirrhosis.

Cholecystectomy, Laparoscopic↗

PubMed2004

Heart failure training: a call for an integrative, patient-focused approach to an emerging cardiology subspecialty.

The coming years will see continued growth in the epidemic of heart failure (HF) and increasingly complex pharmacologic, interventional, and device-based therapies, effective in reducing HF morbidity and mortality. Highly trained clinician-specialists are needed to assist in optimally evaluating and managing patients with HF. The patient is the central element defining the skills needed within this cardiology subspecialty. Primary care education, disease management strategies, and effective communication among HF specialists and other clinicians are key systemic elements needed to deliver the increasingly complex array of treatments to the expanding population of patients with HF.

Cardiology↗

PubMed1999

Managing cognitive impairment in the elderly: conceptual, intervention and methodological issues.

PURPOSE: With the aging of society, the incidence of dementia in the elderly is also increasing, and thus results in increased numbers of individuals with cognitive impairment. Nurses and other researchers have investigated issues concerning the management of cognitive impairment. This article highlights conceptual, intervention and methodological issues associated with this phenomenon. CONCLUSIONS: Cognitive change is a multivariate construct that includes alterations in a variety of information processing mechanisms such as problem solving ability, memory, perception, attention and learning, and judgement. Although there is a large body of research, conceptual, intervention and methodological issues remain. Much of the clinical research on cognitive impairment is atheoretical, with this issue only recently being addressed. While many clinical interventions have been proposed, few have been adequately tested. There are also various methodological concerns, such as small sample sizes and limited statistical power; study design issues (experimental vs. non-experimental), and internal and external validity problems. Clearly, additional research designed to intervene with these difficult behaviors is needed. IMPLICATIONS: A variety of psychosocial, environmental and physical parameters must be considered in the nursing care of persons with cognitive impairment. Special attention has been given to interventions associated with disruptive behaviors. Interventions are complex and knowledge must be integrated from both the biomedical and behavioral sciences in order to deal effectively with the numerous problems that can arise over a long and changing clinical course. Some researchers and clinicians have suggested that a new culture regarding dementia care is needed, one that focuses on changing attitudes and beliefs about persons with dementia and one that changes how organizations deliver that care. This review identifies key conceptual, intervention and methodological issues and recommends how these issues might be addressed in the future.

Journal Article↗

PubMed2001

Motivational interviewing for HIV risk reduction among gay men in commercial and public sex settings.

The present paper addresses the feasibility of combining motivational interviewing and cognitive interventions to HIV risk reduction in commercial venues and public sex environments (PSEs). The logic for these two approaches is considered and an intervention combining key elements of the two is presented. The intervention uses a questionnaire format to encourage individuals to compare their desired versus actual behaviour (i.e. chosen personal risk reduction strategy versus 'slip-ups'/unwanted risk taking), and to recognize their risk-related cognitions. High-risk individuals are identified, and health-focused conversations developed from the brief schedule. The structure and key design issues in the development of a feasible, acceptable and evidence-based tool are reviewed. The limitations of more complex, focused interventions in the context of commercial and PSE settings are discussed.

Cognitive Behavioral Therapy↗

PubMed2001

Reconstructive surgery for combined tracheo-esophageal injuries and their sequelae.

OBJECTIVE: To evaluate surgical options of treatment in combined tracheo-esophageal injuries and their sequelae and elaborate new ones. METHODS: The overlooked diagnosis of combined tracheo-esophageal injury would lead to severe stenosis of the esophagus and trachea with tracheo-esophageal fistula. This condition requires a complex surgical intervention to be performed with non-standard procedure in every single case. Forty patients with combined tracheo-esophageal injuries were treated in our institution. Nine patients were urgently operated while others were transferred to us from other hospitals with chronic sequelae of the initial trauma. RESULTS: In the majority of cases the cause of the injury was penetrating (17 patients) or iatrogenic (13 patients) trauma followed by blunt neck and chest trauma (six patients) and caustic burn (four patients). Three patients had total cut off of the esophagus and trachea, which were repaired with end-to-end anastomoses. Another six patients had tracheal and esophageal disruptions within one-half to three-quarters of circumference. In these cases both the trachea and esophagus were mobilized within wall laceration and sutured by interrupted Vicryl 4/0. One of them died due to pre-existing disease. Thirty-one patients with sequelae of the trauma were also operated on. In spite of the complexity and extent of the tracheo-esophageal stenosis and fistula the surgical treatment was aimed to one-stage reconstruction of both the esophagus and trachea. For this purpose we performed an originally developed surgical intervention, which was to be modified in accordance with patients diagnosis. The main point of the procedure is that after mobilization of the trachea and esophagus we resect an involved part of the trachea, but preserve a pedicled flap fashioned from the tracheal membrane. Then we remove the mucosa from the flap, resect an involved esophageal wall, repair esophageal mucosa and replace the defect of the muscular layer of the esophagus with the tracheal flap. Then a tracheal or laryngo-tracheal anastomosis is established. There were no postoperative mortality and complications among patients with the sequelae. CONCLUSION: Combined tracheo-esophageal injury requires the precise preoperative diagnosis and well organized plan of surgical treatment, which may be unique for every single patient. The main purpose of the treatment is to restore the continuity of both the esophagus and trachea in one-stage intervention.

