PubMed Health⌕ Search

SEARCH · PubMed Health

Results for “Complex intervention”

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

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

At least 1,189 records · Page 66Linked to original sources

Regulatory roles of the N-terminal domain based on crystal structures of human pyruvate dehydrogenase kinase 2 containing physiological and synthetic ligands.

Pyruvate dehydrogenase kinase (PDHK) regulates the activity of the pyruvate dehydrogenase multienzyme complex. PDHK inhibition provides a route for therapeutic intervention in diabetes and cardiovascular disorders. We report crystal structures of human PDHK isozyme 2 complexed with physiological and synthetic ligands. Several of the PDHK2 structures disclosed have C-terminal cross arms that span a large trough region between the N-terminal regulatory (R) domains of the PDHK2 dimers. The structures containing bound ATP and ADP demonstrate variation in the conformation of the active site lid, residues 316-321, which enclose the nucleotide beta and gamma phosphates at the active site in the C-terminal catalytic domain. We have identified three novel ligand binding sites located in the R domain of PDHK2. Dichloroacetate (DCA) binds at the pyruvate binding site in the center of the R domain, which together with ADP, induces significant changes at the active site. Nov3r and AZ12 inhibitors bind at the lipoamide binding site that is located at one end of the R domain. Pfz3 (an allosteric inhibitor) binds in an extended site at the other end of the R domain. We conclude that the N-terminal domain of PDHK has a key regulatory function and propose that the different inhibitor classes act by discrete mechanisms. The structures we describe provide insights that can be used for structure-based design of PDHK inhibitors.

Adenosine Triphosphate↗

A study of primary care teaching comparing academic and community-based settings.

OBJECTIVE: To compare teaching activity and content between academic and community-based practices used in third year medical student primary care training. SETTING: Academic and community-based primary care practices participating in third-year internal medicine, family medicine, and primary care core clerkships. PARTICIPANTS: Five-hundred thirteen preceptor-student encounters involving 32 preceptors and 26 third-year medical students were evaluated. DESIGN: Student-preceptor pairs collected a convenience sample of data from shared patient encounters. Preceptors recorded the content of teaching interventions, and students independently documented learning points received for each clinical encounter. MEASUREMENTS AND MAIN RESULTS: Comparison of problem exposure, frequency and content of teaching interventions, and the effect of patient complexity and patient care workload on teaching frequency was made between the academic and community-based practices. Several small differences were found in the frequency of clinical problem exposure between the 2 settings. The frequency and focus of teaching interventions did not differ by practice type. Teaching by community-based preceptors tended to decrease with increased patient care workload, but increased in academically based practices. CONCLUSIONS: Although several differences exist between educational experiences in community- and academically based primary care practices, they appear to be minor and of minimal educational significance.

Education, Medical, Undergraduate↗

Ternary complex therapy for autoimmune disease.

Induction of an immune response is remarkably simple, involving the interaction of three components: processed antigen, an MHC class II molecule, and a CD4 T-cell receptor. Each part of this ternary complex represents a novel target for interventions that may block subsequent effector phenomena of autoimmune disease. Such specific treatments will be less toxic than those currently available.

Antigen-Antibody Complex↗

Substance use and abuse in trauma: implications for care.

