The computer processing of experimental research data on malaria. 1. The primary processing of the dynamic indices of malarial infection

Universal computer software for primary statistical and graphic analysis of data on malaria dynamics in patients and in the experiment has been suggested. The analysis of the results of investigations on rodent malaria model in based on graded parasitemia assessment according to Moshkovski? [correction of Mashkovsky].     

Assessment of control in asthma: the new focus in management

Several evidence-based guidelines on the management of asthma have been developed in the last two decades. There is a consensus that a stepped-up approach with anti-inflammatory drugs based on severity forms the cornerstone of treatment. Goals of management have been defined. Studies in several countries have however shown that a large majority of patients have failed to attain the goals of treatment. This has led to a reconsideration of strategy of management. The focus is now shifting to an assessment and a treatment approach based on control. The objective is to achieve and monitor to maintain control. The previous treatment algorithms based on assessment of severity are being discarded. It has been emphasised that the state of control is a dynamic one and therefore a regular assessment and modifications of treatment according to changes in its level are necessary. There is a need to use some method to assess control. A wide range of techniques to assess control are available that can be used depending on the requirements, settings and resources. Assessment of control may be an informal global judgement by the physician or simple tools may be used. Several formal instruments to assess the state of control have also been developed and validated in different settings. These allow a more objective and a quantitative evaluation. Control needs to be assessed at every visit of a patient and treatment adjusted accordingly.     

Fibrosis assessment: impact on current management of chronic liver disease and application of quantitative invasive tools

Fibrosis, a common pathogenic pathway of chronic liver disease (CLD), has long been indicated to be significantly and most importantly associated with severe prognosis. Nowadays, with remarkable advances in understanding and/or treatment of major CLDs such as hepatitis C, B, and nonalcoholic fatty liver disease, there is an unprecedented requirement for the diagnosis and assessment of liver fibrosis or cirrhosis in various clinical settings. Among the available approaches, liver biopsy remains the one which possibly provides the most direct and reliable information regarding fibrosis patterns and changes in the parenchyma at different clinical stages and with different etiologies. Thus, many endeavors have been undertaken for developing methodologies based on the strategy of quantitation for the invasive assessment. Here, we analyze the impact of fibrosis assessment on the CLD patient care based on the data of recent clinical studies. We discuss and update the current invasive tools regarding their technological features and potentials for the particular clinical applications. Furthermore, we propose the potential resolutions with application of quantitative invasive tools for some major issues in fibrosis assessment, which appear to be obstacles against the nowadays rapid progress in CLD medicine.     

A Bayesian approach to the assessment of inhibitor risk in studies of factor VIII concentrates

The assessment of inhibitor risk is a crucial component in the clinical development of new and modified factor VIII (FVIII) preparations. There has been a recent discussion about the design of studies and the assessment of inhibitors and inhibitor risk in such studies at a recent FDA-sponsored FVIII Inhibitor Workshop, and new requirements for the success of these trials have been proposed to evaluate inhibitor data based on the use of an upper 95% confidence bound. We review the consequences of these requirements and demonstrate that for any product to succeed, it must have an extremely low underlying risk of inhibitor development. Furthermore, several existing commercially available FVIII products with an excellent safety record would not necessarily pass these endpoints. As a result, we propose an alternative set of acceptance criteria based on a Bayesian statistical paradigm. This approach is based on the determination of a probability that the product in question actually has an inhibitor risk below some pre-set limit, a concept that we believe is more intuitive than the traditional confidence interval method. We show that all existing products would pass this approach, but a product (Bisinact) with known inhibitor risk would not.     

基于累积缺陷原则构建的衰弱指数及其应用进展

衰弱是因机体生理储备和应激适应能力下降和失调而易发生不良结局的临床状态或综合征。目前衰弱的评估无金标准,但研究发现累积缺陷模型对各种不良临床事件的预测能力高于其他衰弱评估方法。本文主要对基于累积缺陷原则构建的衰弱指数及其构建方法、常见种类及其应用等方面相关研究进行综述,为衰弱评估提供新思路和新方法。     

Prediction of outcome of patients admitted to a geriatric department.

The reliability of a clinical prognosis of outcome at six weeks has been investigated in a series of 1092 consecutive admissions to a geriatric department. The prognosis was made within a day of admission and made use only of the history and clinical findings. The results for discharge were good but categorization of patients who died or who stayed longer than six weeks was less reliable. Unpredicted deaths were often sudden or related to disease with developed after assessment. Other errors were due to over-optimism in forecasting response to medical treatment or rehabilitation. In other cases progressive deterioration had not been clearly recognized at our assessment based on a single point in time.     

