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PubMed1993

Protein and amino acid metabolism in cancer cachexia: investigative techniques and therapeutic interventions.

Cancer cachexia is a complex syndrome characterized primarily by diminished nutrient intake and progressive tissue depletion that is manifest clinically as anorexia and host weight loss. The gradual loss of host protein stores is central to this process. This review outlines the techniques that have been used to evaluate human amino acid metabolism, their application in patients with cancer cachexia, and possible therapeutic interventions designed to overcome alterations in host protein and amino acid metabolism associated with malignant cachexia. The techniques of nitrogen balance and 3-methylhistidine excretion provide indirect estimates of overall nitrogen metabolism and skeletal muscle myofibrillar protein breakdown. Measurement of circulating amino acid concentrations, particularly when combined with assessment of arterial-venous differences and regional amino acid balance allows for investigation of interorgan amino acid metabolism. One of the most significant advances in in vivo amino acid metabolic research has been the development of labeled amino acid tracer studies to evaluate whole body and regional amino acid kinetics. The use of stable and unstable amino acid isotopes in these techniques is reviewed in detail. Virtually all of these techniques have now been employed in the evaluation of human cancer cachexia. The results of studies evaluating amino acid concentrations, regional amino acid balance, and 3-methylhistidine excretion are summarized. The use of regional and whole body kinetic studies in cancer cachexia are reviewed extensively. Most investigators have observed increased rates of whole body protein turnover, synthesis, and catabolism in both weight-stable and weight-losing cancer patients. Some studies have suggested a relationship between the extent of disease and the degree of aberration in amino acid kinetic parameters. Investigators have attempted to reverse some of these alterations by provision of substrate (nutritional support) or administration of specific pharmacologic or anabolic agents such as hydrazine sulfate, insulin, growth hormone, and beta-2 agonists. The role of total parenteral nutrition (TPN) in cancer and its effects on protein and amino acid kinetics and tumor growth are addressed. The possible benefits of specific amino acid nutritional formulations with increased branched chain amino acids, arginine, and glutamine are reviewed. Although many of these approaches appear promising, significant impact on clinically definable parameters remains to be demonstrated. A better understanding of the underlying protein catabolic mechanisms of cancer cachexia will likely lead to more effective therapies to reverse the protein calorie malnutrition associated with cancer cachexia.

Amino Acids↗

PubMed1994

Percutaneous excimer laser coronary angioplasty: results in the first consecutive 3,000 patients. The ELCA Investigators.

OBJECTIVES: We report the comprehensive results of the first consecutive 3,000 patients treated in an excimer laser coronary angioplasty registry. BACKGROUND: Excimer laser coronary angioplasty involves the use of a pulsed, 308-nm ultraviolet laser transmitted by optical fibers to reduce coronary stenoses. Preliminary reports have described safety and efficacy profiles in small numbers of patients. METHODS: Patients were enrolled in a prospective, nonrandomized manner. The catheters used were 1.3, 1.6, 2.0, 2.2 and 2.4 mm in diameter, at energy densities up to 70 mJ/mm2. Procedures were performed by standard angioplasty technique with conventional guide catheters. RESULTS: Seventy-five percent of patients were male, 68% were in Canadian Cardiovascular Society functional class III or IV and the cohort included 3,592 lesions. Procedural success (final stenosis < or = 50% without in-hospital Q wave myocardial infarction, coronary artery bypass surgery or death) was 90% and did not differ between the first 2,000 and the last 1,000 patients treated. There was no significant difference in success or complication rates with respect to lesion length, nor were there differences between selected complex and simple lesions. Complications included in-hospital bypass surgery (3.8%), Q wave myocardial infarction (2.1%) and death (0.5%). Coronary artery perforation occurred in 1.2% of patients (1% of lesions) but significantly decreased to 0.4% in the last 1,000 patients (0.3% of lesions). Angiographic dissection occurred in 13% of lesions, transient occlusion in 3.4% and sustained occlusion in 3.1%. Comprehensive lesion morphologic data collected in the latter portion of the study showed the procedure predominantly limited to American College of Cardiology-American Heart Association type B2 and C lesions, with no significant difference in short-term outcome between groups. CONCLUSIONS: Excimer laser angioplasty can be safely and effectively applied, even in a variety of complex lesions not well suited for percutaneous transluminal coronary angioplasty. These types may include aorto-ostial, long lesions, total occlusions crossable with a wire, diffuse disease and vein grafts. Most recent data show a trend for the selection of predominantly complex lesions and a reduction in the incidence of perforation. This procedure may broaden the therapeutic window for the interventional treatment of selected complex coronary artery disease.