Trauma long has been associated with substance use and abuse. Caring for trauma patients who are intoxicated, withdrawing, or otherwise experiencing the negative outcomes of their substance use is difficult under the best of circumstances. The burden of this association can be described in many terms, from economic consequences, to health outcomes, to personal problems. Evidence indicates that untreated substance-associated trauma carries with it extended hospital stays, diminished quality of life, repeat emergency department use, and significant mortality and morbidity. No matter how one examines the burden of the association between substance use and trauma, one is left with the awareness that nurses can improve patient care through better screening, assessment, intervention, an evaluation. Because of the complex nature of the association between substance use and trauma, nursing care for these patients is difficult. Fig. 1 provides an overview of the factors to consider when planning care for these patients. Nurses need to focus on issues of temporality, directionality, and correlates of care as they plan for the needs of their patients. Only with careful considerations of these factors can the nurse clarify the confounding clinical presentation of the trauma overlaid on substance use. Evidence supports the need for all trauma patients to be screened for substance use and for those who have positive screens to receive early intervention. Although there is almost universal awarenes of the of the association between substance use and trauma and of the value of screening, screening rates for trauma patients are surprisingly low. Screening for substance use followed by BMI intervention is cost effective and should be implemented routinely. The high prevalence of substance-associated trauma, coupled with the heterogeneous nature of that association, warrants more study, particularly nursing research, to determine best-care practices. More research is needed to increase the understanding of patterns of use, etiologic models, and effective clinical care strategies. The need for this research is heightened by the awareness that substance-associated trauma is preventable, and the risk is modifiable. Nurses, everyday, are faced with the daunting challenge of meeting the health needs of trauma patients who have associated substance use. More research is needed to help nurses separate out the confounding health needs of these complex patients. That work has begun, and it assuredly will continue to support the need for high-quality nursing interventions to improve the health of trauma patients.

Comorbidity↗

Predicting survival time for kidney dialysis patients: a data mining approach.

The cost for providing care for patients on hemodialysis due to end stage kidney disease is high. Finding ways to improve patient outcomes and reduce the cost of dialysis is important. Dialysis care is intricate and multiple factors may influence patient survival. Over 50 parameters may be monitored on a regular basis in providing kidney dialysis treatments. Understanding the collective role of these parameters in determining outcomes for an individual patient and administering individualized treatments allowing specific interventions is a challenge. Individual patient survival may depend on a complex interrelationship between multiple demographic and clinical parameters, medications, medical interventions, and the dialysis treatment prescription. In this research, data preprocessing, data transformations, and a data mining approach are used to elicit knowledge about the interaction between many of these measured parameters and patient survival. Two different data mining algorithms were employed for extracting knowledge in the form of decision rules. These rules were used by a decision-making algorithm, which predicts survival of new unseen patients. Important parameters identified by data mining are interpreted for their medical significance. The concepts introduced in this research have been applied and tested using data collected at four dialysis sites. The computational results are reported in the paper.

Algorithms↗

Chiral bis(oxazoline) copper(II) complexes: versatile catalysts for enantioselective cycloaddition, Aldol, Michael, and carbonyl ene reactions.

A bis(oxazoline) (box) copper(II) complex and its hydrated counterpart (1 and 2) function as enantioselective Lewis acid catalysts for carbocyclic and hetero Diels-Alder, aldol, Michael, ene, and amination reactions with substrates capable of chelation through six- and five-membered rings. X-ray crystallography of the chiral complexes reveals a propensity for the formation of distorted square planar or square pyramidal geometries. The sense of asymmetric induction is identical for all the processes catalyzed by [Cu((S,S)-t-Bu-box)](X)(2) complexes 1 and 2 (X = OTf and SbF) resulting from the intervention of a distorted square planar catalyst-substrate binary complex. These catalyzed processes exhibit excellent temperature-selectivity profiles. Reactions catalyzed by [Cu(S,S-Ph-pybox)](SbF(6))(2) and their derived chelation complexes are also discussed.

Biological Factors↗

The care transitions intervention: results of a randomized controlled trial.

BACKGROUND: Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce rehospitalization rates. METHODS: Randomized controlled trial. Between September 1, 2002, and August 31, 2003, patients were identified at the time of hospitalization and were randomized to receive the intervention or usual care. The setting was a large integrated delivery system located in Colorado. Subjects (N = 750) included community-dwelling adults 65 years or older admitted to the study hospital with 1 of 11 selected conditions. Intervention patients received (1) tools to promote cross-site communication, (2) encouragement to take a more active role in their care and to assert their preferences, and (3) continuity across settings and guidance from a "transition coach." Rates of rehospitalization were measured at 30, 90, and 180 days. RESULTS: Intervention patients had lower rehospitalization rates at 30 days (8.3 vs 11.9, P = .048) and at 90 days (16.7 vs 22.5, P = .04) than control subjects. Intervention patients had lower rehospitalization rates for the same condition that precipitated the index hospitalization at 90 days (5.3 vs 9.8, P = .04) and at 180 days (8.6 vs 13.9, P = .046) than controls. The mean hospital costs were lower for intervention patients ($2058) vs controls ($2546) at 180 days (log-transformed P = .049). CONCLUSION: Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.

