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PubMed2000

Rationale for directional atherectomy and adjunctive stenting in a patient with non-Q wave myocardial infarction.

The development of percutaneous transluminal balloon angioplasty (PTCA) is the greatest revolution in the management of stenotic coronary artery disease. However, PTCA is limited in its application to some specific subgroups of complex lesions such as bifurcational, ostial and plaque burden lesions. For this reason, some new strategies including directional atherectomy (DCA) have been developed as advanced modalities in the treatment of these complex lesions, which if treated by PTCA would certainly yield poor outcomes. We report a case of non-Q wave myocardial infarction resulting from obstruction of the ostium of left anterior descending artery. DCA and adjunctive stenting to the lesion were successfully performed and the patient was discharged uneventfully after the procedure. We suggest that DCA is a striking method and has much merit in the treatment of complex lesions with a high rate of success. In view of consideration of restenosis remains an importantly unresolved problem in percutaneous coronary intervention in specific subgroups of complex lesions. In the future, adequate debulking by mean of DCA in combination with adjunctive stenting which recently emerges as a promising treatment in the prevention of restenosis may provide a more consistent and attractive method for prevention of restenosis in these complex lesions.

Aged↗

PubMed2002

An intervention study on screening for breast cancer among single African-American women aged 65 and older.

BACKGROUND: Older African-American women with single marital status are least likely to use screening procedures. This study aimed to evaluate a breast screening intervention program conducted in this population. METHODS: Ten public housing complexes were randomly assigned to either the intervention or the control group. African-American women aged 65 and over were recruited into the study if they were widowed, divorced, separated, or never married and did not have a history of breast cancer (n = 325). The intervention program was delivered by lay health educators at the participant's apartment and was designed to increase knowledge about breast screening, reduce psychological problems, and increase support from significant others. Breast-screening-related cognition and behavior were measured at baseline and at 1 and 2 years postintervention. RESULTS: Comparisons of the preintervention and postintervention measurements showed that while the proportion of women who had a clinical breast examination or mammogram in the preceding year was decreased at 1 year postintervention in the control group, it was increased in the intervention group. However, the differences did not reach a significant level. No consistent patterns could be found in changes of breast self-examination and variables in knowledge, attitudes, and beliefs. When analyses were restricted to women whose significant others had provided information or help on breast screening, results were better, but the differences between the intervention and control groups still did not reach statistical significance. CONCLUSIONS: These results did not suggest significant effects of an intervention program that used lay health educators to promote breast cancer screening in older single African-American women.

Black or African American↗

PubMed2000

Investigating the efficacy of a nonpowered pressure-reducing therapeutic mattress: a retrospective multi-site study.

To ascertain the ability of combining data to examine the effectiveness of a lateral support surface, data from independent studies were analyzed. Patients placed on the surface (N = 75) were elderly (mean age 70.2 years), had multiple comorbities, and an average Braden score of 12.66. Of these patients, 8.4% had a history of preexisting pressure ulcers and their average albumin was 3.56. Seventeen patients without wounds and believed to be "at risk" (average Braden score = 10.75) were treated prophylactically for an average of 63.3 days. Records of 45 wounds (32 subjects) were sufficiently complete to be included in the wound healing rate analysis. No ulcers occurred in the preventive group. No impact was associated with combining the data across the setting. A slight impact was anticipated when combining the data by setting and wound stage. Wounds on 28 of the subjects healed or were reduced in size, three remained unchanged, and one worsened. Overall, wound size reduced by an average of 68.85% over 84.69 days on the mattress, or 25.5% per week (n = 45, P = 0.0004). Stage I pressure ulcers reduced 46% per week (n = 6, P = 0.022), Stage II ulcers at 33% per week (n = 22, P = 0.05), Stage III ulcers at 6.97% per week (n = 13, P = 0.004), and Stage IV at 3.24% per week (n = 4, P = 0.058). The results of this retrospective review indicate that data from various sites can be combined and that the support surface may be an effective intervention modality. However, wound healing is a complex process, and support surfaces are only one of many interventions needed to facilitate healing. Future research using valid wound-healing instruments is needed.

Adult↗

PubMed1992

Lung injury after deposition of IgA immune complexes. Requirements for CD18 and L-arginine.

