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PubMed1993

Anesthesia for coronary artery surgery.

Anesthesia for coronary artery bypass graft surgery continues to evolve in concert with changing epidemiology, advances in technology and pharmacology, and refinement in technique. The profile of the cardiac surgical patient is increasingly characterized by factors such as advanced age, reoperation, combination procedures, complications of acute intervention, and more complex disease. Preoperative risk factor assessment offers a means of strategic planning and intervention. Choice of anesthetic agents, muscle relaxants, and anti-ischemic medications affects both perioperative management and long-term outcome. Transesophageal echocardiography and ST segment monitoring are being applied more broadly. Advances have been made in managing postoperative blood loss. As in other areas of medicine, economic issues have become important considerations in anesthesia for the cardiac surgical patient.

Anesthesia↗

PubMed1980

[Immunopathology of arterial diseases (author's transl)].

The clinical manifestations of necrotizing angeiitis are of many types (periarteritis nodosa, Wegener's granulomatosis, hypersensitivity, vasculitis...). Their immunological origin is strongly suggested by their analogy with the experimental models of immune complex diseases, and the presence of many immunological anomalies indicating the presence and intervention of these complexes. Several arguments strongly suggest that immunological factors may be also implicated in the pathogenesis of arterial hypertension and arteriosclerosis.

Antigen-Antibody Complex↗

PubMed2002

CT-guided biopsy of indeterminate renal cystic masses (Bosniak 3 and 2F): accuracy and impact on clinical management.

The purpose of this study was to determine ability of cyst aspiration and core biopsy to differentiate malignancies, and benign lesions needing intervention from benign complex cysts in the group of Bosniak 2F and 3 renal cysts. One hundred ninety-nine indeterminate complex renal cysts were biopsied under CT or US guidance using a coaxial system (19-G sheath, 20- or 21-G Chiba or Franseen or 18-G spring biopsy needle). Cytology, amylase, lipase, LDH, fat, protein, urea nitrogen, creatine, and culture and sensitivity were assessed in all patients, histopathology in 116, and flow cytometry in 32. In 179 patients (87.9%) a definitive diagnosis was made; in 20 the specimen was inadequate. Twenty of 28 malignancies were correctly diagnosed (sensitivity 0.71); 27 of 31 benign lesions needing intervention (sensitivity 0.87) and 128 of 140 benign complex cysts (sensitivity 0.91). All inconclusive biopsies were explored revealing six malignancies. There were four CT biopsy misdiagnoses: two renal cell carcinomas; one angiomyolipoma; and one abscess. Guided cyst puncture aspiration and core biopsy significantly altered management of Bosniak 3 and 2F renal cysts obviating surgery or invasive procedures in 70% of the patients with an affirmed diagnosis of benign complex cyst and rendering timely surgical and other interventions in the remaining patients. Long-term follow-up (mean 5.6 years) revealed no further misdiagnosis.

Adult↗

PubMed2004

A framework for classifying study designs to evaluate health care interventions.

Researchers who are trained in epidemiology recognise and use the standard range of designs, i. e. retrospective and prospective cohort studies and case control studies, for studying aetiological questions. The application of study designs to health care interventions is more complex. Researchers may modify familiar designs, in response to specific problems posed by the interventions being evaluated, and an unambiguous nomenclature has not been established. Also, researchers who set out to evaluate interventions are not always trained in epidemiology and often use familiar study design labels in an ambiguous or inappropriate manner. The susceptibility to bias of different study designs is a critical consideration for users of research evidence. Sources of bias are the same for all studies, i. e. selection, performance, detection and attrition bias, but the susceptibility of studies is likely to vary depending on their design. Evidence of associations between features of study designs, specific biases and their consistent influence on effect estimates is lacking. A framework for classifying study design will be proposed, based on key features of study designs, i. e. what researchers actually did. This framework may (a) help to reduce the ambiguity about study design labels, and uncertainty about how a study was actually carried out, and (b) help methodological researchers to gather evidence about associations between different study design features and susceptibility to bias.

Bias↗

PubMed2006

Psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families.