Activity index in Crohn's disease

The gold standard to quantify Crohn's disease activity is still not defined and a world consensus to unify criteria is necessary. Criticism has been directed towards every existing indexes. We summarize some of the currently used criteria for the assessment of disease activity, point out the controversies and issues that will need further investigations, and discuss their usefulness based on our experience.     

Importance of severity of illness assessment in management of lower respiratory infections

PURPOSE OF REVIEW: Patients with lower respiratory infections display a wide spectrum of disease severity. Management decisions regarding site of care, extent of investigations and level of treatment are mainly based on disease severity. Several severity assessment tools are still undergoing evaluation. This review highlights recent relevant studies. RECENT FINDINGS: Severity prediction rules such as the Pneumonia Severity Index cannot be relied upon as the sole means of identifying patients with lower respiratory infections who do not need hospital admission. Up to 40% of patients assigned to low-risk groups may require hospitalization. The most common medical reason for hospitalization in these circumstances is the presence of unstable comorbid illness. Social factors are equally important in the decision to admit. A new prediction rule based on the British Thoracic Society prediction rule has been proposed. This divides patients with community acquired pneumonia into three management groups based on risk of mortality. A prediction rule for use in patients with HIV-associated community acquired pneumonia has also been proposed. An IL-10 polymorphism has been identified as a prognostic factor in community acquired pneumonia. Audits examining the impact of adherence to severity-based guidelines on the outcome of community acquired pneumonia have revealed conflicting results. Differences in outcome may only be significant for patients with the most severe illness. SUMMARY: Severity of illness assessment is important in guiding management options at various stages in the clinical course of lower respiratory infections. However, no prediction rule should supercede clinical judgment.     

Evaluation of mitral regurgitation by Doppler echocardiography

The diagnosis and assessment of mitral regurgitation has been one of the main challenges for cardiac ultrasound. Imaging techniques (M-mode and two-dimensional echocardiography) provide direct morphologic and etiologic information of the evaluation of patients with suspected mitral regurgitation. The advent of cardiac Doppler increased tremendously the ability to evaluate mitral regurgitation noninvasively. Continuous-wave and pulsed Doppler have been found to be sensitive and specific in the detection of mitral regurgitation. The introduction of color flow Doppler simplified enormously the assessment of patients with suspected mitral regurgitation. The maximal regurgitant area and maximal regurgitant area corrected for left atrial size have become the most commonly used parameters to evaluate mitral regurgitation by color flow Doppler in the clinical setting. However, the color regurgitant jet area is highly dependent on anatomical, hemodynamic, and equipment factors. A new method, based on the proximal isovelocity surface area, is being evaluated and appears to be relatively independent of equipment factors. Transesophageal echocardiography has been shown to be exquisitely sensitive in the detection of mitral regurgitation. Quantitation of mitral regurgitation by transesophageal echocardiography is currently based on the maximal regurgitant area and this parameter appears to correlate closely with the angiographic degree of mitral regurgitation. Pulmonary venous flow analysis had been used in conjunction with color flow mapping for the evaluation of mitral regurgitation by transesophageal echocardiography. The presence of reversed systolic flow has been shown to be sensitive and specific for the diagnosis of severe mitral regurgitation. Patients with clinically difficult surface studies, flail mitral valve leaflets, and prosthetic mitral valve are best evaluated by the transesophageal approach with interrogation of pulmonary venous flow.     

Methods for the assessment of abuse liability of psychomotor stimulants and anorectic agents in humans

Although stimulant drugs have been available and abused for centuries, it is only recently that procedures for evaluating their liability for abuse have been developed. This methodological development relies on several converging assessment procedures, combining to reveal the resultant profile of effects. The first of these, drug self-administration, is based on the principle that those drugs which can serve as reinforcers, maintaining behavior leading to their delivery, have a high liability for abuse. In addition, the more traditional approach to measuring abuse liability has been through assessing self-reported effects in which standardized questionnaires are used. A variant of this, a drug liking' scale has also been used. A third focus of measurement has been the accuracy with which subjects can identify the drug they have been administered, with some laboratories developing procedures for training subjects to discriminate specific substances. The profile of effects obtained with a specific compound can then be compared to the profile obtained with prototypic stimulants such as amphetamine or cocaine. The extent to which these profiles are similar would predict relative liability for abuse. This paper describes the data collected for amphetamine and concludes that the most accurate assessment of abuse liability is obtained when an unknown drug is compared to a drug with abuse liability using as many of these measures as possible.     