Aged↗

Proteomics in clinical interventions: achievements and limitations in biomarker development.

Development of toxicological and clinical biomarkers for disease diagnosis, quantification of toxicant/drug responses and rapid patient care are major concerns in modern biology. Even after human genome sequencing, identification of specific molecular signatures for unambiguous correlation with toxicity and clinical interventions is a challenging task. Differential protein expression patterns and protein-protein interaction studies have started unraveling rigorous molecular explanation of multi-factorial and toxicant borne diseases. Proteome profiling is extensively used to investigate etiology of diseases, develop predictive biomarkers for toxicity and therapeutic interventions and potential strategies for treatment of complex and toxicant mediated diseases. In this review, achievements and limitations of proteomics in developing predictive biomarkers for toxicological and clinical interventions have been discussed.

Animals↗

[Complexity of observable psychological distress after surgical myocardial revascularization in male subjects].

BACKGROUND: Psychological disturbances like anxiety, depression, post-traumatic stress disorder are often associated with coronary artery disease and, in some studies, play a prognostic role after a coronary event. Despite some psychological disturbances following coronary artery bypass graft (CABG) have an impact on outcomes of both the surgical intervention and the rehabilitation program, their complexity as well as their clinical and instrumental determinants are still not fully understood. The aim of this study was to determine in male subjects with coronary artery disease the prevalence and complexity of psychological disturbances occurring after CABG as well as their predictors. METHODS: One hundred eighteen males without history of psychological disturbances consecutively admitted to our rehabilitation inpatient service between September 2002 and September 2003 underwent 11 +/- 2 days after CABG extensive psychometric testing including the Minnesota Multiphasic Personality Inventory-2, the Cognitive Behavioral Assessment.2, and the Hamilton test. Cardiac evaluation included coronary risk factors, NYHA class, coronary heart disease history, medical therapy, CABG number, and echocardiography. RESULTS: Mean age 63.7 +/- 8.1 years; ejection fraction 54.6 +/- 10.3%; NYHA class I 92.4%, NYHA class II and III 7.6%; CABG number 1 (11%), 2 (23.7%), 3 (39.8%), 4 (21.8%), 5 (4.2%); coronary artery disease length 64 +/- 85 months, hospital stay 31.3 +/- 8 days. The score was above clinical cut-off on scale for depression in 16-39.8% of the patients, state anxiety in 27.1%, trauma in 16.1%, type A personality in 16.1%. Subjects above clinical cut-off for depression, anxiety and trauma did not differ from subjects below in terms of clinical and instrumental characteristics. Age, ejection fraction, coronary risk factors, coronary heart disease duration, and CABG number did not predict the development of depression, anxiety and trauma. Psychological disturbances often clustered in the same subjects. CONCLUSIONS: In males following CABG, psychological disturbances are extremely frequent, often clustered, and independent of subjects' characteristics and coronary heart disease severity.

Aged↗

[Technological improvements in interventional cardiology].

In the last few years, the evolution of coronary interventionism has been very important. The primary success rates in the early 1990s were 86-88% with a re-stenosis rate of 30%-40%. Current primary success rates have risen to over 95% with a re-stenosis rate of under 10% even for many types of lesions classically considered complex. Currently the main limitations in interventional cardiology remain coronary segments that cannot be accessed due to chronic total occlusion, or severe proximal tortuosity or calcification. Rapid improvements have led to broader clinical indications for percutaneous revascularization procedures. We describe the latest improvements in techniques.

Angioplasty, Balloon, Coronary↗

[Coronary heart disease and insulin concentration in type II diabetic patients--results of a diabetes intervention study].

