Evaluating the efficacy and safety of vascular IPL for treatment of acute cutaneous leishmaniasis: a randomized controlled trial

Lasers in Medical Science - Treatment of cutaneous leishmaniasis (CL) continues to be a health concern, and alternative therapies with fewer side effects are substantially needed. This study aimed...     

Financial impact of ivabradine on reducing heart failure penalties under the Hospital Readmission Reduction Program

Objective: The introduction of the Hospital Readmission Reduction Program (HRRP) has led to renewed interest in developing strategies to reduce 30?day readmissions among patients with heart failure (HF). In this study, a model was developed to investigate whether the addition of ivabradine to a standard-of-care (SoC) treatment regimen for patients with HF would reduce HRRP penalties incurred by a hypothetical hospital with excess 30?day readmissions.

Research design: A model using a Monte Carlo simulation framework was developed. Model inputs included national hospital characteristics, hospital-specific characteristics, and the ivabradine treatment effect as quantified by a post hoc analysis of the Systolic Heart failure treatment with the I_f inhibitor ivabradine Trial (SHIFT).

Results: The model computed an 83% reduction in HF readmission penalty payments in a hypothetical hospital with a readmission rate of 22.95% (excess readmission ratio = 1.056 over the national average readmission rate of 21.73%), translating into net savings of $44,016. A sensitivity analysis indicated that the readmission penalty is affected by the specific characteristics of the hospital, including the readmission rate, size of the ivabradine-eligible population, and ivabradine utilization.

Conclusions: The results of this study indicate that the addition of ivabradine to an SoC treatment regimen for patients with HF may lead to a reduction in the penalties incurred by hospitals under the HRRP. This highlights the role ivabradine can play as part of a wider effort to optimize the care of patients with HF.     

Q-Switched Ruby Laser Treatment for Postsclerotherapy Hyperpigmentation

BACKGROUND: One of the most common adverse sequelae of sclerotherapy is cutaneous hyperpigmentation. OBJECTIVE: We used the Q-switched ruby laser to treat postsclerotherapy hyperpigmentation. METHODS: Eight patients developed pigmentation lasting more than 1 year (1-2 years on average) after sclerotherapy treatment for reticular and telangiectatic veins in the legs ranging in size from 0.2 to 4 mm in diameter. All patients were treated with a Q-switched ruby laser at 694 nm, 4 mm beam size, and fluence range of 5.6-10.5 J/cm2. RESULTS: Ninety-two percent of lesions lightened after treatment. There was significant (75-100%) resolution of hyperpigmentation in 58% of treated areas, 25% improvement in 33% of treated areas, and no improvement in the remaining areas. CONCLUSION: Our impression is that given a choice of lasers, the Q-switched ruby laser provides the greatest efficacy for treating postsclerotherapy hyperpigmentation.     

Laser microdissection as a new tool to investigate site‐specific gene expression in enteric ganglia of the human intestine

Background Myenteric ganglia are key‐structures for the control of intestinal motility and their mRNA expression profiles might be altered under pathological conditions. A drawback of conventional RT‐PCR from full‐thickness specimens is that gene expression analysis is based on heterogeneously composed tissues. To overcome this problem, laser microdissection combined with real‐time RT‐PCR can be used to detect and quantify low levels of gene expression in isolated enteric ganglia. Methods Fresh unfixed full‐thickness specimens of sigmoid colon were obtained from patients (n = 8) with diseases unrelated to intestinal motility disorders. 10 μm cryo‐sections were mounted on membrane‐coated slides and ultra‐rapidly stained with toluidine blue. Myenteric ganglia were isolated by laser microdissection and catapulting for mRNA isolation. Real‐time RT‐PCR was performed for selected growth factors, neurotransmitter receptors and specific cell type markers. Key Results Collection of 0.5 mm² of ganglionic tissue was sufficient to obtain positive RT‐PCR results. Collection of 4 mm² resulted in ct‐values allowing a reliable quantitative comparison of gene expression levels. mRNA analysis revealed that neurotrophic growth factor, neurotrophin‐3, serotonin receptor 3A, PGP 9.5 and S100β are specifically expressed in myenteric ganglia of the human colon. Conclusions & Inferences Laser microdissection combined with real‐time RT‐PCR is a novel technique to reliably detect and quantify site‐specific expression of low‐abundance mRNAs (e.g. growth factors, neurotransmitter receptors) related to the human enteric nervous system. This technical approach expands the spectrum of available tools to characterize enteric neuropathologies underlying human gastrointestinal motility disorders at the molecular biological level.     

