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PubMed2004

Surgical management of complex intracranial aneurysms.

Despite the improvements in increasing popularity of endovascular therapy for intracranial aneurysms, there remain a large number of these lesions that currently are not amenable to endovascular therapy. As endovascular therapy becomes more popular, those aneurysms requiring surgical intervention will become increasingly complex. To manage these challenging lesions, neurosurgeons must use all available innovations and advances, including diagnostic, technical and perioperative adjuncts. In this review article, we discuss limitations of endovascular therapy, the populations of aneurysms that continue to require surgical treatment, the factors that make an aneurysm complex and the multiple adjuncts utilized to successfully treat these challenging lesions.

Cerebral Angiography↗

PubMed2003

Pericardial tamponade complicating central venous interventions.

Cardiac tamponade is defined as an accumulation of fluid within the pericardial sac that is large enough to impair the diastolic filling of the ventricles. There are numerous causes, including cardiac disease, malignancy, and trauma (penetrating, blunt, and iatrogenic). With increasing complexity of percutaneous endovascular interventions, interventional radiologists must learn to recognize the preexisting and iatrogenic presence of cardiac tamponade during procedures and be familiar with its treatment. Two cases of pericardial tamponade complicating central venous interventions are described. In addition, the clinical condition is discussed and its diagnosis and treatment are reviewed.

Cardiac Tamponade↗

PubMed2005

Angiographic and clinical outcomes of polytetrafluoroethylene-covered stent use in significant coronary perforations.

Coronary perforations remain a rare but life-threatening complication of percutaneous coronary intervention. In the setting of complex coronary lesions, 14 of 25 consecutive perforations related to percutaneous coronary intervention were managed with stents covered with polytetrafluoroethylene (PTFE), and 11 were managed conventionally with reversal of anticoagulation and prolonged balloon inflation. Procedural success was achieved in 71.4% (10 of 14 perforations) of the PTFE arm compared with 27.3% (3 of 11 perforations) in the standard management arm (p = 0.047). Smaller final percent diameter stenosis and postprocedural cessation of dye extravasation were achieved with PTFE-covered stents. No delayed cardiac tamponade or in-hospital mortality was reported among patients in the PTFE group.

Aged↗

PubMed2002

Highly active antiretroviral therapy adherence: the patient's point of view.

There is a widespread acknowledgment that successful treatment with highly active antiretroviral therapy (HAART) requires the patient to maintain consistent adherence to the prescribed regimen on a long-term basis. Adherent patients have been shown to have reduced viral loads and increased CD4 counts, live longer, and have better quality-adjusted survival. The consequences of nonadherence are also obvious: poorer adherence leads to inadequate viral suppression and continued disease progression. With the astonishing advances in medical therapeutics during the past two decades, one may expect a similar proliferation of studies of the nature of nonadherence and tests of strategies to help patients overcome it. However, the literature and the know-how concerning interventions to improve adherence are still surprisingly weak. The unique challenges posed by combination therapies for HIV and AIDS require healthcare providers to address the issues created by adherence to complex regimens through multifactorial interventions tailored to patients' needs.

Antiretroviral Therapy, Highly Active↗

PubMed1995

Pharmacological effects of oral enzyme combinations.

Combinations of hydrolytic enzymes have been used for therapy of variety of diseases for a long time, their pharmacology, however, is being recognized only in the course of last decades. In the article, the following pharmacological effects of combinations of oral hydrolytic enzymes are reviewed: fibrinolytic, hemorheologic, anti-edematous, anti-inflammatory, activation of macrophages and NK cells, modulation of adhesion molecules, cytokines and immune complexes. Pharmacological effects are classified on four levels: biochemical, physiological, medical, and immunological. A spectrum of indications of enzyme therapy is inferred from the pharmacological effects: inflammations, traumatological events, surgical interventions, autoimmune and immune complex diseases, rheumatological diseases, viral infections and malignant tumors.

Administration, Oral↗

PubMed2002

Complex regulation of thyroid hormone action: multiple opportunities for pharmacological intervention.

The thyroid hormone (TH; 3,3',5,5'-tetra-iodothyronine and 3,3',5'-triiodothyronine) regulates growth, development, and critical metabolic functions. Thyroid diseases are among the most prevalent group of metabolic disorders in the Western world. TH exerts effects through complex biological pathways, which offer a wealth of opportunities to pharmacologically intervene in TH signalling at numerous steps. These include biosynthesis, cell-specific uptake or export (involving L-type amino acid transporter, organic anion transporter, organic cation transporter, or multidrug resistance transporter), as well as nuclear targeting and actions (the latter including TH receptor binding and histone acetylation/deacetylation). Such processes represent potentially important pharmacological targets for the design of novel or improved therapies for TH disorders, obesity, and cardiovascular diseases.