There is experimental, clinical and epidemiological evidence that elevated insulin levels are associated with development of atherosclerosis. Early results came from studies in non-diabetics, but the situation with respect to diabetes is more complex and not so clear. The Diabetes Intervention Study is a population-based follow-up study in newly detected type II diabetics (30- to 55-yr-old). After 5 years 431 men and 320 women received a complex check up with oral glucose tolerance tests and measurements of plasma insulin and glucose levels, fasting and 2h post-load. Regarding the metabolic parameters, the fasting and postprandial insulin levels were higher among the patients having coronary heart disease (15% of men, 36% of women), as compared to patients without this disease. In multivariate analysis sex, age, antihypertensive treatment, blood pressure, body mass index, and fasting insulin levels were independently associated with the prevalence of coronary heart disease in patients with non-insulin dependent diabetes mellitus (NIDDM) treated with diet and/or oral antidiabetics. Body mass index and triglycerides were the only variables that independently correlated to insulin: fasting insulin = 0.4 (body mass index) + 0.1 (triglycerides) - 4,2. In future prospective studies of diabetics relating insulin concentrations to the development of vascular disease are of particular interest and necessity. Because hyperinsulinemia may contribute to accelerated atherosclerosis in NIDDM-patients, the aim of the treatment of type II-diabetes should be to correct hyperglycemia without aggravating insulin levels and other cardiovascular risk factors.

Adult↗

[Rehabilitation of deafness in the elderly: multidisciplinary intervention in experimental university center].

The loss of hearing abilities can be seen as a complex event because psychological discomfort and relational inhibitions interact and lead to behaviours and attitudes which are insidious and dangerous for the quality of life of the patient. The complexity of the psychological-organic inconvenience, such as impairement disability and handicap led to the testing of recovery patterns. In this specific context interventions coming from different fields sustained from a complex operative model where different professional competences and evaluation processes interact. Therapeutic interventions have been carried out by an audiologist, an audiometrist, a speech therapist, an audioprostethist and a psychologist, all sharing the obtaining of the same result. The role of the audiologist is simply clinical and concerns the knowledge of the entire process of rehabilitation through the use of a prosthesis. This process concerns the audiologist, who operates in close collaboration with the audiometrist and the audioprosthesist: it is therefore a therapeutic activity that is interested mainly in the prescription of the prosthesis and the restoring of the communicative function. The speech therapist and the psychologist carry their interventions through a relationship with the patient, which places the respect of the patient's personality before any other procedural and technical aspect. Therefore they pay attention more to ergonomic factors than to the hearing loss, through the obtaining of the patient's self-confidence and of a better general psychological situation. Therefore the main purpose of each intervention is to create a process of rehabilitation aimed at restoring the communicative functions and the individual motivation in trying to do so both in the domestic and in the social environment. The authors refer the experience and the informations put together during three years of research activity. The results of the therapeutic intervention have brought to the acceptance of the prosthesis help, the adaptation to amplification, the reduction of the subjective and relational uneasiness for the use of prosthesis, the use of the prosthesis, the reintroduction to the world of sounds, the restoring of levels of autonomy and of self-estime, the discover of eventual abilities, which had never been used or underestimated, the reactivation of more rewarding social relationships and the reduction of the conditions of dependency related to the hearing disability.

Aged↗

Computed tomographic evaluation of morphological and functional condition of left ventricle in heart aneurysm.

Computed tomography is a valuable method for the diagnosis of post-infarction aneurysm of the left ventricle of the heart. It gives additional information concerning the morphological and functional condition of the left ventricle. The suggested method of layer-by-layer scanning improves the diagnostic efficiency of CT during examination of patients with heart aneurysm and is noninvasive. Precise individual calculation of the peak concentration of contrast medium, defined by dynamic scanning, optimises the process of gated CT. CT makes it possible to study changes in cavity configuration, left ventricle wall thinning, induration and calcification of the myocardium, changes in left ventricle wall mobility, decreased thickening of the myocardium at systole and left ventricle cavity thrombosis--all changes characteristic of left ventricular aneurysm. CT provides important additional information about the condition of the inter-ventricular septum. EDV, ESV and EF data obtained using CT produce important information about the functional state of the left ventricle. Computed tomography can be used as an independent method of left ventricle aneurysm detection, especially in those institutions where more complicated investigation methods are not used and interventional cardiac procedures are not practised. Complex use of computed tomography and left ventriculography in cardiosurgical institutions makes it possible to improve significantly the diagnosis of cardiac aneurysm. Calculation of integral data about left ventricle pumping function based on CT and LVG data gives proper evaluation of the indications for operative intervention in left ventricular aneurysm.