Acute lung injury produced by deposition of IgA immune complexes is complement-dependent, neutrophil-independent, oxygen radical-mediated, and may be a result of the formation of the hydroxyl radical (HO) generated directly or indirectly from activated lung macrophages. The current studies were designed to evaluate further the pathophysiologic events that occur after intrapulmonary deposition of IgA immune complexes. Pretreatment of rats with the human recombinant soluble complement receptor-1 resulted in marked attenuation of IgA immune complex-induced lung injury. Intravenous administration of antibody to CD18, but not antibody to CD11b, was highly protective against lung injury. Treatment of animals with either anti-endothelial leukocyte-adhesion molecule-1 or anti-TNF-alpha, both of which were highly protective against IgG immune complex-induced lung injury, had no protective effects in the model of IgA immune complex-induced lung injury. Immunohistochemical analysis revealed up-regulation of the endothelial leukocyte adhesion molecule-1 in the pulmonary vasculature after deposition of IgA immune complexes. This up-regulation was TNF-alpha-dependent. The arginine analog, NG-monomethyl-L-arginine, was highly protective against IgA immune complex-induced lung injury. This protective effect was reversed by the co-presence of L-arginine (but not D-arginine). Protective interventions against IgA immune complex-induced lung injury were inversely correlated with the numbers of macrophages that could be retrieved by lung lavage. These data suggest fundamental differences in the pathogenesis of lung injury after intrapulmonary deposition of IgA immune complexes, as compared with injury caused by deposition of IgG immune complexes. In the latter, neutrophils, intrapulmonary generation of TNF-alpha, and up-regulation of pulmonary vascular endothelial leukocyte-adhesion molecule-1 are required for the full development of lung injury, whereas no such requirements appear in the case of IgA immune complex-induced lung injury. Full expression of IgA immune complex-induced lung injury also appears to require L-arginine, suggesting a possible role for nitric oxide or its derivatives in events ultimately leading to injury.

Animals↗

PubMed1989

Interventions to facilitate pain management in myocardial infarction.

Pain is a complex perceptual experience involving physiologic and psychologic factors. Nursing interventions such as reassurance, relaxation techniques, repositioning, distraction, and enhancement of the placebo effect may be used as adjuncts to pharmacologic therapy for the pain of acute myocardial infarction. The potential effectiveness of independent nursing interventions is supported here through a review of empirical studies. A description of gate-control theory is included as well as a case study and theory-based plan of care.

Adult↗

PubMed2004

Association of lesion complexity following fibrinolytic administration with mortality in ST-elevation myocardial infarction.

Greater lesion complexity, according to the American College of Cardiology and American Heart Association, has been associated with decreased success rates of percutaneous coronary intervention. We hypothesized that greater lesion complexity after fibrinolytic administration for ST-segment elevation myocardial infarction would similarly be associated with increased mortality and other adverse events at 30 days. We studies 2,605 patients from the Thrombolysis In Myocardial Infarction 10B and 14, Integrilin and Tenecteplase in Acute Myocardial Infarction, ENTIRE, and FASTER studies. For all studies, angiographic outcomes were assessed immediately after fibrinolytic administration and clinical outcomes were assessed at 30 days. Greater lesion complexity was associated with poorer epicardial flow and decreased myocardial perfusion at 60 minutes and after percutaneous coronary intervention and with a higher risk of shock and mortality within 30 days. In a multivariate model, type C lesion complexity remained associated with an increased 30-day mortality rate.

Angioplasty, Balloon, Coronary↗

PubMed2004

[The anatomy of the ulnocarpal complex].

The ulnocarpal complex (triangular fibrocartilage complex; TFCC) represents an intricate system of structures which secures motion guidance, stability and pressure transmission in the ulnocarpal compartment of the wrist joint. Anatomically, this complex consists of the ulnocarpal disc (triangular disc), palmar and dorsal radioulnar ligaments, ulnolunate, ulnotriquetral and ulnocapitate ligaments, ulnocarpal meniscus homologue, ulnar recess (prestyloid recess), ulnocarpal collateral ligament and tendon sheath of the extensor carpi ulnaris. The distal radioulnar joint and the interosseous membrane of the forearm, which lie close together, also belong functionally to the ulnocarpal complex. Together with the proximal radioulnar joint, they permit rotational movements of the hand (pronation and supination). This review highlights all components of the ulnocarpal complex systematically. Distinctive characteristics involving size, as well as variations, are listed, and their functional meaning analyzed. The accumulated knowledge serves as a basis for possible interventions both at the ulnocarpal complex and the distal radioulnar joint.

Carpal Bones↗

PubMed2006

Analysis of the stepwise clinical introduction of experimental percutaneous fetoscopic surgical techniques for upcoming minimally invasive fetal cardiac interventions.