Psychoeducation was originally conceived as a composite of numerous therapeutic elements within a complex family therapy intervention. Patients and their relatives were, by means of preliminary briefing concerning the illness, supposed to develop a fundamental understanding of the therapy and further be convinced to commit to more long-term involvement. Since the mid 1980s, psychoeducation in German-speaking countries has evolved into an independent therapeutic program with a focus on the didactically skillful communication of key information within the framework of a cognitive-behavioral approach. Through this, patients and their relatives should be empowered to understand and accept the illness and cope with it in a successful manner. Achievement of this basic-level competency is considered to constitute an "obligatory-exercise" program upon which additional "voluntary-exercise" programs such as individual behavioral therapy, self-assertiveness training, problem-solving training, communication training, and further family therapy interventions can be built. Psychoeducation looks to combine the factor of empowerment of the affected with scientifically founded treatment expertise in as efficient a manner as possible. A randomized multicenter study based in Munich showed that within a 2-year period such a program was related to a significant reduction in rehospitalization rates from 58% to 41% and also a shortening of intermittent days spent in hospital from 78 to 39 days. Psychoeducation, in the form of an obligatory-exercise program, should be made available to all patients suffering from a schizophrenic disorder and their families.

Cognition↗

PubMed2005

A brief history and some current dimensions of adolescent treatment in the United States.

Resources for the treatment of adolescent substance use disorders have increased over the past century in tandem with the increased visibility and cultural alarm regarding adolescent substance-related problems. The United States now has a multi-branched and growing system of adolescent treatment services that spans public and private sectors and offers services in both specialty and non-specialty service settings. Most adolescents are entering treatment due to alcohol and/or cannabis-related problems (and, to a lesser degree, other illicit drugs), but present with a wide array of co-occurring problems and obstacles to recovery. Multiple levels of specialized care are available but most adolescents being treated via outpatient counseling. The number and methodological rigor of adolescent treatment outcome studies have increased dramatically in recent years. The findings of these studies suggest the need for earlier systems of problem identification and intervention, a model of sustained recovery support for adolescents presenting with high problem severity and complexity, and sustained interventions with the adolescent's post-treatment family and social environment. In the opening decade of the twenty-first century, the treatment of adolescent substance use disorders is itself maturing into a professionalized and science-guided service arena.

Adolescent↗

PubMed2005

[Should disease management be feared? (2): outpatient care].

Outpatient disease management is a multidisciplinary team intervention for managing complex processes of chronic diseases, in order to improve healthcare quality and decrease process variations. Interventions are based on: (1) evidence-based guidelines; (2) educational programs; (3) close patient follow-up. This can be achieved by telephone follow-up, by outpatient clinic programs, or by homecare visits performed by case managers. For the management of patients with chronic heart failure, disease management programs have resulted in a 25% decrease in hospitalization and in reduced costs. In our Swiss health care system, however, a majority of patients are taken care of by private practitioners; thus, the involvement of these physicians in the development and in the realization of disease management programs will be key to their success.

Community Health Services↗

PubMed1978

Regulation of collagenase. Therapeutic considerations.

Why the cornea ulcerates, in the sense of what goes awry, may be related to the trapping of wound healing in a phase of proteolytic debridement related to a persistent epithelial defect. The initial avascularity of the cornea makes it particularly vulnerable to proteolytic damage. Studies on the biochemistry and cell biology of corneal ulceration have indicated that sequential interactions occur which result in the generation of collagenase activity and the development of ulceration. It is likely that the interactions are susceptible to intervention; and it is thought that eventual, successful treatment of corneal ulceration will require a complex therapy, with interventions at multiple sites of regulation.

Animals↗

PubMed1996

Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications.

BACKGROUND: Low adherence of patients to prescribed, self-administered medical interventions is ubiquitous. Low adherence limits the benefits of current medical care. Efforts to assist patients to follow treatments might improve the efficiency of care and substantially enhance benefits. Our objective was to summarise the results of randomised controlled trials (RCTs) of interventions to help patients follow prescriptions for medications. METHODS: A previous systematic review was updated through computerised searches in Medline, International Pharmaceutical Abstracts, Psychinfo, and HSTAR online databases; bibliographies in articles on patient adherence; articles in the reviewers' personal collections; and contact with authors. Articles were judged of interest if they reported original data concerning an unconfounded RCT of an intervention to improve adherence with prescribed medications, with one or more measure of medication adherence, one or more measure of treatment outcome, at least 80% follow-up of each group studied, and, for long-term treatments, at least 6 months of follow-up for studies with positive initial findings. Information on study design features, interventions and controls, and findings were extracted by one reviewer (RK) and checked by the other two reviewers. FINDINGS: 1,553 relevant citations and abstracts were screened, 252 full text articles were reviewed in detail, and 13 RCTs met all criteria. The studies were too disparate in clinical problems, adherence interventions, measures and reporting of adherence, and the clinical outcomes studied to warrant meta-analysis. Seven of 15 interventions were associated with improvements in adherence and six interventions led to improvements in treatment outcomes. For short-term treatments, one study showed an effect on adherence and outcome of counselling and written information. The interventions that were effective for long-term care were complex, including various combinations of more convenient care, information, counselling, reminders, self-monitoring, reinforcement, family therapy, and other forms of additional supervision or attention. Even the most effective interventions did not lead to substantial improvements in adherence. INTERPRETATION: Although adherence and treatment outcomes can be improved by certain-usually complex-interventions, full benefits of medications cannot be realised at currently achievable levels of adherence. It is time that additional efforts be directed towards developing and testing innovative approaches to assist patients to follow treatment prescriptions.

