电子喉镜在确定阻塞性睡眠呼吸暂停低通气综合征阻塞部位的应用价值

目的：探讨诱导睡眠下应用电子喉镜对阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者,进行上呼吸道阻塞部位的定位诊断的应用价值。方法：将经PSG确诊的OSAHS患者132例,随机分成A、B两组,A组61例,术前给予咪唑安定诱导睡眠后用电子喉镜对上呼吸道进行动态观察,以确定阻塞部位。B组71例作为对照,术前行常规上呼吸道检查。均根据定位诊断结果实施针对性的手术治疗。结果：A组OSAHS患者中存在多部位阻塞者达72.1%,而B组患者中存在多部位阻塞者仅33.8%。两组差异有显著性（P〈0.05）。患者术后均随访6个月以上,A组总有效率达91.8%,B组仅为64.8%。A、B两组治愈率、显效率、总有效率的差异均有统计学意义（P〈0.05）。结论：OSAHS患者术前在诱导睡眠下应用电子喉镜进行上呼吸道阻塞部位的定位诊断,并据此进行针对性的手术治疗,可以显著提高OSAHS手术治疗的效果。     

The relationship between human adipocyte and monocyte insulin binding

The assumption that insulin binding to monocytes reflects that of insulin binding to adipocytes has been examined. In normal, diabetic, thyrotoxic and cirrhotic subjects no correlation was observed between monocyte and adipocyte insulin binding. Extrapolation is not justified from monocyte binding data to conclusions about insulin-sensitive tissues.     

Population-focused practice: introduction to baccalaureate-level nursing students

This article describes a clinical nursing experience which introduces baccalaureate students to population-focused practice in the community. The importance of such practice in community health nursing is discussed as is the rationale for including it at the undergraduate level. An overview of how the experience fits within the baccalaureate nursing curriculum is presented. Individual and group student responsibilities are outlined, explaining the structure of this nursing experience. Student projects with two groups--the well elderly and the school-aged are described to illustrate the clinical experience. Finally, an evaluation of the experience is presented which indicates that it has benefits for clients, community health nurses, students and faculty.     

Impact of a Health Information Technology Intervention on the Follow-up Management of Pulmonary Nodules

Lung cancer is the leading cause of cancer deaths in the USA. The most common abnormalities suspicious for lung cancer on CT scan include pulmonary nodules. Recommendations to improve care for patients with pulmonary nodules require follow-up management. However, transitions in care, especially for patients undergoing transitions to ambulatory care sites from the emergency department (ED) and inpatient settings, can exacerbate failures in follow-up testing and compromise patient safety. We evaluate the impact of a discharge module that includes follow-up recommendations for further management of pulmonary nodules on the study outcome and follow-up management of patients with pulmonary nodules within 1 year after discharge. After IRB approval, we collected data on all patients undergoing chest or abdominal CT exams over a 12-month baseline and 12-month intervention period at an academic medical center. The inpatient discharge module was implemented in November 2011; the ED module was implemented in May 2012. Multivariable logistic regression was performed to account for care setting, imaging modality, recommendations, and patient demographics. Implementation of a discharge module resulted in improved follow-up of patients with pulmonary nodules within 1 year after discharge (OR = 1.64, p = 0.01); the ED implementation resulted in better follow-up compared to the inpatient module (OR = 2.24, p < 0.01). Twenty-seven percent of patients with pulmonary nodules received follow-up management, which, although significantly improved from the 18% baseline, remains low. An electronic discharge module is associated with improved follow-up management of patients with pulmonary nodules, and may be combined with interventions to further improve management of these patients.     

Hodgkin's disease: a population-adjusted clinical epidemiology study (PACE) of management at presentation. Northern Region Lymphoma Group

Between January 1991 and December 1993, all newly-diagnosed patients with Hodgkin's disease in the Northern Health Region (population 3.08 million) were entered into a prospective population-based (PACE) study to assess the accuracy of staging at diagnosis, and to evaluate treatment and outcome. On histological review, 202 patients were confirmed to have Hodgkin's disease, an incidence of 2.2 per 100,000 per annum. Radiological review revealed that only 12% of patients were staged to recognized guidelines. In early-stage disease, treatment outcome was comparable to published results in Stage IA disease, but disappointing for Stage IIA. This was partly due to inadequate or inaccurate staging. In-built audit in the process was followed by the introduction and implementation of improved guidelines. Of younger patients (15-55 years) with 'poor-risk disease', 75% of the eligible population were entered into the appropriate randomized controlled trial. This intensive treatment has led to improved survival in this group over that which might be expected on four-drug therapy. The results of the randomized trial are not discussed as it is currently ongoing. This combined research/audit programme has resulted in greater standardization of care across a whole region, and confirms that the PACE (population-adjusted clinical epidemiology) approach facilitates the flow of information from research into practice and vice versa.      

Implementing a Program of <Emphasis Type="Italic">Talimogene laherparepvec</Emphasis>

Background

Oncolytic viruses are genetically engineered or naturally occurring viruses that selectively replicate in cancer cells without harming normal cells. Talimogene laherparepvec (Imlygic^®), the first oncolytic viral therapy approved for treatment of cancer, was approved for treatment of locally advanced melanoma in October 2015.