Should a statin be given to all hypertensive patients?

Statins have become an essential treatment for primary and secondary prevention of cardiovascular risk. This has been firmly established for patients with a relatively high risk for cardiovascular complications. Recent studies, in particular the HOPE trial, has extended this observation to patients with intermediate cardiovascular risk, including hypertensive patients. On the other hand, statin use has been associated with side effects in a small percentage of patients. The decision to add a statin to the drug treatment of a hypertensive patient should be based on an assessment of the individual's potential risk reduction and the perceived side effects of the treatment.     

Clinical assessment of a new method for pacing pulse detection using a hybrid circuit in digital Holter monitoring

Holter monitoring is widely used for the detection of arrhythmia and ischemic episodes. Traditionally, analog amplitude-modulated Holter devices have been used for detecting arrhythmia, but they produce signal distortion due to contour effects and phase distortion caused by the tape recorders. A digital Holter device without these disadvantages has been developed and can reproduce clinically accurate electrocardiographic waveforms useful for assessment of arrhythmia and ST segments. However, their reliability is questionable when detecting pacing pulses in pacemaker patients. Because electrocardiographic signals are digitized based on sampling rate, pacing pulses are occasionally missed. Therefore, the FM-300 was developed, a new device for detecting pacing pulses on digital recordings that has both digital and analog circuits in one system and indicates pacing pulse timing with arrows. This device can automatically detect and recognize pacing pulses from various artifacts and pacing modalities, making it easy to identify pacing pulses on digitally recorded electrocardiograms. The FM-300 is useful in the diagnosis and assessment of pacemaker function and has improved the reliability of pulse detection in digital Holter monitoring.     

Establishing and using a community inter-agency client monitoring system to develop addictions treatment programs

The Substance Abuse Monitor is a comprehensive community-based addictions information system that forms the basis for an innovative approach to community needs assessment. This paper describes: (1) the conditions that created the need and support for the monitoring system; (2) the community development strategy that was employed to secure the commitment of agencies to the project; (3) the specifics of the needs assessment procedures; (4) some of the theoretical, clinical and methodological issues on which the procedures are based; (5) the practical applications of the system; and (6) the limitations of the system. The establishment of the database was based upon the idea that there would be benefits at several levels: the community, the participating agencies, the individual counsellors and the clients. The realization of these benefits requires that the information collected and the results generated must be capable of addressing specific service delivery problems with practical and tangible solutions. It is argued that the project has been successful in generating such solutions, and has considerable potential as an ongoing needs assessment tool.     

过程化考核在留学生《人体寄生虫学》教学中的探索与实践

教学评价是检验教学质量的一种重要手段。为更好地实现医学留学生培养目标,根据留学生具体情况,结合《人体寄生虫学》学科特点,建立了留学生过程化考核评价体系,突出考核过程化、形式多样化和试题探索性等特点,应用随堂测试、实验操作、翻转课堂、案例讨论等形式评价考核。实施过程化考核后,5个年级留学生《人体寄生虫学》学期考核总体优秀（考核成绩≥ 90分）（13.09%）和良好（80 ~ 89分）比例（36.13%）均较实施前（分别为3.25%和18.83%）提高（t = 5.995和7.505,P均 < 0.001）,总体不及格（< 60分）比例（3.24%）较实施前（12.34%）降低（t = 7.303,P < 0.000 1）。结果表明,过程化考核提升了留学生《人体寄生虫学》考核成绩、提高了教学质量。     

Direct migration inhibition test with leukocytes as indicator of mycobacterial antigens in the human body.

In 32 patients with newly detected pulmonary tuberculosis positive on smear and culture, included in a controlled clinical trial, a significant correlation between diminishing inhibition of leukocyte migration (induced by PPD) and reduction of mycobacterial population in the sputum during the course of chemotherapy has been demonstrated. The changes of mycobacterial population in the host have been assessed in two ways: an indirect assessment was made from the time taken to achieve sputum smear and culture negativity; a direct assessment was based on repeated quantitative determinations of tubercle bacilli in the sputum. The direct migration inhibition test with peripheral buff-coated leukocytes, is an easy and reliable correlate of delayed hypersensitivity to mycobacterial antigens in the human body. It is suggested that its use in individual patients could indicate changes in mycobacterial population, particularly after microbiological negativity has been obtained, and thus could be helpful in estimating the optimum duration of chemotherapy.     