Angioplasty, Balloon, Coronary↗

PubMed2006

Sexual risk behavior among people living with HIV/AIDS in Togo.

Since HIV in Africa is spread primarily through unprotected sex, safe sex practices such as condom use can reduce HIV spread significantly. Nevertheless, because sexual behavior involves complex dynamics, condom use is not an easy option for many people in Africa despite years of condom distribution intervention. In fact, the complex nature of sexuality complicates efforts to combat HIV spread and limits the effectiveness of many prevention efforts. This paper uses theoretical explanations--social representation theory, situated rationality theory, and social action theory--to examine the patterns of sexual risk behavior and the underlying reasons and rationalization among people living with HIV/AIDS in Lomé, Togo. Qualitative interviews were conducted with 151 people living with HIV/AIDS, recruited from 3 HIV/AIDS centers. The results of this in-depth study suggest that although people living with HIV/AIDS may be aware of the risk of infecting their sexual partners, they deliberately ignore the risk because other considerations, such as wanting a baby, take precedence. Consequently, condom access is inadequate to change risky sexual behavior that spreads HIV. It must be supplemented with adequate empowerment.

Adult↗

PubMed2006

Taenia solium: the complex interactions, of biological, social, geographical and commercial factors, involved in the transmission dynamics of pig cysticercosis in highly endemic areas.

If a programme for the control of pig cysticercosis is to be effective it has to be based on good data on the local epidemiology of Taenia solium. In 2002-2003, in a cross-sectional study of pig cysticercosis in the Mexican state of Morelos, 1747 pigs that had been born and reared in rural areas of the state were checked for T. solium infection by tongue inspection. The prevalence of cysticercosis in the pigs was found to vary from 0% to 30% according to the municipality from which the pigs came. Although prevalence appeared to be unaffected by the socio-economic status of the municipality, it was relatively high in areas that lacked latrines, and in pigs that were castrated, pregnant and/or of the native (rather than an imported) breed. The results of questionnaire-based interviews with pig owners revealed that most (64.5%) of the rural pigs, whether infected or not, are slaughtered and consumed within the locality where they were reared. The other pigs are sold at low prices to organised traffickers who take the uninspected pigs to neighbouring urban areas for sale. The observed complexity in the factors affecting the transmission of T. solium to the pigs of Morelos state calls for an intervention strategy of matching complexity, initially targeted at those villages with the highest prevalences of pig cysticercosis. The road transport of pigs needs to be better regulated, and the vaccination and genetic improvement of the rural pigs, and delaying the castration of the boars, should all be considered.

Age Distribution↗

PubMedDate not supplied

Critical elements in the process of decision making: a nursing perspective.

Decision making is a fundamental element of nursing work, one that is essential to understand as organizations explore cost effective ways to deliver quality health care. While the importance of decision making has been well articulated, previous descriptions of nursing work have had difficulty describing completely this cognitive component. This paper identifies critical elements within the process of nursing decision making that have not been addressed adequately within current decision making frameworks. In this exploratory research, nursing personnel described their work; qualitative content analysis was used to categorize components of nursing decision making within these descriptions. Revealed are complex nursing decisions that occur after the selection of nursing intervention, and prior to the implementation of that intervention. These decisions address the complex network of interactions involved with enactment of the nursing role, the repertoire of leadership skills such as collaboration, negotiation, and delegation required to elicit the involvement of other individuals; discretionary decisions made in the allocation of resources; priority setting; and strategizing. These findings have implications for nursing competency and quality of care, cost-effective delivery of health care, and nursing education.

Attitude of Health Personnel↗

PubMed1999

Duplex ultrasound insertion of inferior vena cava filters in multitrauma patients.