Receptors, Thyroid Hormone↗

PubMed2006

Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks?

BACKGROUND: Out-of-hospital rescuers often perform tracheal intubation (TI) prior to other cardiopulmonary resuscitation (CPR) interventions. TI is a complex and error-prone procedure that may interfere with other key resuscitation tasks. We compared the effects of TI versus esophageal tracheal combitube (ETC) insertion on the accomplishment of other interventions during simulated cardiopulmonary resuscitation. METHODS: In this prospective trial using a human simulator, two-paramedic teams simulated resuscitation of a ventricular fibrillation cardiopulmonary arrest using standard Advanced Cardiac Life Support guidelines. In each of two trials, teams used either TI or ETC as the primary airway device. Following delivery of three rescue shocks, we measured time intervals to successful airway placement, intravenous (IV) line insertion, drug administration, delivery of fourth rescue shock and completion of all four tasks. We also measured the total time without chest compressions. We compared task completion times using non-parametric statistics (Wilcoxon signed-ranks test) with a Bonferroni-adjusted p-value of 0.008. RESULTS: Twenty teams each completed two scenarios. Participants required a median of 172.5 s (IQR: 146.5-225.5) to accomplish all four tasks. Elapsed time to airway placement was significantly less for ETC than TI (median difference 26.5 s (IQR 13-44.5), p=0.002). Time without chest compressions was less for ETC than TI (median difference 8.5 s (IQR 2.5-23.5), p=0.005). There were no differences between ETC and TI in times to IV placement (median difference 23.5 s (IQR -20 to 61), p=0.11), drug delivery (39.5 s (IQR -18 to 63), p=0.07), delivery of fourth rescue shock (39.5 s (IQR -21.5 to 87.5), p=0.07) or completion of all four tasks (33 s (IQR -11 to 74.5), p=0.08). CONCLUSION: Compared with TI, ETC reduced time to airway placement and time without chest compressions, but did not affect elapsed times to accomplish other interventions. Additional time differences may be realized if translated to clinical out-of-hospital conditions.

Cardiopulmonary Resuscitation↗

PubMed2002

Assessing change in early intervention programs for children with autism.

Assessing the efficacy of any intervention can be a difficult task. In the case of children with autism who require comprehensive and long-lasting interventions, the task becomes even more difficult. In this paper, intervention studies based on comprehensive interventions for young children with autism are reviewed and examined in reference to elements that are essential to a well-designed treatment study, e.g., randomization/matching procedures, and outcome measures. Given the complexity of these comprehensive intervention programs, and the few data available on interventions with clear empirical validation, a plea is made for studies to consider the active ingredients or component parts of an intervention, e.g., number of hours, type of setting, and teaching approach. Suggestions are further made for improving future studies, including more rigorous designs, and measuring change.

Autistic Disorder↗

PubMed2001

Reducing medication regimen complexity: a controlled trial.

OBJECTIVE: To determine if a visual intervention (medication grid) delivered to physicians can reduce medication regimen complexity. DESIGN: Nonrandomized, controlled trial. SETTING: Veterans Affairs medical center. PATIENTS/PARTICIPANTS: Eight hundred thirty-six patients taking at least 5 medications at the time of admission and the 48 teams of physicians and students on the general medicine inpatient service. INTERVENTION: For intervention patients, a medication grid was created that displayed all of the patients' medicines and the times of administration for 1 week. This grid was delivered to the admitting resident soon after admission. MEASUREMENTS AND MAIN RESULTS: For the patients of each team of physicians, we calculated the change in the average number of medications and doses from admission to discharge. The number of medications in the intervention group decreased by 0.92 per patient, and increased by 1.65 in the control group (P <.001). The mean number of doses per day in the intervention group decreased by 2.47 per patient and increased by 3.83 in the control group (P <.001). CONCLUSIONS: This simple intervention had a significant impact on medication regimen complexity in this population. Apparently, physicians were able to address polypharmacy when the issue was brought to their attention.

Adult↗

PubMed2003

Development and first patient trial of a surgical robot for complex trajectory milling.

