Endoscopic ultrasonography guided drainage:Summary of consortium meeting,May 21,2012,San Diego,California

Endoscopic retrograde cholangiopancreatography(ERCP) is the preferred procedure for biliary and pancreatic drainage.While ERCP is successful in about 95% of cases,a small subset of cases are unsuccessful due to altered anatomy,peri-ampullary pathology,or malignant obstruction.Endoscopic ultrasound-guided drainage is a promising technique for biliary,pancreatic and recently gallbladder decompression,which provides multiple advantages over percutaneous or surgical biliary drainage.Multiple retrospective and some prospective studies have shown endoscopic ultrasoundguided drainage to be safe and effective.Based on the currently reported literature,regardless of the approach,the cumulative success rate is 84%-93% with an overall complication rate of 16%-35%.endoscopic ultrasoundguided drainage seems a viable therapeutic modality for failed conventional drainage when performed by highly skilled advanced endoscopists at tertiary centers with expertise in both echo-endoscopy and therapeutic endoscopy     

Clinical evaluation of brushing time and plaque removal potential of two manual toothbrushes

Abstract: Aim: To compare plaque removal efficacy of Oral‐B CrossAction (CA) used for 1 min with an American Dental Association (ADA) manual toothbrush used for 2 or 5 min in an examiner‐blind, three‐treatment, six‐period crossover study. Materials and methods: After refraining from all oral hygiene procedures for 23–25 h, subjects were randomly assigned to one of nine possible six‐period (visit) treatment sequences. Plaque was assessed at baseline (Rustogi Modified Navy Plaque Index). Post‐brushing scores were recorded after brushing with a marketed dentifrice and the assigned toothbrush for the specified duration. The same procedure was followed at each of six subsequent visits. Clinical measurements were carried out by the same examiner. Results: Forty subjects completed the study. All three treatments effectively removed plaque from the whole mouth, along the gingival margin and from approximal surfaces. Whole mouth and gingival margin plaque removal scores with CA for 1 min did not differ significantly from scores with the ADA toothbrush used for 2 min. The ADA brush used for 5 min showed significantly greater whole mouth (P < 0.001) and gingival margin (P < 0.001) plaque reduction than the two other treatments. Approximal plaque removal scores did not differ between the three treatments. Conclusions: Efficient plaque removal can be achieved after 1 min of brushing with CA. The amount of plaque removed did not differ significantly from that achieved with the ADA brush after 2 min of brushing. Greater whole mouth and gingival margin plaque removal scores were seen with the ADA brush after 5 min.     

Evolution of the HALT-C Trial: pegylated interferon as maintenance therapy for chronic hepatitis C in previous interferon nonresponders

The Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial was designed to determine whether maintenance interferon therapy could slow disease progression in patients who had failed to eradicate hepatitis C virus (HCV) during prior interferon treatment (nonresponders). Ten clinical sites, a virological testing center, and a data coordinating center (DCC) were selected to collaborate in the design and implementation of the final protocol. Eligible patients had been treated previously with interferon for at least 12 weeks, with or without another antiviral, ribavirin, but still had persistent viremia. Because patients had received a variety of prior treatments, and as a perceived benefit of enrollment, we incorporated a Lead-in period of treatment with long-acting pegylated interferon alfa-2a plus ribavirin into the study design, a combination believed to be more effective but not approved by the Food and Drug Administration at the Trial's inception. If patients failed to achieve clearance of virus from the blood after 20 weeks of this Lead-in therapy, they were entered into the main trial at week 24 and randomized to receive either a lower dose of pegylated interferon weekly alone or no further therapy for an additional 3 1/2 years. The original protocol was amended later in three respects to improve enrollment and to adapt to Food and Drug Administration approval of the Lead-in therapy, including allowing patients to proceed directly to the randomized part of the study if treatment resembling the Lead-in had been completed. The protocol changes enhanced enrollment while upholding the original goals of the study and its integrity.     