Adult↗

A proposed ethical framework for interventional cognitive neuroscience: a consideration of deep brain stimulation in impaired consciousness.

Advances in neuromodulation techniques offer the promise of new therapeutic interventions for patients with neuropsychiatric maladies. Several complex social, ethical and policy issues will attend developments in this area. In this paper an ethical framework for clinical research in interventional cognitive neuroscience is advanced. Deep brain stimulation in traumatic brain injury is considered as a paradigm case to examine ethical obligations in human subject research. These include balancing access to novel therapies versus protection of vulnerable study populations, rational evaluation of study design and research strategies, informed consent, and the importance of achieving societal consensus for this line of scientific inquiry.

Brain↗

Evaluating the impact of health promotion programs: using the RE-AIM framework to form summary measures for decision making involving complex issues.

Current public health and medical evidence rely heavily on efficacy information to make decisions regarding intervention impact. This evidence base could be enhanced by research studies that evaluate and report multiple indicators of internal and external validity such as Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) as well as their combined impact. However, indices that summarize the combined impact of, and complex interactions among, intervention outcome dimensions are not currently available. We propose and discuss a series of composite metrics that combine two or more RE-AIM dimensions, and can be used to estimate overall intervention impact. Although speculative and, at this point, there have been limited empirical data on these metrics, they extend current methods and are offered to yield more integrated composite outcomes relevant to public health. Such approaches offer potential to help identify interventions most likely to meaningfully impact population health.

Decision Making↗

Methanolysis of nitrocefin catalyzed by one and two Zn(2+) ions. A simplified model for class B beta-lactamases.

The methanolysis of nitrocefin (1) was investigated at 25 degrees C in anhydrous methanol as a function of [Zn(2+)] and as a model for the chemistry believed to occur in the active site of Zn(2+)(-)beta-lactamases. In the absence of metal ion, the vs rate constant profile shows a long plateau region having k(obs) = 9 x 10(-5) s(-1) between 7.5 and 12 generated after ionization of the COOH of 1 (kinetic pK(a) of 7.34) followed by attack of CH(3)O(-) with k(CH)3(O) = 1.18 M(-1) s(-1). Strong catalysis of the methanolysis is observed at all pH values between 7.95 and 11.34 in the presence of as little as 0.05-3 mM Zn(2+). Plots of the pseudo-first-order rate constant for methanolysis (k(obs)) as a function of reveal a saturation phenomenon indicative of formation of a 1:Zn(2+) complex, followed by a linear section indicative of the intervention of a second Zn(2+) ion in promoting the methanolysis of the complex. The two processes can be separated since the slope of the linear part of the plots gives the second-order rate constant (k(2)(obs)) for the second Zn process, while the intercept gives the spontaneous rate constant for methanolysis of 1:Zn(2+) (k(cat.)(obs)). A plot of log k(cat.)(obs) vs is bell-shaped, maximizing at 10, with ascending and descending domains both first order in [CH(3)O(-)]. A plot of log k(2) vs gives an ascending domain second order in [CH(3)O(-)], followed by a plateau above 9.5. The data are analyzed in terms of a one-Zn and two-Zn model in which the former involves rate-limiting attack of methoxide on a 1:Zn(2+) complex up to the maximum and a spontaneous reaction of 1:Zn(2+):(CH(3)O(-))(2), while the latter involves bimolecular attack of Zn(2+)(CH(3)O(-))(2) on both 1:Zn(2+) and 1:Zn(2+):(CH(3)O(-))(2). The relevance of these observations is discussed in terms of the currently accepted mechanism for hydrolyses of beta-lactams promoted by the Zn(2+)(-)beta-lactamases.

Algorithms↗

Stability of the bone-implant complex. Results of longitudinal testing to 60 months with the Periotest device on endosseous dental implants.