BACKGROUND: This study assessed the feasibility and safety of surgical techniques developed in sheep for fetoscopic fetal cardiac interventions during three selected less complex procedures for noncardiac fetal conditions in humans. On the basis of this assessment, the implications for the clinical introduction of minimally invasive fetoscopic fetal cardiac interventions in the near future are discussed. METHODS: The authors performed 16 percutaneous fetoscopic procedures in 13 human fetuses at between 19 + 2 and 34 + 6 weeks of gestation, then analyzed various parameters of surgical relevance for minimally invasive fetoscopic fetal cardiac interventions. Each of the three noncardiac malformations posed typical surgical challenges that will be critical for the technical success of minimally invasive fetoscopic cardiac interventions. RESULTS: Overall technical success was achieved in 14 of the 16 procedures. Percutaneous fetoscopic surgery did not result in any untoward effects and was well tolerated by all but two pregnant women: one with bleeding complication and one with mild postoperative pulmonary edema. No fetal complications or injuries from the various percutaneous fetoscopic surgical approaches were observed. CONCLUSIONS: The author's experience with surgical techniques introduced for percutaneous fetoscopic fetal cardiac intervention in selected noncardiac fetal lesions has led them to believe the time has come for the clinical introduction of fetoscopic fetal cardiac interventions. After an adequate learning curve supervised by committees of human research, the overall outcome and quality of postnatal life for the unborn patients ultimately will determine whether fetoscopic or other fetal cardiac interventions will be better therapeutic alternatives to currently available postnatal procedures.

Female↗

PubMedDate not supplied

Health care interventions for intimate partner violence: what women want.

OBJECTIVE: We sought to determine what women want from health care interventions for intimate partner violence (IPV) and understand why they found certain interventions useful or not useful. METHODS: We conducted interviews with 21 women who have a past or current history of intimate partner violence. Participants were given cards describing various IPV interventions and asked to perform a pile sort by placing cards into three categories ("definitely yes," "maybe," and "definitely no") indicating whether they would want that resource available. They were then asked to explain their categorizations. RESULTS: The pile sort identified that the majority of participants supported informational interventions and individual counseling. Only 9 of 17, however, felt couple's counseling was a good idea with seven reporting it was definitely not useful. Half wanted help with substance use and treatment for depression. Interventions not well regarded included "Receiving a follow-up telephone call from the doctor's office/clinic" and "Go stay at shelter" with only 7 and 5 of the 21 women placing these cards in the "definitely yes" pile. "Health provider reporting to police" was the intervention most often placed in the "definitely no" pile, with 9 of 19 women doing so. The women described several elements that affected their likelihood of using particular IPV interventions. One theme related stages of "readiness" for change. Another theme dealt with the complexity of many women's lives. Interventions that could accommodate various stages of "readiness" and helped address concomitant issues were deemed more useful. Characteristics of such interventions included: 1) not requiring disclosure or identification as IPV victims, 2) presenting multiple options, and 3) preserving respect for autonomy. CONCLUSIONS: Women who had experienced IPV described not only what they wanted from IPV interventions but how they wished to receive these services and why they would chose to use certain resources. They advised providing a variety of options to allow individualizing according to different needs and readiness to seek help. They emphasized interventions that protected safety, privacy, and autonomy.

Adult↗

PubMed1990

The feeding relationship: problems and interventions.

The feeding relationship is the complex of interactions that take place between parent and child as they engage in food selection, ingestion, and regulation behaviors. Effective feeding supports a child's developmental tasks of homeostasis, attachment, and separation. Feeding of the newborn infant is most successful when parents allow the infant to determine timing, amount, preference, pacing, and eating capability. During the attachment phase, such infant-controlled behaviors allow parents to engage affectively with the child. Successful regulation of state and attachment provides the groundwork for the separation-individuation phase. In feeding, effective parents provide opportunities to explore but also provide structure and limits. Feeding and growth problems often stem from distorted dynamics around feeding, which can be indicative of distorted parent-child interactions. Incidence estimates range from 1% to 2% for severe and prolonged problems to 25% to 35% for common difficulties such as food refusal and "overeating." An evaluation of feeding dynamics should always be made as part of the diagnostic study of a child who is eating or growing inappropriately. To prevent problems in feeding, practitioners may teach and support positive feeding dynamics as part of primary care, refer parents for instruction in positive approaches to feeding, and detect and refer attitudinal and behavioral problems early.

Adult↗

PubMed2006

The diabetes educator: trying hard, but must concentrate more on behaviour.

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self-efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients' sense of self-efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self-management. These conclusions have implications for future research and clinical practice.

Adaptation, Psychological↗

PubMed1998

[Fibrous-cavernous pulmonary tuberculosis in diabetics].

