Tightening the clinical trial

Randomized clinical trials adhere more closely to pre-agreed-on protocols than almost any other type of experiment; yet we can tighten up their analysis if we desire. If we convert the analysis into a randomization analysis—where the one set of data is analyzed many times—once as though each acceptable assignment has been employed, we can eliminate any dependence of the analysis on statistical or probabilistic assumptions. To do this effectively when many assignments could be acceptable, we can go to double randomization, in which a subset, usefully kept balanced, of acceptable assignments is selected (perhaps randomly) before data acquisition.If we have one covariate, adjustment for which answers a question that is at least as appropriate, we can easily build on this. Imperfect covariance adjustments can help almost as much as perfect ones. If it is appropriate to work with many covariate(s), it is often desirable to first construct a (few) compound covariate(s) and then work with it (them). Often we can base the coefficients in our compound covariate on the univariate regressions of response on single covariates. Doing this within each arm of the trial and pooling keeps the fitting of the final adjustment unbiased. Since we can prespecify how the compounds are to be calculated and fitted, we can do all this while retaining rigid prespecification.Prespecification, randomization, and intelligent use of covariates combined to make the resulting significance analysis of platinum standard quality. (If we want confidence statements, as we ordinarily should, it may make sense, for technical reasons, to plan for somewhat less than platinum standard quality.)     

Zenker's diverticulum: a cause for complete esophageal obstruction and its management

Besides the gastroenterologists, we as gastroenterology nurses and associates are probably the first line of help for patients with this disorder. By having a sound background knowledge of the mechanisms by which Zenker's diverticulum can occur and the possible complications that can arise, we can coordinate a task force of appropriate paramedical personnel: the nutritionist who can instruct the patient on good healthy dietetics, the social worker who may be able to arrange "meals on wheels," the physical therapist who can teach the patient to re-think the way he or she swallows and good deep breathing exercises. We can give our patients a sound understanding of their problem by educating them in language that they understand. By so doing we will be encouraging them in their own preventative measures to promote wellness, which is one of endoscopy's major aims in health care.     

Clinical anisotropy: A case for shared decision making in the age of too much data and patient dis‐integration

Today, in the age of big data, we are more capable than ever before. But even having the world at our disposal with naught but the touch of a button, we find ourselves exceedingly vulnerable in the patient chair. With insurmountable amounts of knowledge being published and disseminated around the world, how can clinicians keep up and what can be done about it? And sitting in the patient chair, bewildered by the ever‐changing landscape of medicine at the blink of an eye, how can we, as patients, ever hope to be part of the conversations revolving around our own health? In this work, we explore the present‐day problems of big data in the clinical context, how failing to integrate patients can result in detrimental outcomes, and what shared decision making can do about it.     

Radical toxicity of phenols: a reference point for obtaining perspective in the formulation of QSAR

In this report we discuss some of the surprising ways phenols interact in vivo and how some of their toxic activity can be understood in terms of QSAR and in fact can be related via electronic terms to be similar to processes of simple chemical reactions. A simple two-term QSAR is found to be a good predictor of estrogenic toxicity. However, it is also shown that even the simplest of phenols can yield quite unexpected results than can be elucidated via QSAR. We still have a long way to go before we can predict under what conditions a phenol will produce toxic effects such as cancer and how much phytophenols one can consume before reaping a toxic reaction.     

脑出血动物血液及胃液胃泌素变化的实验研究

胃泌素是一种由胃肠道Ｇ细胞分泌的脑肠肽，具有刺激胃酸分泌，增加胃粘膜血流量和营养胃肠道粘膜的作用。目前，对实验性脑出血后不同时期血液及胃液ＣＡＳ含量变化的报道较少。     

Automated correction of improperly rotated diffusion gradient orientations in diffusion weighted MRI

Ensuring one is using the correct gradient orientations in a diffusion MRI study can be a challenging task. As different scanners, file formats and processing tools use different coordinate frame conventions, in practice, users can end up with improperly oriented gradient orientations. Using such wrongly oriented gradient orientations for subsequent diffusion parameter estimation will invalidate all rotationally variant parameters and fiber tractography results. While large misalignments can be detected by visual inspection, small rotations of the gradient table (e.g. due to angulation of the acquisition plane), are much more difficult to detect. In this work, we propose an automated method to align the coordinate frame of the gradient orientations with that of the corresponding diffusion weighted images, using a metric based on whole brain fiber tractography. By transforming the gradient table and measuring the average fiber trajectory length, we search for the transformation that results in the best global ‘connectivity’. To ensure a fast calculation of the metric we included a range of algorithmic optimizations in our tractography routine. To make the optimization routine robust to spurious local maxima, we use a stochastic optimization routine that selects a random set of seed points on each evaluation. Using simulations, we show that our method can recover the correct gradient orientations with high accuracy and precision. In addition, we demonstrate that our technique can successfully recover rotated gradient tables on a wide range of clinically realistic data sets. As such, our method provides a practical and robust solution to an often overlooked pitfall in the processing of diffusion MRI.     