OBJECTIVE: Today's surgical robots normally perform "simple" trajectories, e.g., assisting as tool-holding devices in neurosurgery, or milling linear paths for cavities in total hip replacement. From a clinical point of view, it is still a complex undertaking to implement robots in the operating room. Until now, robot systems have not been used in patient trials to mill "complex" trajectories, which involve many positional and orientation changes and are often necessary in cranio-maxillofacial (CMF) surgery. This paper presents the RobaCKa surgical robot system, which allows more precise execution of surgical interventions and milling of "complex" trajectories. MATERIALS AND METHODS: The main components of the RobaCKa system are a (former) CASPAR robot system, a POLARIS system, and a force-torque sensor. RESULTS: In the first patient trial (April 2003) the planned trajectory was executed with an error of 0.66 +/- 0.2 mm. CONCLUSIONS: The use of former industrial robots for surgical applications is possible but complex. The advantages are improved precision and quality and the possibility of documentation. The use of such systems is normally limited to research institutions or large clinics, because it is hardly possible to implement the necessary technical and logistic efforts in routine surgical work.

Craniotomy↗

PubMed1993

Oocyte maturation in humans: the role of gonadotropins and growth factors.

OBJECTIVE: To determine the effect of FSH/LH in vivo and epidermal growth factor (EGF) and insulin-like growth factor I (IGF-I) in vitro on human oocyte maturation. DESIGN: Oocyte-cumulus complexes were harvested from three different groups of patients: [1] unstimulated ovaries from women undergoing surgery; [2] multifollicular development achieved with a combination of FSH and LH in the absence of an ovulatory dose of hCG; and [3] oocyte-cumulus complexes retrieved after appropriate ovarian stimulation with FSH/LH and hCG for IVF purposes. SETTING, PATIENTS: In vitro fertilization program and patients undergoing surgery for benign disorders at the Instituto Valenciano de Infertilidad, Valencia, Spain. INTERVENTIONS: Oocyte-cumulus complexes from unstimulated ovaries collected at surgery by follicular puncture and washing. Oocyte-cumulus complexes from stimulated cycles obtained by ultrasound-guided transvaginal aspiration. Oocyte-cumulus complexes cultured in vitro in the absence or presence of different concentrations of EGF and IGF-I. MAIN OUTCOME MEASURE: Germinal vesicle breakdown and metaphase-II stage after 24 and 48 hours. RESULTS: Comparison of the spontaneous resumption of meiosis and metaphase II oocytes among groups showed significant differences between unstimulated and stimulated ovaries after 24 and 48 hours in culture. Administration of hCG accelerated the percentage of maturation by 24 hours. Further incubation of unstimulated oocyte-cumulus complexes with EGF and IGF-I significantly increased the percentage of metaphase-II oocytes after 24 and 48 hours in culture. CONCLUSIONS: Epidermal growth factor and IGF-I are able to augment spontaneous maturaion in immature human oocytes. Because spontaneous maturation is mainly observed when follicles have been exposed to pharmacological doses of hMG, it is suggested that increasing FSH levels within the follicle is coincident with the generation of a positive signal necessary to complete oocyte maturation in humans. This signal may be linked to the dynamics of growth factors within the follicle itself.

Adult↗

PubMedDate not supplied

A review of quantitative studies of adherence to mental health clinical practice guidelines.

Mental health clinical practice guidelines have proliferated, but there is little evidence regarding the degree to which they are actually implemented in clinical practice. The goal of this study was to locate and review all peer-reviewed reports published through 2000 that provide quantitative information on rates of adherence to specific mental health guidelines. A literature search yielded 41 pertinent studies. These studies were of three types: 26 were cross-sectional investigations performed after the release of guidelines, six were conducted before and after release of guidelines without any specific intervention (pre/post), and nine involved a controlled trial of a specific intervention. Only 37% were conducted in the mental health specialty sector. Adequate adherence was found in 27% of the cross-sectional and pre/post studies but in 67% of the controlled trials. Successful interventions tended to be complex, involving system redesign or additional resources. Only six of 13 investigations (46%) that also measured patient outcome found that better outcome was associated with greater guideline adherence. Several studies showed that after cessation of interventions, adherence rates returned to preintervention levels. Thus, evidence indicates that guideline adherence is not high without specific intervention, but that certain interventions (typically multifaceted and resource-intensive ones) improve adherence. However, the public health challenge is to design and implement interventions that are sustainable in general clinical practice.

Attitude of Health Personnel↗

PubMedDate not supplied

A brief overview and introduction to artificial neural networks.

This article is designed to acquaint professionals working in the field of substance use intervention with a range of artificial intelligence nonlinear, powerful tools, artificial neural networks, concepts, and paradigms. The family of ANNs, when appropriately selected and used, permits the maximization of what can be derived from available data as well as our studying and understanding the many people, processes, and phenomena which comprise substance use and its intervention. The latter represent complex, dynamic, multidimensional phenomena which are unpredictable and uncontrollable in the traditional "cause and effect" sense. As such they are likely to be nonlinear in their very essence. Using linear-based paradigms for planned intervention with nonlinear phenomena brooks the all-too-common possibility of using inappropriate intervention paradigms and/or drawing misleading conclusions about what is and/or has happened.