A total of 75 patients with diabetes mellitus who underwent surgical interventions on the lungs for fibrocavernous tuberculosis were followed up. A complex preparation for surgery being completed, operative interventions under endotracheal narcosis were carried out in all cases. Postoperative complications occurred in 32 percent of cases, four patients (5.33%) died after the operation. The clinical efficiency was recordable in 94.87 percent of patients. During the postoperative 1- to 15-year follow-up the achieved effect was still to be seen in 83.8 percent of those having been operated on. A major proportion of patients showed improvement in the course of diabetes mellitus.

Adolescent↗

PubMedDate not supplied

[Intensive therapy for multiple organ dysfunction in neonatal infants after cardiosurgical interventions].

This study was undertaken to evaluate the efficiency of complex intensive therapy for multiple organ dysfunction syndrome (MODS) after cardiosurgical interventions at the resuscitative and intensive care unit of the A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences. In 2003-2004, MODS developed in 70 (37%) of the neonatal infants operated on the heart and vessels. The babies' age ranged from 6 hours of life to 1 month (8.3 +/- 2.1 days of life, their body weight was from 1.7 to 4.1 kg (3.0 +/- 0.49 kg). All the patients were found to have significant renal and respiratory failures. There were more than 4 (4.1 +/- 0.5) failing vital viscera. The use of phosphodiesterase (III) inhibitors in therapy for acute left ventricular insufficiency significantly improved the performance of the left heart whereas nitric oxide inhalation significantly lowered pulmonary pressure in babies with acute right ventricular insufficiency and improved oxygenation in patients with MODS. The efficiency of nitric oxide inhalation in MODS significantly increased when it was used in combination with endotracheal administration of a surfactant and high-frequency oscillatory ventilation. Peritoneal dialysis effectively replaced renal function when acute renal failure (ARF) developed. Nevertheless, the development of ARF in the pattern of MODS is a marker of high mortality (89% in ARF versus 46% in MODS without ARF).

Acute Kidney Injury↗

PubMed2004

In silico experiments of existing and hypothetical cytokine-directed clinical trials using agent-based modeling.

OBJECTIVES: To introduce a form of mathematical modeling, agent-based modeling (ABM), and demonstrate its potential uses in the evaluation of the dynamics of the innate immune response (IIR) and the development of possible treatments for systemic inflammatory response syndrome (SIRS)/multiple organ failure (MOF). RATIONALE: The IIR can be categorized as a complex system that responds to interventions in a nonintuitive fashion, leading to difficulty in translating basic science knowledge into effective treatments for SIRS/MOF. It is proposed that ABM is particularly well suited to examining the complex interactions of the IIR and its disordered states of SIRS/MOF. STUDY DESIGN: Computer simulation and mathematical modeling. DATA SOURCE: Review articles on components and mechanisms involved in the IIR. Published results from phase III anticytokine/mediator trials. Published results from smaller clinical trials and animal studies. MAIN RESULTS: An abstract ABM of the IIR was created. The model reproduces the general behavior of the IIR with respect to outcome and cause of system "death." Patterns of levels of individual cytokines matched patterns of measured cytokines reported in the existing literature. Clinical trials of anticytokine therapy were simulated and produced outcomes qualitatively similar to those reported in the literature. A series of hypothetical treatment regimes (variation of dose and length of treatment [anti-tumor necrosis factor and anti-interleukin-1], anti-CD-18, and multiple-drug regimes [combination of anti-tumor necrosis factor, anti-interleukin-1, and anti-CD-18]) were formulated and implemented in the ABM. None of the simulated therapies showed a statistically significant improvement in system mortality. CONCLUSIONS: Presented herein is an abstracted ABM of the IIR. This model is intended primarily as an introduction to and demonstration of this technique. However, even this relatively simple model demonstrates counterintuitive system responses and the difficulty of effectively manipulating a complex system like the IIR. ABM may provide a synthetic, analytical platform to integrate basic science data on the IIR, thus eventually aiding in formulating and testing future mediator-directed therapies for SIRS/MOF before clinical trials, and it may provide insights into directions of future research.

Clinical Trials as Topic↗

PubMed2004

Iron complexes of (e)- and (z)-1,2-dichlorodisilenes.

Novel disilene-iron complexes [(E)- (1E) and (Z)-(eta2-R3SiClSi=SiClSiR3)Fe(CO)4 (1Z), SiR3 = tBu2MeSi] were synthesized by the reaction of the corresponding tetrachlorodisilane with an excess amount of K2Fe(CO)4, and the structures of 1E and 1Z were determined by X-ray crystallography. These complexes constitute not only the first transition-metal complexes with E,Z-isomerism but also the first complexes with halogen-substituted disilene ligands. The initial formation of 1Z during the synthetic reaction and the slow one-way isomerization of 1Z to 1E are rationalized by the intervention of the corresponding silylene complex (R3SiCl2Si)(R3Si)Si=Fe(CO)4.