BACKGROUND: Techniques for placement of inferior vena cava (IVC) filters have undergone continued evolution from open surgical exposure of the venous insertion site to percutaneous insertion in most cases today. However, the required transport either to an operating room or interventional suite can be complex and potentially hazardous for the multiply injured trauma patient who may require ventilator support, controlled intravenous infusions, or skeletal immobilization. Increased experience with color-flow duplex scanning for routine IVC imaging and portability of ultrasound equipment have suggested the usefulness of duplex-guided IVC filter insertion (DGFI) in critically ill trauma and intensive care unit (ICU) patients. METHODS: A total of 25 multitrauma/ICU patients were considered for DGIF. Screening color-flow duplex scans were performed on all patients, and obesity or bowel gas prevented ultrasound imaging in 2 cases, leaving 23 patients suitable for DGFI. In each case, the IVC was imaged in the transverse and longitudinal planes. The right renal artery was identified as it passed posterior to the IVC and was used as a landmark of the infrarenal segment of the IVC. All procedures were performed at the bedside in a monitored ICU setting using percutaneous placement of titanium Greenfield filters. Duplex scanning after insertion was used to document proper placement, and circumferential engagement of the filter struts in the IVC wall. An abdominal radiograph was also obtained in each case to confirm proper filter location. Duplex ultrasound imaging was repeated within 1 week of insertion to assess IVC and insertion site patency. RESULTS: DGFI was successful in all cases. The filter was deployed at a suprarenal level in one case, as was recognized at the time of postprocedural scanning. Three patients died as a result of their injuries but there were no pulmonary embolism deaths. Repeat duplex scanning was obtained in 17 patients, and revealed no case of IVC or insertion site thrombosis. CONCLUSIONS: Vena caval interruption can be safely performed under ultrasound guidance in a monitored, ICU environment. In selected multiply injured trauma patients, this will reduce the risk, complexity and cost of transport for these critically ill patients. DGFI also reduces procedural costs compared with an operating room or interventional suite, and eliminates intravenous contrast exposure. Preprocedural scanning is essential to identify patients suitable for DGFI, and careful attention must be paid to the known ultrasonographic anatomical landmarks.

Adult↗

PubMed1988

Educational and behavioral strategies for improving medication compliance in juvenile rheumatoid arthritis.

Compliance with regimens for chronic conditions such as juvenile rheumatoid arthritis (JRA) is often poor, and the potential benefits of therapy are thus compromised. In this study a compliance intervention involving educational and behavioral strategies was shown effective in improving medication compliance for two of three patients with JRA. The intervention was introduced in a time-lagged fashion (multiple baseline design) with repeated measures of compliance. The strategies were less complex than other compliance interventions, such as token reinforcement strategies, and therefore would be more practical in pediatric outpatient settings.

Adolescent↗

PubMed1998

Dietary interventions of human carcinogenesis.

The diet is a complex mixture that is associated with approximately 30% of human cancer in the U.S. Extensive laboratory studies indicate that the diet is composed of many mutagens/carcinogens as well as antimutagens/anticarcinogens. Overwhelming evidence from epidemiological studies indicates that a diverse diet that is high in fruits and vegetables and low in certain fats, along with moderate caloric intake and exercise, is most closely associated with reduced cancer risk. Dietary intervention studies using complex food items (fruits, vegetables, and fats) support these epidemiological observations; dietary interventions using single compounds (vitamins, antioxidants, etc.) have generally not. Estimates suggest that appropriate dietary changes could reduce the percentage of deaths due to prostate, colorectal, pancreatic, and breast cancer by >/=50%.

Anticarcinogenic Agents↗

PubMed2002

Evaluating comprehensive tobacco control interventions: challenges and recommendations for future action. Report of a workshop convened by the Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health.

This report summarises a workshop on evaluation of tobacco control interventions convened in Santa Fe, New Mexico in June 2001 by the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health. The evaluation of such interventions is filled with complexities which intensify as the scope of tobacco control programmes increase. Evaluators are charged with the task of determining the effect of interventions in terms of magnitude of change, the relative contribution of programme components, and the relative impact for different populations. The report explores the theoretical foundations of tobacco control evaluation and provides a conceptual framework for capturing elements necessary for evaluating interventions. It then provides two case studies of challenges encountered when evaluating large scale tobacco control initiatives. The report summarises the discussions and recommendations of the workshop's three working groups. Participants were certain and unanimous that the current state of evaluation research must be improved to evaluate accurately the dynamic nature of comprehensive tobacco control programmes. Hierarchical or multilevel modelling approaches were seen as promising for further research. Coordinated evaluation will provide a better understanding of local, state, and national tobacco control efforts.

Guidelines as Topic↗

PubMed1993

Increasing resource allocation and research into tobacco control activities: a comprehensive approach including primary prevention, treatment and brief intervention.