Drug Therapy↗

PubMed1979

[Relapse symptom complex in rectal cancer after radical surgical interventions].

The analysis of 78 questionnaires of patients with recurrence of rectal cancer was performed which revealed this complication of surgery to occur in 60% of cases within a year after operation. Recurrences of the rectum cancer show a characteristic complex of symptoms with a certain structure of painful sensations as a central criterion.

Anal Canal↗

PubMed1994

Fractal analysis of role of smooth muscle Ca2+ fluxes in genesis of chaotic arterial pressure oscillations.

We have investigated the role of vascular smooth muscle Ca2+ fluxes in the genesis of chaotic pressure oscillations induced by histamine in isolated resistance arteries from the rabbit ear. The responses exhibited distinct "fast" and "slow" components, with periods of 5-20 s and 1-5 min, respectively, which could be dissociated pharmacologically. The fast subsystem involved ion movements at the cell membrane and was inhibited by both low (< 2 mM) and high (> 5 mM) extracellular Ca2+ concentration ([Ca2+]o) by verapamil (which inhibits voltage-dependent Ca2+ influx) and by charybdotoxin (ChTX) and apamin (which block Ca(2+)-activated K+ channels). In contrast, the slow subsystem was intracellular and was selectively attenuated by ryanodine, which inhibits Ca(2+)-induced Ca2+ release from sarcoplasmic reticulum. The effects of these interventions on the complexity of the responses were quantified by calculating their fractal dimension, a parameter that estimates the minimum number of independent variables contributing to an irregular time series. Its mean value was generally > 2 under control conditions but decreased to < 2 in a concentration-dependent fashion in the presence of verapamil, ChTX, apamin, or ryanodine and when [Ca2+]o was outside the range of 2-3 mM. Each intervention thus removed one dimension of complexity from the mechanisms generating the rhythmic activity. We conclude that the interaction of a fast membrane oscillator, which involves Ca2+ influx, Ca(2+)-activated K+ efflux, and therefore presumably changes in membrane potential, and a slow intracellular oscillator involving Ca2+ sequestration and release from stores is responsible for vascular chaos in our model. The coupling between these subsystems is likely to be mediated by cytosolic [Ca2+].

Animals↗

PubMed2005

Anesthesia for neuroradiology.

PURPOSE OF REVIEW: The role of anesthesia outside the operating room is rapidly expanding and evolving alongside with the advances in interventional neuroradiology. Increasingly complex diagnostic and therapeutic neuroradiological procedures are being performed on sicker patients. This review provides an overview of the principles of anesthetic management and summarizes recent advances in interventional neuroradiology. RECENT FINDINGS: There are many new areas of development in interventional neuroradiology, but each also brings with it controversy. Use of newer agents for anesthesia and for anticoagulation may change the intraoperative management of patients. The role of neurophysiological monitoring during endovascular procedures is still to be validated. The optimal mode of treating cerebral aneurysms is still being debated. There has been increasing interest in and evidence of the efficacy of carotid artery stenting in the treatment of carotid artery disease. The utility of intraoperative magnetic resonance imaging in neurosurgery is expanding rapidly. SUMMARY: Providing anesthesia in the interventional neuroradiology suite continues to be a challenge to the anesthesiologist. Understanding the anesthetic constraints and complexities and keeping abreast of the current developments in neuroradiology are crucial in ensuring the maximal benefits to and safety of patients.

Journal Article↗

PubMed1999

Protein movement during complex-formation between tissue plasminogen activator and plasminogen activator inhibitor-1.