Quality assurance in ambulatory care.

This article is one example of how a more simplified audit system for evaluating patient outcomes can be implemented and can be applied to an ambulatory care setting. Quality assurance activities are here to stay, either as a result of our feeling a professional obligation to monitor our own practice in relationship to the public we serve, or as a result of pressure from consumers and third-party payers. I prefer to believe that as professionals, we do recognize our obligation to be accountable for our actions, and that only we can set the standards of practice to which we will be held accountable. Through the development of criteria for care, we are able to establish these standards of practice. In complex care settings such as our Ambulatory Care Service, the CMA/CHA audit process is a reasonable approach to assuring quality by looking at patient outcomes. This process supports the team approach to patient care, is a less expensive method because less time is required to orient personnel to the audit process, and meets JCAH requirements for accreditation.     

Nurses and Loss: A Call to Action

As we seek to understand how best to support the health and well-being of nurses, we must include a better understanding of the impact of loss and grief on the heart of a nurse. The chronic accumulation of unacknowledged, unattended grief can express itself as detachment, distancing, and avoiding caring connections, but it can also be a primary cause of more severe problems that nurses struggle with. If we courageously explore the inevitable heartbreak that is inherent in our work, it can serve as a catalyst into actions, innovations, and changes that will better prepare and support our nursing workforce.     

Quilting narrative: using repetition techniques to help elderly communicators

As we gain a better understanding of narratives presented by both normally aging adults and those with cognitive deficits, we are able to communicate more effectively. We can select more interactive ways to help construct meaning with individuals who appear to have lost the ability to communicate. We can listen for formulaic expressions or colloquial speech, furnish beginnings, echo details, add to endings. We can recall what we were told in an earlier conversation and reintroduce the topic so that the speaker with Alzheimer disease (AD) can recognize information and expand it instead of being asked to recall it. By using the repetition technique of quilting narrative, nurses can help family members see that the person with AD is trying to signal some part of a life event, which helps convey to others who he or she is.     

循环肿瘤细胞研究新进展

恶性肿瘤释放癌细胞进入血液、形成远处转移灶,导致治疗效果差、预后不良。如果在转移灶形成之前能够在血液中发现循环肿瘤细胞(CTCs),则可早期发现转移灶,在治疗期间通过外周CTCs检测来观察治疗效果和判断预后。通过检测外周CTCs的凋亡和上皮间质转变,以及对循环肿瘤干细胞(CSCs)特性的研究,可以为临床治疗提供有效数据,因此,能否有效地检测出外周血CTCs以及研究其特性直接关系到恶性肿瘤的治疗和预后。本文就外周CTCs在恶性肿瘤中的研究进展做一综述。     

Analysis of sensitivity in quantitative micro-elastography

Quantitative micro-elastography (QME), a variant of compression optical coherence elastography (OCE), is a technique to image tissue elasticity on the microscale. QME has been proposed for a range of applications, most notably tumor margin assessment in breast-conserving surgery. However, QME sensitivity, a key imaging metric, has yet to be systematically analyzed. Consequently, it is difficult to optimize imaging performance and to assess the potential of QME in new application areas. To address this, we present a framework for analyzing sensitivity that incorporates the three main steps in QME image formation: mechanical deformation, its detection using optical coherence tomography (OCT), and signal processing used to estimate elasticity. Firstly, we present an analytical model of QME sensitivity, validated by experimental data, and demonstrate that sub-kPa elasticity sensitivity can be achieved in QME. Using silicone phantoms, we demonstrate that sensitivity is dependent on friction, OCT focus depth, and averaging methods in signal processing. For the first time, we show that whilst lubrication of layer improves accuracy by reducing surface friction, it reduces sensitivity due to the time-dependent effect of lubricant exudation from the layer boundaries resulting in increased friction. Furthermore, we demonstrate how signal processing in QME provides a trade-off between sensitivity and resolution that can be used to optimize imaging performance. We believe that our framework to analyze sensitivity can help to sustain the development of QME and, also, that it can be readily adapted to other OCE techniques.     

Unconventional patient moves

EMS is a dynamic occupation. Every day, we face new challenges. Without some "outside-the-box" thinking, it is difficult, if not impossible, to keep up. In this article, we have discussed only a few of the "tools" we apply in adverse situations. As members of the only hospital-based EMS heavy-rescue unit in the United States, we believe collectively that our primary mission is safety, first for providers and then for patients. Much of what is carried on an average heavy-rescue unit goes unused or is used only rarely. If we can take tools, equipment and techniques that we would ordinarily only apply for their most obvious use and use them in a unique and unconventional way while promoting the safety of all parties involved, then we have accomplished our primary objective. Don't let your equipment collect dust because you are only willing to use it for obvious reasons. Apply it to every rescue situation you safely can.     