Purpose

As a biologic product, use of T. laherparepvec in the clinical setting requires pretreatment planning and a unique systematic approach to deliver the therapy. The processes we describe herein could be adopted by other centers that choose to prescribe T. laherparepvec.

Methods

We studied our clinical trial experience with T. laherparepvec before we embarked on using commercially available T. laherparepvec. We created a standard operating procedure (SOP) with multidisciplinary buy-in and oversight from leadership in Infection Control at our institution. We reflected on clinical cases and the actual procedures of administering T. laherparepvec to create the SOP.

Results

The preimplementation planning, patient selection, identification of lesions to treat, the actual procedure, and ongoing assessment of patients are described. Tumoral-related factors that lead to unique challenges are described.

Conclusions

A process to ensure safe and responsible implementation of a program to administer T. laherparepvec for treatment of melanoma may improve the quality of treatment for patients who suffer from advanced melanoma.

     

Associations between craving,trauma, and the DARNU scale: Dissatisfied,anxious, restless,nervous, and uncomfortable

This study evaluated the clinical utility of a measure of negative emotionality, the DARNU scale (Dissatisfied, Anxious, Restless, Nervous, and Uncomfortable), using data from a naturalistic sample of consecutive admissions to a residential substance use treatment program. Data derived from routine clinical assessments of 124 (55.6% male) patients were analyzed to assess study aims. The DARNU scale in addition to measures of drug and alcohol craving, severity of posttraumatic stress disorder (PTSD), and severity of substance use disorder (SUD) were administered to all patients. Results revealed significant positive correlations between DARNU and PTSD (r = .783), craving (r = .366), and SUD (r = .331). The DARNU scale yielded a Cronbach’s alpha of .91. When patients were categorized into quartiles based on DARNU elevations, 88.9% of patients in the highest quartile met diagnostic criteria for PTSD, while 89.2% of patients in the lowest quartile did not receive a PTSD diagnosis. Linear regression indicated that the affective vulnerability measured by DARNU mediated the relationship between PTSD and craving. The DARNU scale may identify patients at elevated risk for relapse, and may have the potential to serve as a brief clinical indicator of PTSD without asking about a specific traumatic event.     

The use of plasma as a replacement fluid in plasma exchange. Canadian Apheresis Group

BACKGROUND: The Canadian Apheresis Group has maintained a national registry of apheresis activities for the past 16 years. Since 1991, the use of plasma as a replacement fluid in plasma exchange has been recorded. STUDY DESIGN AND METHODS: Six years of data from the registry on the use of plasma as a replacement fluid were analyzed. RESULTS: Plasma was used in more than 25 percent of all plasma exchange procedures. Of 41,519 plasma exchange procedures reported, 11,970 used plasma alone or in combination with albumin. In 1991, 1026 (78%) of these procedures used plasma appropriately for either thrombotic thrombocytopenic purpura (TTP) or adult hemolytic uremic syndrome (HUS); between 1992 and 1996, these numbers were 1043 (81%), 1570 (86%), 1171 (87%), 2192 (92%), and 2741 (90%), respectively. In the remaining procedures, frozen or cryosupernatant plasma was administered to 326 patients for a total of 40 diseases other than TTP or HUS. CONCLUSIONS: In those diseases for which plasma was administered as the sole replacement fluid, no disease appears to justify such treatment without the existence of an associated condition requiring specific replenishment of some plasma component. Further evaluation of the specific indications for the use of plasma as a replacement fluid in plasma exchange is required for diseases other than TTP or HUS.     

Integration of mechanistic and pharmacokinetic information to derive oral reference dose and margin‐of‐exposure values for hexavalent chromium

The current US Environmental Protection Agency (EPA) reference dose (RfD) for oral exposure to chromium, 0.003 mg kg^?1 day^?1, is based on a no‐observable‐adverse‐effect‐level from a 1958 bioassay of rats exposed to ≤25 ppm hexavalent chromium [Cr(VI)] in drinking water. EPA characterizes the confidence in this RfD as “low.” A more recent cancer bioassay indicates that Cr(VI) in drinking water is carcinogenic to mice at ≥30 ppm. To assess whether the existing RfD is health protective, neoplastic and non‐neoplastic lesions from the 2 year cancer bioassay were modeled in a three‐step process. First, a rodent physiological‐based pharmacokinetic (PBPK) model was used to estimate internal dose metrics relevant to each lesion. Second, benchmark dose modeling was conducted on each lesion using the internal dose metrics. Third, a human PBPK model was used to estimate the daily mg kg^?1 dose that would produce the same internal dose metric in both normal and susceptible humans. Mechanistic research into the mode of action for Cr(VI)‐induced intestinal tumors in mice supports a threshold mechanism involving intestinal wounding and chronic regenerative hyperplasia. As such, an RfD was developed using incidence data for the precursor lesion diffuse epithelial hyperplasia. This RfD was compared to RfDs for other non‐cancer endpoints; all RfD values ranged 0.003–0.02 mg kg^?1 day^?1. The lowest of these values is identical to EPA's existing RfD value. Although the RfD value remains 0.003 mg kg^?1 day^?1, the confidence is greatly improved due to the use of a 2‐year bioassay, mechanistic data, PBPK models and benchmark dose modeling.