Adolescent↗

PubMed1998

Complex uterine surgery: a cooperative role for interventional radiology with hysteroscopic surgery.

OBJECTIVE: To describe the value of concurrent interventional radiology with hysteroscopy for the management of complex intrauterine abnormalities. DESIGN: A new descriptive technique. SETTING: Tertiary care center. PATIENT(S): Three case reports. INTERVENTION(S): Interventional radiology with the placement of guidewires and/or dilatation of resistant structures may assist with hysteroscopic management of complex intrauterine abnormalities or may be a primary therapeutic option. MAIN OUTCOME MEASURE(S): Resolution of dysmenorrhea and restoration of fertility. RESULT(S): The placement of a guidewire into an occluded portion of the intrauterine cavity provides direction and safety for hysteroscopic resolution of the underlying problem. In the last case, placement of the guidewire and passing dilators over the guidewire provided complete treatment. CONCLUSION(S): The uterine cavity or a smaller segment of it may be blocked by occlusive fibrous tissue that is not amenable to standard hysteroscopic dissection. Combining radiologic imaging with hysteroscopic surgery allows visual access to instrumentation and the hidden structures or organs throughout the entire procedure. It adds complexity to the surgery but may allow restoration of function to an organ or structure that is otherwise inaccessible.

Adolescent↗

PubMed2004

Cost-effectiveness of sirolimus-eluting stents for treatment of complex coronary stenoses: results from the Sirolimus-Eluting Balloon Expandable Stent in the Treatment of Patients With De Novo Native Coronary Artery Lesions (SIRIUS) trial.

BACKGROUND: Recently, sirolimus-eluting stents (SESs) have been shown to dramatically reduce the risk of angiographic and clinical restenosis compared with bare metal stent (BMS) implantation. However, the overall cost-effectiveness of this strategy is unknown. METHODS AND RESULTS: Between February and August 2001, 1058 patients with complex coronary stenoses were enrolled in the SIRIUS trial and randomized to percutaneous coronary revascularization with either a SES or BMS. Clinical outcomes, resource use, and costs were assessed prospectively for all patients over a 1-year follow-up period. Initial hospital costs were increased by 2881 dollars per patient with SESs. Over the 1-year follow-up period, use of SESs led to substantial reductions in the need for repeat revascularization, including repeat percutaneous coronary intervention and bypass surgery. Although follow-up costs were reduced by 2571 dollars per patient with SESs, aggregate 1-year costs remained 309 dollars per patient higher. The incremental cost-effectiveness ratio for SES was 1650 dollars per repeat revascularization event avoided or 27,540 dollars per quality-adjusted year of life gained, values that compare reasonably with other accepted medical interventions. Under updated treatment assumptions regarding available stent lengths and duration of antiplatelet therapy, use of SESs was projected to reduce total 1-year costs compared with BMSs. CONCLUSIONS: Although use of SESs was not cost-saving compared with BMS implantation, for patients undergoing percutaneous coronary intervention of complex coronary stenoses, their use appears to be reasonably cost-effective within the context of the US healthcare system.

Angioplasty, Balloon, Coronary↗

PubMed2003

Cardiac resynchronization therapy with or without an implantable defibrillator: only indicated when everything else has failed?