DRUGS AND RHETORICAL DEVILS

It is well-known among students of persuasive communication that we can be unified and mobilized in terms both of what we love in common and of what we mutually hate. Indeed some theorists and perhaps all demagogues suspect that whereas the key to personal achievement may lie in 'positive thinking', collective triumph frequently depends on the power of negative thinking—on the ability to create a rhetorical devil. Eric Hoffer generalized the principle when he observed that, 'Mass movements can rise and spread without belief in a God, but never without belief in a devil' (1).     

Exploring language about families.

When we work with families in health care settings, it is important to be aware of the way we communicate. Often overlooked is how the language we use to describe and understand families affects how we work with them. The language we use in thinking about a family can shape our perceptions of the family and may affect how we approach working with them. The language we use in describing a family to another health care provider can affect how that person will perceive and approach the family. The language families hear us use can affect families' perceptions of themselves, their perceptions of us, and, consequently, how they relate to us. In Project Copernicus' Family Centered Communication Skills: Facilitator's Guide (Edelman, Greenland, & Mills, 1993), an activity entitled "Watch Our Language" explores commonly used negative terminology about families and guidelines for better language. This exercise has been used with groups of nurses and other health care providers at several conferences and has generated thoughtful brainstorming about negative language related to families, its impact on families, and its impact on the nurses working with them. Those participating in the workshops explored better terminology about families and brainstormed a list of selected family strengths which are shared here.     

Représentation corporelle et douleur

Pain is an event felt in our body but the representation we have of our body is not frozen. Several studies on the representation of the body and the environment in healthy subjects and painful patients have led to the emergence of a link between these elements. Body representation includes the image we have of our body and the pattern we use to move it. Chronic pain can alter the body image by making perception deformed (e.g., swollen, elongated) as we find during anesthesia. It can also alter the body’s pattern, making it difficult to move or imagine moving or even painful simply imagining to move. The representation of space can be modified in chronic pain and can explain part of the symptoms of patients. This review incorporates some of the data from clinical research to understand the relationship between pain and body representation, also discusses the evaluation and specific therapeutics.     

Home care for the dying child

The death of a child suffering from a terminal illness or congenital anomalies incompatible with life is the most painful life experience a family has to face. We, as health-care providers, cannot always prevent the death or cure the disease process. However, we can allow the family appropriate decision-making processes, such as allowing the child to die at home. We cannot take the death away, but we can walk the child's and family's journey toward his transition. Few persons in life are as privileged to share such a depth of intimacy in life as we in health care do when living the life experience of death. Death can be likened to shedding or releasing of our physical earth coats toward physical death and individual family beliefs of transition. This journey is a sacred, private, individual, and painful experience. Fear and anxiety can be decreased with appropriate education, and providing an environment of excellent clinical expertise, support, compassion, trust, and love.     

癫痫持续状态的临床研究

目的观察癫痫持续状态的临床特点及治疗。方法采用病例的回顾，对49例癫痫持续状态的临床资料进行分析。结果引起癫痫持续状态的病因以脑血管病常见；突然停药或不规则服用抗癫痫药物是癫痫持续状态的常见诱因；采用安定和苯巴比妥钠联合应用对控制癫痫持续状态有较好的临床疗效；及时有效的控制癫痫持续状态是挽救生命改善其预后的关键。结论癫痫持续状态的正确诊断，及时处理，抢救成功率高。     

Sexuality education for youth with chronic conditions

Pediatric nursing has long neglected the important topic of sexuality, supporting the myth that children are asexual. How can we learn about this crucial topic? How can we incorporate sexuality education into our nursing care in a respectful and supportive manner? How can we honor the whole person, including the sexual self? This article addresses the need for sexuality education for children with chronic conditions and their families; describes a framework for education for the separate yet inter-relating aspects of sexuality; provides practical pointers for nurses to include sexuality education in their client care; and identifies sources of information for health care providers and families.     

Seeing the invisible in differential interference contrast microscopy images

Automated microscopy image restoration, especially in Differential Interference Contrast (DIC) imaging modality, has attracted increasing attentions since it greatly facilitates long-term living cell analysis without staining. Although the previous work on DIC image restoration is able to restore the nuclei regions of living cells, it is still challenging to reconstruct the unnoticeable cytoplasm details in DIC images. In this paper, we propose to extract the tiny movement information of living cells in DIC images and reveal the hidden details in DIC images by magnifying the cells’ motion as well as attenuating the intensity variation from the background. From our restored images, we can clearly observe the previously-invisible details in DIC images. Experiments on two DIC image datasets show that the motion-based restoration method can reveal the hidden details of living cells. In addition, we demonstrate our restoration method can also be applied to other imaging modalities such as the phase contrast microscopy to enhance cells’ details. Furthermore, based on the pixel-level restoration results, we can obtain the object-level segmentation by leveraging a label propagation approach, providing promising results on facilitating the cell shape and behavior analysis. The proposed algorithm can be a software module to enhance the visualization capability of microscopes.