The range of tobacco control activities should be viewed as essential parts of a complex multi-component puzzle. Intervention strategies designed to address tobacco control should be comprehensive and include both primary and secondary prevention activities and be multi-faceted and capable of bringing about change at both the individual and broader social and cultural levels. In this paper I argue for a mutually inclusive framework in which the various components contribute in important and different ways. I examine the prevalence of smoking and identify the high risk groups, then I examine the range of available strategies and present the evidence for their success. I discuss the primary prevention approaches such as warning labels, taxes, price increases, workplace bans, education in schools, mass media and self-help materials, as well as brief interventions and treatment strategies which are conducted at the worksite, general practice and specialized cessation clinics. The areas for future research are delineated for increased resource allocation and include: the best ways to disseminate brief interventions to smokers, methods to motivate smokers; training of health professionals to deliver brief interventions; enhancing quitting and access to existing treatment resources among specific disadvantaged minority groups, e.g. migrants, unemployed youth, the effect on smoking prevalence of warning labels on cigarette packets and price rises on cigarettes.

Journal Article↗

PubMed2001

Alexithymia: a challenge for mental health nursing practice.

Alexithymia, under-recognized and under-diagnosed, presents a significant challenge to mental health nurses. This article explores the alexithymia construct, and presents the view that better recognition of this trait will allow nursing intervention to be more specific and effective. The mental health nurses' role is potentially the cornerstone of successful intervention with this group of complex patients, who do poorly when offered conventional, insight-orientated interventions. Standard psychotherapeutic treatments need to be modified in order to focus on increasing the ability to self-regulate affect, otherwise treatment may be both counterproductive and potentially damaging.

Affective Symptoms↗

PubMed2006

Involving service users in interprofessional education narrowing the gap between theory and practice.

Calls for greater collaboration between professionals in health and social care have led to pressures to move toward interprofessional education (IPE) at both pre- and post-registration levels. Whilst this move has evolved out of "common sense" demands, such a multiple systems approach to education does not fit easily into existing traditional educational frameworks and there is, as yet, no proven theoretical framework to guide its development. A research study of an IPE intervention at the University of Liverpool in the UK drew on complexity theory to conceptualize the intervention and to evaluate its impact on a group of approximately 500 students studying physiotherapy, medicine, occupational therapy, nursing and social work. The intervention blended a multidisciplinary (non-interactive) plenary with self-directed e-learning and a series of interdisciplinary (interactive) workshops. Two evaluations took place: the first when the workshops were facilitated by trained practitioners; the second when the practitioners co-facilitated with trained service users. This paper reports findings from the second evaluation which focused on narrowing the gap between theory and practice. A multi-stakeholder evaluation was used including: students' reflective narratives, a focus group with practitioners and individual semi-structured interviews with service users. Findings showed that service users can make an important contribution to IPE for health and social care students in the early stages of their training. By exposure to a service user perspective, first year students can begin to learn and apply the principles of team work, to place the service user at the centre of the care process, to make connections between theory and "real life" experiences, and to narrow the gap between theory and practice. Findings also revealed benefits for facilitators and service users.

Clinical Competence↗

PubMed2005

Criteria for the systematic review of health promotion and public health interventions.

Systematic reviews of public health interventions are fraught with challenges. Complexity is inherent; this may be due to multi-component interventions, diverse study populations, multiple outcomes measured, mixed study designs utilized and the effect of context on intervention design, implementation and effectiveness. For policy makers and practitioners to use systematic reviews to implement effective public health programmes, systematic reviews must include this information, which seeks to answer the questions posed by decision makers, including recipients of programmes. This necessitates expanding the traditional evaluation of evidence to incorporate the assessment of theory, integrity of interventions, context and sustainability of the interventions and outcomes. Unfortunately however, the critical information required for judging both the quality of a public health intervention and whether or not an intervention is worthwhile or replicable is missing from most public health intervention studies. When the raw material is not available in primary studies the systematic review process becomes even more challenging. Systematic reviews, which highlight these critical gaps, may act to encourage better reporting in primary studies. This paper provides recommendations to reviewers on the issues to address within a public health systematic review and, indirectly, provides advice to researchers on the reporting requirements of primary studies for the production of high quality systematic reviews.

Humans↗

PubMed2000

Approach to the management of complex hepatic injuries.