BACKGROUND: Maintenance of the health and integrity of the bone-implant complex (osseointegration) has been shown to be essential for long term success of root-form, endosseous dental implants. If reliable clinical indicators of adequacy of the bone-implant complex existed, they could stimulate new and innovative early intervention research to arrest of reverse early deterioration of the bone-implant complex. In the absence of such indicators, this has been problematic. The Periotest may have the potential to provide this information by indirectly assessing the status of the bone-implant complex. However, little information is available that documents either the capability of the Periotest to reliably assess changes of the bone-implant complex or the "normal variations" in Periotest values (PTVs) for both HA-coated and non-coated implants. METHODS: The purpose of this paper was to document changes in PTVs as influenced by various implant surfaces, implant designs, and bone densities. The mean PTVs recorded for each visit, for all implant types and bone densities, were combined to provide an overall average PTV (A-PTV). The changes in stability (PTVs) were analyzed using a generalized linear model (GLM) with repeated measures (Hotelling's Trace). RESULTS: The A-PTV for all implants over all visits was -3.5. The mean PTVs ranged from -4.2 (SD = 2.4) at uncovering to -3.9 (SD = 2.9) at 60 months. All implants in bone qualities 1 and 2 (BQ-1 and BQ-2) became more stable over time, while those in bone quality 3 or 4 (BQ-3 and BQ-4) showed a slight decrease in stability. In BQ-1, the mean PTVs increased from -4.7 at uncovering to -4.9 at 60 months. A similar increase in stability occurred in BQ-2 (-4.1 at uncovering to -4.4 at 60 months). In BQ-3, the stability of the implants decreased over time (-3.6 at uncovering to -2.9 at 60 months), with similar changes recorded for BQ-4 (-2.5 at uncovering to -1.0 at 60 months). When comparing the stability of all HA-coated with all non-coated implants, the HA implants became less stable (-4.4 to -3.4) over time, while non-coated implants showed an improvement in stability (-3.5 to -4.5). The changes in stability found in BQ-1, BQ-2, and BQ-3 were similar, with HA implants becoming less stable and non-coated more stable. HA- and non-coated comparisons were not possible in BQ-4 since there were too few non-coated implants placed in this type of bone. The HA-coated screw showed a decrease in stability when compared to the non-coated screw. CONCLUSIONS: Conclusions of the study are as follows: 1) PTVs are influenced by bone quality and surface coating of the implant; 2) the PTVs at the time of uncovering provide the best estimate of a clinically acceptable PTV for that bone-implant complex; 3) while the PTVs for any bone-implant complex may fluctuate +/- 1.0 around the uncovering PTV during routine healing and loading of the implant, a consistent shift toward a positive PTV that approaches "0" should be cause for concern that the bone-implant complex may be at risk of failure; 4) HA-coated implants became slightly less stable (more positive PTVs) over time, while the non-coated implants became more stable (more negative PTVs); and 5) until a "critical PTV" can be accurately identified, it is suggested that a consistent shift in recorded PTVs that exceeds the +3.0 value on the PTV scale should be viewed with concern for possible deterioration at the bone-implant complex.

Alloys↗

Selectivity within primary health care.

While great strides have been made in improving socioeconomic conditions in the developing world, prospects for health for all remain remote. Resources are few, and difficult decisions must be made concerning the priorities for their use. This paper addresses several topics involved in making these choices including the methods for determining priorities and ensuring effectiveness of resource use. First, prioritizing. Information is needed concerning the prevalence, mortality, morbidity, feasibility and cost of control for each disease of importance in the area under consideration. Second, the use of technology. In discussion of health care some have denigrated the concentration many programs have placed on specific methods and technologies. Nevertheless, technological advances, while some have had detrimental results, have often led to improved living conditions; for example, improved seed and fertilizer use, improved water pumps, family planning efforts. These technologies required a larger investment in management, financial and communication systems. Health interventions are frequently more various and complex than these and need a similar support system for impact. However there are many shortcomings in health services; the paper looks at some of these learnt through experience, and concludes that the lack of impact on health of large scale health programs that have provided selective interventions is probably related to an inadequate recognition of the importance of community and political involvement and of the necessary social, cultural, financial, management and administrative underpinnings.

Developing Countries↗