Plasminogen activator inhibitor-1 (PAI-1) rapidly inactivates tissue plasminogen activator (tPA). After initial binding and cleavage of the reactive-centre loop of PAI-1, this complex is believed to undergo a major rearrangement. Using surface plasmon resonance and SDS-PAGE, we have studied the influence of a panel of monoclonal antibodies on the reaction leading to the final covalent complex. On the basis of these data, we suggest the mechanisms for the action of different classes of inhibitory antibodies. We propose that the antibodies which convert PAI-1 into a substrate for tPA do this by means of preventing the conversion of the initial PAI-1/tPA complex into the final complex by sterical intervention. Moreover, the localisation of the binding epitopes on free PAI-1, as well as on the PAI-1/tPA complex, suggests that tPA in the final complex cannot be located near helices E and F, as has previously been proposed.

Antibodies, Monoclonal↗

PubMed2006

A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME Guide No. 8.

BACKGROUND: Preparing healthcare professionals for teaching is regarded as essential to enhancing teaching effectiveness. Although many reports describe various faculty development interventions, there is a paucity of research demonstrating their effectiveness. OBJECTIVE: To synthesize the existing evidence that addresses the question: "What are the effects of faculty development interventions on the knowledge, attitudes and skills of teachers in medical education, and on the institutions in which they work?" METHODS: The search, covering the period 1980-2002, included three databases (Medline, ERIC and EMBASE) and used the keywords: staff development; in-service training; medical faculty; faculty training/development; continuing medical education. Manual searches were also conducted. Articles with a focus on faculty development to improve teaching effectiveness, targeting basic and clinical scientists, were reviewed. All study designs that included outcome data beyond participant satisfaction were accepted. From an initial 2777 abstracts, 53 papers met the review criteria. Data were extracted by six coders, using the standardized BEME coding sheet, adapted for our use. Two reviewers coded each study and coding differences were resolved through discussion. Data were synthesized using Kirkpatrick's four levels of educational outcomes. Findings were grouped by type of intervention and described according to levels of outcome. In addition, 8 high-quality studies were analysed in a 'focused picture'. RESULTS: The majority of the interventions targeted practicing clinicians. All of the reports focused on teaching improvement and the interventions included workshops, seminar series, short courses, longitudinal programs and 'other interventions'. The study designs included 6 randomized controlled trials and 47 quasi-experimental studies, of which 31 used a pre-test-post-test design. KEY POINTS: Despite methodological limitations, the faculty development literature tends to support the following outcomes: Overall satisfaction with faculty development programs was high. Participants consistently found programs acceptable, useful and relevant to their objectives. Participants reported positive changes in attitudes toward faculty development and teaching. Participants reported increased knowledge of educational principles and gains in teaching skills. Where formal tests of knowledge were used, significant gains were shown. Changes in teaching behavior were consistently reported by participants and were also detected by students. Changes in organizational practice and student learning were not frequently investigated. However, reported changes included greater educational involvement and establishment of collegiate networks. Key features of effective faculty development contributing to effectiveness included the use of experiential learning, provision of feedback, effective peer and colleague relationships, well-designed interventions following principles of teaching and learning, and the use of a diversity of educational methods within single interventions. Methodological issues: More rigorous designs and a greater use of qualitative and mixed methods are needed to capture the complexity of the interventions. Newer methods of performance-based assessment, utilizing diverse data sources, should be explored, and reliable and valid outcome measures should be developed. The maintenance of change over time should also be considered, as should process-oriented studies comparing different faculty development strategies. CONCLUSIONS: Faculty development activities appear highly valued by participants, who also report changes in learning and behavior. Notwithstanding the methodological limitations in the literature, certain program characteristics appear to be consistently associated with effectiveness. Further research to explore these associations and document outcomes, at the individual and organizational level, is required.

Cooperative Behavior↗

PubMed2005

What impact will shortened training have on urological service delivery?

INTRODUCTION: Modernisation of Medical Careers dictates a shortening of the training required to achieve consultant status. Precisely what type of work these consultants could be expected to accomplish, and be trained to do, is not clear. The objective of this study was to demonstrate a method of stratifying urological workload so as to determine what a urological trainee, undergoing shortened training, might be expected to do as a consultant and to use this stratification to help manpower planning within the specialty. PATIENTS AND METHODS: A cohort study of all urological activity undertaken over a 3-year period in a single teaching hospital in the UK was performed. All out-patient, in-patient or day-case activity within the urological department was analysed in the years 2000-2002. Urological activity was stratified according to the absolute numbers of patients presenting for different types of out-patient consultation, the grade of complexity of any surgical intervention undertaken, and the theatre resource consumed by the study population. RESULTS: Utilising prospectively collected data, it was possible to aggregate information about the contributions generalist and sub-specialty activity made to the overall workload of a urological unit. Whilst the majority of out-patient activity, and almost 88% of the surgical workload, could be accomplished by consultants undergoing shortened training, 11.9% of specialised urological activity, consuming nearly 43% of the available theatre resource, was outwith the remit of such a specialist. CONCLUSIONS: Shortened training seems able to satisfy the service delivery needs of the majority of out-patient and day-case urological activity. It will not, however, fulfil the need for subspecialty-based training required to cope with the large minority of patients necessitating complex surgical intervention. Specialist training programmes, promoting advanced operative skills, need to be evolved in parallel to shortened training so as to ensure global urological service provision for the future.