BACKGROUND: Complex hepatic injuries American Association for the Surgery of Trauma Organ Injury Scale grades IV and V incur high mortality rate ranging from 40 to 80%, respectively. The objective of this study is to assess the clinical experience with an aggressive approach to the management of these, the most complex of hepatic injuries. METHODS: This is a retrospective 6-year study (1992-1997) at an American College of Surgeons urban Level I trauma center of patients sustaining complex hepatic injuries whose interventions included surgery, angiographic embolization, endoscopic retrograde cholangiopancreatography plus biliary stenting and percutaneous computed tomographic-guided drainage. The main outcome measure was survival. RESULTS: A total of 22 patients sustaining complex hepatic injuries; mean age of 26 years (range, 10-52 years), mean Revised Trauma Scale score of 9.9, mean Injury Severity Score of 32 (range, 16-75), American Association for the Surgery of Trauma - Organ Injury Scale grade IV (13 cases); grade V (9 cases). Mean estimated blood loss was 4,600 mL; mean number of units of blood transfused was 15. The patients underwent the following interventions: surgery (n = 22), re-operated (n = 13), mean number of operations 1.6 (range, 1-4), extensive hepatotomy and hepatorrhaphy (n = 17), nonanatomic resection (n = 7), formal hepatectomy (n = 4), packing (n = 10), direct approach to hepatic veins (n = 3); angiographic embolization (n = 15); endoscopic retrograde cholangiopancreatography and stenting (n = 5); computed tomographic guided drainage (n = 6). Mean length of stay in the intensive care unit was 21 days (range, 2-134 days), mean hospital length of stay was 40 days (range, 2-147 days). Overall mortality rate was 14% (3 of 22 cases), hepatic mortality rate was 9% (2 of 22 cases), mortality rate by injury grade was 8% grade IV (1 of 13 cases) and 22% grade V (2 of 9 cases). CONCLUSION: In this select patient population, improvements in mortality rates can be achieved with an aggressive approach to the management of complex hepatic injuries, including surgery, early packing, angiographic embolization, endoscopic retrograde cholangiopancreatography and stenting of biliary leaks, and drainage of hepatic abscesses.

Adolescent↗

PubMedDate not supplied

Anesthesia practice and clinical trends in interventional radiology: a European survey.

PURPOSE: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends. METHODS: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived from a similar survey of interventional practice in the United States. RESULTS: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds. CONCLUSION: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.

Anesthesia↗

PubMed2004

Interventions for seropositive injectors-research and evaluation: an integrated behavioral intervention with HIV-positive injection drug users to address medical care, adherence, and risk reduction.

BACKGROUND: Behavioral interventions to address the complex medical and HIV risk reduction needs of HIV-seropositive (HIV-positive) injection drug users (IDUs) are urgently needed. We describe the development of Interventions for Seropositive Injectors-Research and Evaluation (INSPIRE), a randomized controlled trial of an integrated intervention for HIV-positive IDUs, and the characteristics of the baseline sample. METHODS: HIV-positive IDUs were recruited from community settings in 4 US cities. After completing a baseline assessment, participants who attended the first session were randomly assigned to (1) a 10-session peer mentoring intervention designed to improve utilization of HIV care, to improve adherence to HIV medications, and to reduce sexual and injection risk or (2) an 8-session videotape control. Periodic follow-up for 12 months is ongoing. RESULTS: A total of 1161 HIV-positive IDUs completed the baseline assessment, and 966 (83%) were randomized. Retention rates are greater than 80% for all follow-up periods. Approximately 79% of baseline participants reported a recent medical visit, 49% were taking highly active antiretroviral therapy, and 19% had an undetectable viral load. Use of injection and noninjection substances was prevalent, and sexual and injection risks were each reported by more than 25% of participants. CONCLUSION: There is a need for an integrated intervention for HIV-positive IDUs, and these data show the acceptability of such an approach.

Educational Status↗

PubMed1985

[Reconstructive interventions following femoral fractures].

The complex and simple fractures seen in polytrauma patients after initial treatment sometimes show signs of poor setting and non-union with possible unfavourable functional consequences making reconstructive surgery necessary. In this report characteristic posttrauma problems and reconstructive surgery of the proximal femur, the femoral shaft and the distal femur are discussed. Possibilities other than prothesis or joint fusion, especially in the hip or knee joint, should be considered.

Bone Plates↗

PubMedDate not supplied

[Dental pathology in malformation syndromes: the methodology and intervention timing].

Due to the complexity and potential vulnerability of the cranio-facial area (skull, face, nose, oral cavity), specific alterations of this region are associated to genetic and acquired malformations in a high percentage of cases (75%). Often, the specificity and extent of the pathological symptoms occurring in the cranio-facial area are the dominant aspects of the malformation syndrome according to which it is classified. When multiple development anomalies in a newborn suggest the existence of a syndrome, the patient should be placed in the care of a pediatrician, who, together with a team of specialists, will follow the child and face the various problems related to the syndrome at the right time. The frequent marked involvement of the craniofacial area in malformation syndromes suggests the opportunity of a specialist methodology to standardize odontostomatological therapy.

Abnormalities, Multiple↗