Cardiac resynchronization therapy (CRT) is potentially an important new treatment for patients with heart failure due to left ventricular systolic dysfunction and cardiac dyssynchrony. There is growing evidence that CRT can improve symptoms although it is possible that similar benefits could be obtained by skillful manipulation of pharmacological therapy. There is also preliminary but inconclusive evidence to suggest that CRT alone or in synergy with an implantable cardiac defibrillator (ICD) may reduce morbidity and mortality. However, fashion is in danger of overtaking facts and it is important to ensure that benefits are not only statistically proven but clinically meaningful and cost-effective. Optimal timing of intervention and patient selection will be essential to ensure that treatment is deployed efficiently. If CRT with or without ICD becomes part of mainstream therapy for heart failure this will have far-reaching consequences for heart failure management. Implantation is a skilled and often time-consuming procedure. Long-term management of both CRT and ICD is likely to provide challenges in terms of lead technology, pacing thresholds and device management. Heart failure physicians will have to learn new skills and collaborate more closely with electrophysiologists. Such developments, in addition to the need for complex pharmacological interventions will accelerate the move away from general practice and towards specialist care for this most common of malignant diseases. If CRT does reduce mortality, it will graduate from an adjunctive therapy which could be used to an essential one that should be used as part of routine therapy for appropriate patients. Currently, CRT is a symptomatic therapy for patients with severe heart failure resistant to intensive pharmacological therapy delivered by a heart failure specialist.

Arrhythmias, Cardiac↗

PubMed2000

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Decision Making↗

PubMed2000

Analysis of 153 gunshot wounds of the liver.

BACKGROUND: Gunshot wounds of the liver may result in substantial morbidity and death, and optimal management of complex injuries is controversial. METHODS: One hundred and fifty-three patients with civilian gunshot liver injuries were treated during the 10-year period 1986-1995. Demographic, clinical and operative data were recorded. Factors influencing postoperative complications and death were analysed. RESULTS: One hundred and forty-two patients (93 per cent) had single missile injuries and 11 (7 per cent) had shotgun injuries. Three patients were treated non-operatively and 150 patients underwent operation. In 105 patients (70 per cent) the injuries to the liver were minor and required either no treatment (93) or simple suture of bleeding vessels (12). Forty-five patients (30 per cent) had major injuries which were either packed only (26) or required more complex surgical intervention (19). This included resectional debridement (ten), major venous repair (eight) and hepatotomy (one); eight of these patients required packing combined with the procedure. Associated intra-abdominal injuries occurred in 115 patients (77 per cent). The overall mortality rate was 17 per cent (26 patients). Death was directly attributable to the liver injury in 13 patients (8 per cent), 12 of whom died from uncontrolled bleeding. Complications occurred in 63 (51 per cent) of 124 survivors, and correlated with the type and severity of the liver injury and the number of associated injuries. CONCLUSION: Most gunshot liver injuries can be managed by simple surgical techniques. In complex injuries control of major haemorrhage is vital and perihepatic packing may be life saving before undertaking definitive repair of the injury under controlled conditions.

Adolescent↗

PubMed2006

Orthogonal interlocking tandem clipping technique for the reconstruction of complex middle cerebral artery aneurysms.

OBJECTIVE: Complex aneurysms arising at the middle cerebral artery (MCA) bifurcation frequently present a microsurgical challenge to effectively obliterate while maintaining patency of the distal MCA branches. These aneurysms are often multilobed, with their long axis aligned with the long axis of the M1 trunk, placing the dome of the aneurysm in the surgeons' line of sight, preventing an unobstructed view of the entire bifurcation and proximal M1 segment. MCA aneurysms often have a broad neck, splaying the bifurcation. An orthogonal interlocking tandem clipping technique, maximizing the use of fenestrated aneurysm clips, is presented as a means to completely obliterate the aneurysm and simultaneously "reconstruct" the MCA bifurcation. CLINICAL PRESENTATIONS AND INTERVENTION: Fifteen complex MCA aneurysms were treated using an interlocking tandem clipping technique. In its simplest application, the blades of the initial aneurysm clip are incorporated into the fenestration of the second clip. Obliteration of the residual aneurysm is achieved with the blades of the second, fenestrated clip. RESULTS: Satisfactory aneurysm obliteration and reconstruction of the MCA bifurcation was achieved in all cases using this technique, with excellent neurological outcomes. CONCLUSION: Morphologically complex multilobed MCA aneurysms can be effectively clipped with "reconstruction" of the normal vascular anatomy using a tandem interlocking clipping technique. A fenestrated clip is used to incorporate the blades of the initial clip, while obliterating the remainder of the aneurysm.