Journal Article↗

PubMed1998

Six month follow-up: the crucial test of multidisciplinary developmental assessment.

Participation of parents in the developmental assessment process is thought to be beneficial in promoting understanding of their child's disability, and improving consensus between parents and professionals about appropriate intervention programmes. If costly multidisciplinary assessments are to be justified, it is necessary to establish long-term benefits for the child. This highlights a need for research identifying how families use services after diagnostic assessment and what they understand to be important for their child. Poor parent-professional agreement about diagnosis may be a factor contributing to low compliance with recommendations. The major purpose of the current study was to follow-up families 6 months after developmental assessment, in order to investigate use of recommended intervention services. In addition, mothers' opinions about diagnostic findings, recommendations and early intervention services were examined. Subjects were 40 pre-school children who presented for developmental assessment, and their mothers. The majority were diagnosed with developmental problems in multiple domains. Results indicated that most mothers recalled and agreed with their child's diagnosis, but underestimated the severity of developmental delay. Families had not accessed the range of multidisciplinary intervention programmes recommended, given the complexity of their children's disabilities. Speech therapy was considered the service of highest priority by mothers, and was the treatment most frequently received. Mothers recognized a need for more therapeutic interventions for their child. An unexpected finding was the high prevalence of families who organized nonprescribed therapies. Possible explanations of the findings and implications for service delivery are discussed.

Adult↗

PubMed1994

Clarithromycin therapy for bacteremic Mycobacterium avium complex disease. A randomized, double-blind, dose-ranging study in patients with AIDS. AIDS Clinical Trials Group Protocol 157 Study Team.

OBJECTIVE: To determine the antimicrobial activity and tolerability of clarithromycin for treating bacteremic Mycobacterium avium complex disease in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: A randomized, double-blind, dose-ranging study. SETTING: Outpatient clinics. PATIENTS: 154 patients with human immunodeficiency virus (HIV) infection and blood cultures positive for M. avium complex who had symptomatic disease. INTERVENTIONS: Random assignment to clarithromycin at dosages of 500 mg, 1000 mg, or 2000 mg twice daily for 12 weeks. MAIN OUTCOME MEASURE: Median number of colony-forming units of M. avium complex per milliliter of blood. RESULTS: Clarithromycin decreased mycobacterial CFUs from 2.7 to 2.8 log 10/mL of blood at baseline to less than 0 log 10/mL during follow-up (P < 0.0001). After 2 weeks, patients receiving 500 mg twice daily were less likely to be culture negative than were patients receiving 1000 or 2000 mg twice daily (11% compared with 33% or 29%; P = 0.08). At 6 weeks, the median number of CFUs of M. avium complex/mL of blood was 0 or 1 for all three groups. Clarithromycin-resistant isolates of M. avium complex developed in 46% of patients at a median of 16 weeks. Median survival was longer in patients assigned to 500 mg twice daily (median, 249 days) than in patients assigned to 1000 mg or 2000 mg. Death in the first 12 weeks was lowest in the 500-mg group (P = 0.007). CONCLUSIONS: Clarithromycin therapy acutely decreased M. avium complex bacteremia in patients with HIV infection by more than 99%. Clarithromycin, 500 mg twice daily, was well tolerated and associated with better survival. Emergence of clarithromycin-resistant organisms was an important problem.

AIDS-Related Opportunistic Infections↗

PubMed1986

Assisting adolescents toward mental health.

The developmental stage of adolescence may be so turbulent as to require psychiatric intervention. The adaptive difficulties experienced by Offer's tumultuous group of adolescents were once considered normal problems for that age group. Now they are considered to be a precursor to more serious psychosocial problems and require entry into the mental health care system. The adolescent psychiatric patient may experience adaptive difficulties, such as delinquency, substance abuse, and sexual acting out, or a diagnosed psychiatric disorder. The level of care an adolescent requires depends upon the type and severity of his dysfunction. Early detection and prevention is largely accomplished through education. Assessment and crisis intervention require the structure of an acute care inpatient setting. Long-term treatment may be necessary to provide a corrective emotional experience for the severely dysfunctional adolescent. Research endeavors should be directed toward further exploration of the relationship between adaptive difficulties and adult psychiatric disorder. Outcome studies would be helpful in evaluating the success of psychiatric nursing intervention at multiple levels of complexity.

Adaptation, Psychological↗