Respiratory insufficiency in neuronopathic and neuropathic disorders

Twenty-nine patients with a neuronopathic or neuropathic disorder were referred for assessment of respiratory insufficiency between 1978 and 1994. Diagnoses included spinal muscular atrophy (6), chronic idiopathic demyelinating neuropathy (4), Vialetto-van Laere syndrome (3), hereditary motor and sensory neuropathy (3) and a miscellaneous group (5). We also describe seven patients with Guillain-Barre syndrome (GBS) who required long-term ventilatory support for over 6 months to 7 years after the initial illness. Respiratory insufficiency occurred as a consequence of respiratory muscle weakness, impaired bulbar function and restrictive lung defects. In some groups presentation was with progressive nocturnal hypoventilation culminating in acute respiratory failure. Five patients with GBS or chronic idiopathic demyelinating neuropathy were weaned from ventilatory support up to 18 months after the initial illness. The remaining 24 patients required continuous or nocturnal ventilatory support using intermittent positive-pressure ventilation (13), negative pressure ventilation (4), nasal-mask-delivered intermittent positive-pressure ventilation (4), nasal-mask-delivered continuous positive-pressure ventilation (3), mouthpiece-assisted ventilation by day (2) and rocking bed (1). None have been weaned from support after a period of ventilation ranging from one month to 10 years. Eight patients have subsequently died.      

An innovative interdisciplinary approach to self-directed learning with a focus on the continuum of patient care.

Current regulatory review standards emphasize the hospital's role in providing continuum of care. Today, patient care staff must know more about the "continuum of care" concept so they can help patients more fully understand their treatment and take an active role in their own care. One of the challenges is finding creative and effective ways to get the message across to everyone on the staff. This article describes one approach to self-directed learning that takes into consideration individual learning styles and level of proficiency with a focus on the continuum of patient care.     

Effect of mate tea (Ilex paraguariensis) on the expression of the leukocyte NADPH oxidase subunit p47phox and on circulating inflammatory cytokines in healthy men: a pilot study

Increased superoxide production by phagocytic NADPH oxidase has been associated with inflammatory conditions. Growing evidences suggest that dietary polyphenols may modulate the expression of NADPH oxidase subunits. Herein, we examined whether soluble mate tea (SMT) consumption – a polyphenol-rich beverage – affects the expression of the leukocyte NADPH oxidase protein p47^phox and/or circulating biomarkers of inflammation and antioxidant biomarkers in humans. In a two-phase study, nine men were requested to drink water (control) for 8 d and then follow a second 8-d period drinking SMT. Blood samples were analysed for p47^phox protein in CD16⁺/CD14^? cells, interleukin (IL)-1β (IL-1β), tumour necrosis factor-alpha (TNF-α), IL-6, total phenols, and reduced and oxidised glutathione (GSH and GSSG, respectively) after each study phase. After SMT intake, CD16⁺/CD14^? cells' p47^phox protein and serum TNF-α and IL-6 levels were significantly attenuated (P?<?.05) while plasma phenolic compounds and blood GSH:GSSG ratio were significantly enhanced (P?<?.05). Consumption of SMT favourably affected leukocytes' p47^phox expression and inflammatory cytokine and antioxidants levels in peripheral blood, which may help decrease oxidative stress and low-grade inflammation.     

EHR Adoption and Hospital Performance: Time‐Related Effects

Objective

To assess whether, 5 years into the HITECH programs, national data reflect a consistent relationship between EHR adoption and hospital outcomes across three important dimensions of hospital performance.

Data Sources/Study Setting

Secondary data from the American Hospital Association and CMS (Hospital Compare and EHR Incentive Programs) for nonfederal, acute‐care hospitals (2009–2012).

Study Design

We examined the relationship between EHR adoption and three hospital outcomes (process adherence, patient satisfaction, efficiency) using ordinary least squares models with hospital fixed effects. Time‐related effects were assessed through comparing the impact of EHR adoption pre (2008/2009) versus post (2010/2011) meaningful use and by meaningful use attestation cohort (2011, 2012, 2013, Never). We used a continuous measure of hospital EHR adoption based on the proportion of electronic functions implemented.

Data Collection/Extraction Methods

We created a panel dataset with hospital‐year observations.

Principal Findings

Higher levels of EHR adoption were associated with better performance on process adherence (0.147; p < .001) and patient satisfaction (0.118; p < .001), but not efficiency (0.01; p = .78). For all three outcomes, there was a stronger, positive relationship between EHR adoption and performance in 2010/2011 compared to 2008/2009. We found mixed results based on meaningful use attestation cohort.

Conclusions

Performance gains associated with EHR adoption are apparent in more recent years. The large national investment in EHRs appears to be delivering more consistent benefits than indicated by earlier national studies.