Adult↗

PubMed1995

New invasive techniques of assessment of the physiological significance of coronary stenoses in humans.

Pressure and flow velocity can be measured distal to coronary stenoses by means of miniaturized sensors with guidewire technology. This is an alternative non-invasive method of assessing functional coronary vessel stenosis severity, applicable for the intermediate stenoses and for the results of coronary interventions. The complexity of the coronary circulation, however, limits the possibility of establishing simple cut-off criteria to identify flow-limiting stenoses. In this paper, we review advantages and limitations of the different pressure and velocity indices and their application in different clinical settings.

Blood Flow Velocity↗

PubMedDate not supplied

Randomized trials stopped early for harm in HIV/AIDS: a systematic survey.

PURPOSE: The decision to stop trials early because of the harmful effects of the intervention is complex and requires weighing statistical, logistical, and ethical considerations. We assessed the prevalence of randomized clinical trials (RCTs) stopped early for harm in HIV/AIDS and determined the quality of reporting of methods to inform the decision to stop the trial. METHOD: We searched 11 electronic databases and major conference abstract databases, contacted trialist and advocacy groups, and searched the Internet. We selected RCTs stopped early for harm. We extracted data on journal and year of publication, reporting of methods and funding, planned sample size, number and planning of interim analyses, stopping rules, and effect size of the harm outcomes. RESULTS: We found 10 RCTs stopped early for harm (median, n = 85; range, 7-1227). Most interventions (n = 9) were antiviral drugs; one trial studied vitamins to prevent vertical transmission of HIV. Five studies reported a priori defined adverse events, and only 1 trial reported planned stopping guidelines. The primary harm outcomes reported across trials included toxicity, death, and increased mother-to-child transmission. Two trials were stopped due to sudden unanticipated adverse events (Stevens-Johnson syndrome, death, and encephalopathy). Relative risk point estimates for harm ranged from 1 to 6.18. Six studies reported the presence of a data safety and monitoring board. CONCLUSION: The reporting of methods to inform the decision to stop trials for harm in this population is deficient in a variety of ways, including lack of stopping guidelines. Clinicians should interpret RCTs stopped early for harm with caution and interpret the results in light of related evidence. Trialists should improve the transparency of their decision-making regarding early stopping for harmful effects.

Anti-HIV Agents↗

PubMedDate not supplied

Public nutrition in complex emergencies.

Public nutrition is a broad-based, problem-solving approach to addressing malnutrition in complex emergencies that combines analysis of nutritional risk and vulnerability with action-oriented strategies, including policies, programmes, and capacity development. This paper focuses on six broad areas: nutritional assessment, distribution of a general food ration, prevention and treatment of moderate malnutrition, treatment of severe malnutrition in children and adults, prevention and treatment of micronutrient deficiency diseases, and nutritional support for at-risk groups, including infants, pregnant and lactating women, elderly people, and people living with HIV. Learning and documenting good practice from previous emergencies, the promotion of good practice in current emergencies, and adherence to international standards and guidelines have contributed to establishing the field of public nutrition. However, many practical challenges reduce the effectiveness of nutritional interventions in complex emergencies, and important research and programmatic questions remain.

Africa↗

PubMed2002

Nursing-led in-patient units for intermediate care: a survey of multidisciplinary discharge planning practice.

The effectiveness of post-acute intermediate care in nursing-led intermediate care in-patient units (NLIU) has been studied over the past 20 years. Accounts, both positive and negative, have tended to view it as a uni-disciplinary intervention. The previous studies are in effect a series of single case studies and as such need to be accompanied by richer descriptions of care processes in order to be useful. A survey was conducted, in parallel with a randomized-controlled trial (n=177), to compare multidisciplinary care and discharge planning practice on the NLIU with 16 wards that referred patients to it. The findings identify that a wide range of professions participate in care on the NLIU with physiotherapists and occupational therapists most widely involved. In general the team composition and care processes differed little between the NLIU and control wards. There was some evidence that there was lower participation in care on the NLIU from occupational therapy and social work. It is concluded that the NLIU is a complex multidisciplinary intervention. Positive results from some NLIUs may only be generalizable to settings with similar skill mix across the multidisciplinary team as that found in the acute hospital. Reduced skill mix may be a causal factor leading to extended stays and increased total care costs. This caution should be extended to other models of intermediate care, whether or not they are nursing-led.