Ambulatory Surgical Procedures↗

PubMed1996

Genetic screening for colorectal cancer and intervention.

There is a complex interaction between environmental/dietary factors and genetics underlying the pathogenesis of colon carcinogenesis. Little data exist concerning the impact of diet on the phenotypic expression of genetically linked colon cancer. As a result, it has been difficult to develop rationally designed dietary intervention studies in first-degree relatives of patients with established familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC) and other familial colon cancer syndromes. Only 2 double-blinded, placebo-controlled trials have been published concerning the use of preventive strategies in patients with genetically inherited colorectal cancer syndromes, both in patients with FAP. One study evaluated the effects of vitamin C plus vitamin E with or without a high-dose wheat bran fiber supplement on the recurrence of rectal adenomas. Over a 48-month intervention period, only the wheat bran fiber intervention significantly reduced polyp growth. A second study reported that intervention with the NSAID sulindac for 9 months in young patients with FAP resulted in a significant reduction in both polyp number and size in the rectosigmoid colon. All of the large-scale (i.e., >500 randomized participants) phase III nutrient or chemopreventive agent intervention studies thus far have targeted participants with a history of non-familial, sporadic colorectal adenomas. Current clinical adenoma trials do not measure whether the regimen being tested can prevent genotoxic events occurring in early stages of abnormal cell development that contribute to the eventual formation of adenomas nor whether the agent(s) can inhibit events occurring during the progression of adenomas to carcinomas. Therefore, future clinical trial designs may have to consider (i) lengthening the clinical trial period before adenomas develop, (ii) testing at early patient ages and/or (iii) measuring the growth of adenomas as they progress to carcinomas.

Clinical Trials as Topic↗

PubMed1999

The role of statisticians in intervention trials.

The planning, conduct, analysis and reporting of randomized trials to reliably evaluate an intervention create a complex intellectual and logistical endeavour. Success generally requires active collaboration of a well-trained, experienced and committed statistician. A good intervention trial asks an important question, gets a reliable answer and is honestly reported. Many trials fail on one of these components and some of these failures could have been avoided with better statistical involvement. Many subject matter investigators do not understand how to effectively collaborate with statisticians. The objective here is to outline some of the important responsibilities of the statistician in intervention trials.

Clinical Trials as Topic↗

PubMed1991

Vector population responses to control interventions.

In 1981, Kenyan authorities attempted eradication of tsetse (Glossina pallidipes) from the Lambwe valley, by sequential aerial spraying of endosulfan. Fly populations were reduced by over 99.9% in the main habitats, but recovered to their original levels within one year. In 1986, an Argentine research team attempted local elimination of domestic Triatominae (Triatoma infestans) in an area of Santiago del Estero. House infestation rates were reduced to an apparent zero, but recovered to pre-control levels in two years. In Sri Lanka, a combination of mosquito control with active case detection and treatment reduced malaria incidence to just 17 cases in 1964. Interruption of the programme then saw case incidence return to over 500,000 by 1969. These three examples-from African trypanosomiasis, South American Chagas disease and malaria-all illustrate the same process. Vector populations, infestation rates, and rates of disease transmission, can be reduced. The real problem is not in achieving the initial reduction, but in subsequently either driving the disease to extinction or maintaining it below acceptable levels. And this problem takes us beyond the simple analysis of interventions, into the complex realms of population behaviour set in its political, social and economic context. It seems that we have been too rarely concerned to plan and implement the long term surveillance and selective interventions that are required to translate initial gains into real success. In biological terms, we tend to ignore the complexity and robustness of vector populations and disease transmission cycles, especially their varied capacity to recover from interference. Moreover, in socio-political terms, a reduced problem-even one representing potential for future catastrophe-tends to claim less priority than present problems, even though premature redeployment of resources may abnegate gains already achieved. The problem is strongly compounded by methods of economic analysis where the benefits of avoiding future problems are strongly discounted in favour of short-term temporary gains. This paper seeks to open discussion on these long-term planning issues.

Animals↗