Primary diagnosis of malignant mesothelioma by fine-needle aspiration of a supraclavicular lymph node

Malignant mesothelioma is a rare neoplasm with poor prognosis. The pleural form is defined as a malignant tumor of mesothelial cells with a diffuse growth pattern involving the visceral and parietal surfaces of the pleura. To our knowledge, there have only been two reported cases in the literature where fine-needle aspiration (FNA) of a lymph node was the primary mode of diagnosis of malignant mesothelioma. We describe a 40-yr-old male in whom the primary diagnosis of malignant mesothelioma was made by FNA of a supraclavicular lymph node. The mesothelial origin of the tumor was confirmed with immunohistochemical studies. A pleural biopsy immediately preceding the FNA was interpreted as chronic inflammation. Most patients with clinically documented lymph node metastases of malignant mesothelioma have had a previously established diagnosis of mesothelioma. Our case demonstrates that FNA can be a simple and invaluable method of diagnosis in those unusual cases where diagnosis of malignant mesothelioma has not already been made before lymphadenopathy.     

Integrated decision support in a hospital cancer registry

In this paper we present (a) a shell for integrated knowledge-based functions that is destined to support decision processes of the users of the Giessener Tumordokumentationssystem (GTDS) and (b) some results we obtained during a 6-month observation period at one of the customers of the GTDS. A special characteristic of the provided decision support is the high degree of integration in the underlying information system GTDS, i.e. the functions are triggered by events in the patient database, existing patient data is reused as input for the reasoning process and generated alerts are presented instantly to the end-user. The first routine field of application was supporting registrars to adhere to integrity constraints as defined by the International Agency of Research on Cancer (IARC) during the documentation process. This information is important for the registrars since the checks of the IARC are an accepted standard for data quality in cancer registries. The expected benefit of this application area is less effort in achieving adherence to the specification of the IARC by preventing the costly rectification at a later time. During the last 5 months of the observation period 164 alerts were displayed. About 65% of the assessed alerts were considered to be correct. Especially, the analysis of the incorrect alerts revealed some shortcomings in the knowledge behind some of the integrity constraints of the IARC. The general feedback from the end-users indicate positive user satisfaction. Currently, the shell is in use in six hospital cancer registries.     

Value of XML in the implementation of clinical practice guidelines--the issue of content retrieval and presentation

The purpose of guidelines in clinical practice is to improve the effectiveness and efficiency of clinical care. It is known that nationally or internationally produced guidelines which, in particular, do not involve medical processes at the time of consultation, do not take local factors into account, and have no consistent implementation strategy, have limited impact in changing either the behaviour of physicians, or patterns of care. The literature provides evidence for the effectiveness of computerization of CPGs for increasing compliance and improving patient outcomes. Probably the most effective concepts are knowledge-based functions for decision support or monitoring that are integrated in clinical information systems. This approach is mostly restricted by the effort required for development and maintenance of the information systems and the limited number of implemented medical rules. Most of the guidelines are text-based, and are primarily published in medical journals and posted on the internet. However, internet-published guidelines have little impact on the behaviour of physicians. It can be difficult and time-consuming to browse the internet to find (a) the correct guidelines to an existing diagnosis and (b) and adequate recommendation for a specific clinical problem. Our objective is to provide a web-based guideline service that takes as input clinical data on a particular patient and returns as output a customizable set of recommendations regarding diagnosis and treatment. Information in healthcare is to a very large extent transmitted and stored as unstructured or slightly structured text such as discharge letters, reports, forms, etc. The same applies for facilities containing medical information resources for clinical purposes and research such as text books, articles, guidelines, etc. Physicians are used to obtaining information from text-based sources. Since most guidelines are text-based, it would be practical to use a document-based solution that preserves the original cohesiveness. The lack of structure limits the automatic identification and extraction of the information contained in these resources. For this reason, we have chosen a document-based approach using eXtensible Markup Language (XML) with its schema definition and related technologies. XML empowers the applications for in-context searching. In addition it allows the same content to be represented in different ways. Our XML reference clinical data model for guidelines has been realized with the XML schema definition. The schema is used for structuring new text-based guidelines and updating existing documents. It is also used to establish search strategies on the document base. We hypothesize that enabling the physicians to query the available CPGs easily, and to get access to selected and specific information at the point of care will foster increased use. Based on current evidence we are confident that it will have substantial impact on the care provided, and will improve health outcomes.