Coronary physiology in the cath lab: beyond the basics

The adoption of invasive coronary physiologic lesion assessment before percutaneous coronary intervention has become routine in many catheterization laboratories. In the last decade, numerous studies have demonstrated favorable outcomes for revascularization decisions based on in-lab coronary physiology in many patients. The use of coronary physiology in the laboratory has been identified as a class IIa recommendation for patients in whom the clinical presentation and supporting data are too inconclusive to make an objective decision regarding treatment. This article reviews pertinent concepts and studies of the more complex applications of translesional pressure measurements for optimal patient outcomes.     

Outcome measures and treatment endpoints other than platelet count in childhood idiopathic thrombocytopenic purpura.

Therapy for children with acute idiopathic thrombocytopenic purpura (ITP) has been controversial, in great part because it is not evidence based. Some physicians are activists, treaters, or interventionists with regard to therapy of ITP whereas others have been described as nontreaters or noninterventionists. Platelet count (which is often extremely low in ITP) has generally been employed as a surrogate measure of hemorrhagic risk even though life-threatening or fatal bleeding is rare. Virtually all of the randomized clinical trials conducted in childhood ITP have focused on platelet counts as the sole outcome measure. However, other determinants should influence clinical decision making, including assessment of bleeding tendency. Laboratory testing has not been helpful in this regard, but clinical assessment by means of semiquantitative bleeding scores may prove more useful than simply designating a patient as having a "dry" or "wet" purpura. The side effects as well as costs (direct and indirect) of therapy must also be considered when attempting to weigh the merits of drug therapy against their risks. Finally, the effect of ITP and its treatment on health-related quality of life should be determined. Measurement tools to assess each of these alternative outcome measures are in early stages of development. Employing them in addition to platelet counts in future clinical trials will allow treatment to be based more on scientific data than treatment philosophy.     

Identification and assessment of the malnourished patient

The assessment of protein-energy malnutrition has become important for identifying patients whose nutritional status increases their risk of an adverse outcome during hospitalization. Anthropometric, biochemical and immunological measurements, used either alone or in combination are not sensitive or specific enough for monitoring short-term nutritional changes, although some of these variables are associated with an increased incidence of postoperative complications after surgical procedures. The sensitivity of clinical assessment is dependent on the training of the clinician and the outcome variable being sought. For most clinicians, objective measurements are needed to raise their awareness to potential nutritional problems. The relationship of nutritional status to clinical events, particularly stress events during hospitalization, is critical to the interpretation of nutritional measurements and relating them to outcome variables. A classification based on the concepts of nutritional depletion and stress is presented. The prevalence of PEM has been shown to be between 20 and 30% in western hospitals, depending on the population studied and the criteria used to define PEM. In studies which have claimed an association between nutritional status and outcome, the contribution of nutritional variables to the development of postoperative complications has been overestimated and the relevance of technical factors underestimated.     

Community-acquired pneumonia: severity of illness evaluation

Severity-of-illness assessment is now an accepted part of clinical practice and clinical research for the management of adults who have community-acquired pneumonia. Several approaches to this issue have been devised based on severity-of-illness scores or rules, some related to site of management. No single approach has been found to be superior to others, but further research into their effect on outcome in clinical practice is required. It is likely that different approaches may suit different populations and health care systems.     

The art of cardiovascular risk assessment

Cardiovascular disease (CVD) remains the leading cause of death in the United States. Healthcare expenditures have been principally allocated toward treatment of CVD at the end of the health/disease continuum, rather than toward health promotion and disease prevention. A focused effort on both primordial and primary prevention can promote cardiovascular health and reduce the burden of CVD. Risk‐factor assessment for predicting atherosclerotic CVD events serves as the foundation of preventive cardiology and has been driven by population‐based scoring algorithms based on traditional risk factors. Incorporating individual nontraditional risk factors, biomarkers, and selective use of noninvasive measures may help identify more at‐risk patients as well as truly low‐risk individuals, allowing for better targeting of treatment intensity. Using a combination of validated population‐based atherosclerotic CVD risk‐assessment tools, nontraditional risk factors, social health determinants, and novel markers of atherosclerotic disease, we should be able to improve our ability to assess CVD risk. Through scientific evidence, clinical judgment, and discussion between the patient and clinician, we can implement an effective evidence‐based strategy to assess and reduce CVD risk.