Humans↗

PubMed2003

Generation of a phenotypic array of hypothalamic neuronal cell models to study complex neuroendocrine disorders.

Knowledge of how the brain achieves its diverse central control of basic physiology is severely limited by the virtual absence of appropriate cell models. Isolation of clonal populations of unique peptidergic neurons from the hypothalamus will facilitate these studies. Herein we describe the mass immortalization of mouse primary hypothalamic cells in monolayer culture, resulting in the generation of a vast representation of hypothalamic cell types. Subcloning of the heterogeneous cell populations resulted in the establishment of 38 representative clonal neuronal cell lines, of which 16 have been further characterized by analysis of 28 neuroendocrine markers. These cell lines represent the first available models to study the regulation of neuropeptides associated with the control of feeding behavior, including neuropeptide Y, ghrelin, urocortin, proopiomelanocortin, melanin-concentrating hormone, neurotensin, proglucagon, and GHRH. Importantly, a representative cell line responds appropriately to leptin stimulation and results in the repression of neuropeptide Y gene expression. These cell models can be used for detailed molecular analysis of neuropeptide gene regulation and signal transduction events involved in the direct hormonal control of unique hypothalamic neurons, not yet possible in the whole brain. Such studies may contribute information necessary for the strategic design of therapeutic interventions for complex neuroendocrine disorders, such as obesity.

Animals↗

PubMed2002

Carbon-dioxide-guided vascular interventions: technique and pitfalls.

PURPOSE: To evaluate the usefulness of carbon dioxide (CO2) angiography to guide vascular interventions. METHODS: A prospective study was carried out of 50 procedures (angioplasty, stenting, stent-grafting and embolization) using CO2 angiography. Indications for using CO2 were renal impairment, cardiac failure, previous reaction to conventional iodinated contrast, or likelihood of needing high doses of conventional contrast. CO2 was intended to be the sole contrast agent. The use of additional conventional contrast or gadolinium was recorded, as were procedural complications. Radiation dose was compared with similar procedures using conventional contrast. RESULTS: Angiographic quality was satisfactory in 44 (88%) procedures and CO2 guidance was all that was required; in 6 (12%) cases adjunctive use of conventional contrast or gadolinium was necessary. Contrast doses were significantly reduced and there was a trend toward decreased radiation doses with CO2. There were two significant complications but only one related to the use of CO2. CONCLUSION: CO2 angiography is well tolerated and can be successfully used to guide even complex vascular interventions. High-risk patients can be spared the risks of conventional contrast agents.

Aged↗

PubMed1993

Role of leukocyte adhesion molecules in complement-induced lung injury.

The bolus i.v. infusion of cobra venom factor into rats results in acute lung injury that is neutrophil-dependent, oxygen radical-mediated, and requires CD18. In our studies a more precise definition regarding the role of beta-integrins and requirements for cytokines was obtained by the use of blocking antibodies. Lung injury was quantitated by changes in permeability (leakage of 125I-BSA) and hemorrhage (extravasation of 51Cr-RBC). In animals treated with anti-CD11a, the permeability and hemorrhage parameters were reduced by 30 and 29%, respectively. Treatment with anti-CD11b resulted in reductions in permeability and hemorrhage by 53 and 48%, respectively, whereas anti-intercellular adhesion molecule-1 reduced the parameters of injury by 60 and 75%, respectively. Not surprisingly, treatment with antibodies to very late Ag-4, TNF-alpha and IL-1 failed to show any protective effects, which contrasts to the requirements for these molecules in lung injury after deposition of IgG immune complexes. Protective interventions were associated with a reduction in lung content of myeloperoxidase. These studies indicate that, in the cobra venom factor model of acute lung injury in rats, engagement of Mac-1, lymphocyte function-associated Ag-1, and intercellular adhesion molecule-1 are essential, whereas, in contrast to other models of neutrophil mediated lung injury, cytokines (TNF-alpha and IL-1) and very late Ag-4 are not required for the full development of injury.

Animals↗