Alcoholism↗

PubMedDate not supplied

[Cholera in Kazan. Organization and implementation of cholera control interventions].

Data on emergent epidemiological analysis of the cholera outbreak in Kazan are presented. A version of the cholera focus emergence was confirmed, namely water route of transmission as a result of bathing in a water reservoir where sewage waters had penetrated. The outbreak had local and acute character. The complex of cholera control interventions aimed at localization and liquidation of the focus proved to be effective.

Cholera↗

PubMed1997

Feasibility of using volunteer research staff to deliver and evaluate a low-fat dietary intervention: the American Cancer Society Breast Cancer Dietary Intervention Project.

This report presents the results of a study to examine the feasibility of using volunteers as research staff for a randomized trial of whether reduction in dietary fat intake could prevent or delay breast cancer recurrence. We examined whether volunteers could be trained to recruit study participants, deliver a complex and intensive dietary intervention, and monitor intervention effectiveness. Volunteers, who were mostly employed nurses and dietitians, screened 521 women, of whom 293 were eligible and 144 were randomized. Participants were postmenopausal women under age 75, who had recently been diagnosed with breast cancer and treated with either mastectomy or lumpectomy. At 1 year postrandomization, 77% of intervention and 75% of control participants remained active in the study. Intervention effects (change in intervention group minus change in control group) at 3, 6, and 12 months postrandomization were 5.9, 8.4, and 7.2% energy from fat and 1.7, 3.0, and 3.5 kg body weight (all P < 0.001). These results were similar to those from other studies that used paid, professional staff to deliver and monitor interventions. Results from this feasibility study suggest that volunteer-based health organizations can provide research opportunities for health practitioners and can conduct high-quality research at lower costs.

Adult↗

PubMed2002

Traversing boundaries: clinical ethics, moral experience, and the withdrawal of life supports.

While many have suggested that to withdraw medical interventions is ethically equivalent to withholding them, the moral complexity of actually withdrawing life supportive interventions from a patient cannot be ignored. Utilizing interplay between expository and narrative styles, and drawing upon our experiences with patients, families, nurses, and physicians when life supports have been withdrawn, we explore the changeable character of "boundaries" in end-of-life situations. We consider ways in which boundaries imply differences--for example, between cognition and performance--and how the encounter with boundaries can generate altered meanings important for understanding decisions and actions in these contexts. We conclude that the reliance on mere roles to support the moral weight of withdrawing medical interventions is inadequate. Roles that lead us to such moments are exceeded by the responsibility encountered in such moments. And here, we suggest, is the momentous character of withdrawal: it presents the grave astonishment, the trembling awe, in the "not-being-there" of the other in death.

Ethicists↗

PubMed2006

Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions.

Diagnosis in psychiatry increasingly struggles to fulfil its key purposes, namely, to guide treatment and to predict outcome. The clinical staging model, widely used in clinical medicine yet virtually ignored in psychiatry, is proposed as a more refined form of diagnosis which could restore the utility of diagnosis, promote early intervention and also make more sense of the confusing array of biological research findings in psychiatry by organizing data into a coherent clinicopathological framework. A selective review of key papers in clinical medicine and psychiatry which describe clinical and clinicopathological staging, and a range of related issues. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry just as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of disorder, and they could be selected on clear-cut risk/benefit criteria. Biological variables and a range of candidate risk factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorder could be greatly clarified. A clinicopathological framework could be progressively constructed. Clinical staging with a restructure across and within diagnostic boundaries with the explicit operationalization of criteria for extent and progression of disorder should be actively explored in psychiatry as a heuristic strategy for the development and evaluation of earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders.

Combined Modality Therapy↗

PubMed2004

Developing the role of the social worker as coordinator of services at the surrogate parenting center.

A law permitting couples to conceive biological children through surrogacy was legislated in Israel in March 1996. The Rambam Medical Center has established the only nonprofit Surrogate Parenting Center at a public hospital in Israel. The multidisciplinary teamwork at the Center is case managed by a social worker. An important role of the social work intervention is consultation and support for the couple and the surrogate at all stages of the process. The case study presented in the article illustrates the need for sensitive and professional intervention due to the complexity of the surrogacy process and the crisis it involves for both the surrogate and the couple. In light of the growing parenting surrogacy cases in the United States, Europe, and Israel, a structured social work intervention model is described, which may be implemented at public or private surrogate parenting centers.

Adaptation, Psychological↗