ABSTRACT
Knee pain Is one of the most common reasons patients visit their physician. In this regard Magnetic Resonance Imaging [MRI] is the tool of preference for diagnosis. The aim of this study was to determine appropriate guidelines for knee MRI administration using the RAND Appropriateness Method [RAM]-2013. This qualitative study was done in the Mashhad University of Medical Sciences in 2013. The most appropriate approved knee MRI administration clinical guidelines were evaluated using Guidelines Evaluation and Research Appraisal [AGREE]. Panel members consisting of six orthopedic and three rheumatologic doctors gave scores ranging from 1 to 9 for each scenario. The indications were grouped as appropriate, equivocal and inappropriate. Data were analyzed by descriptive statistics and SPSS ver. 18 software. Sixty-three scenarios were extracted from the guidelines and then the scenarios were evaluated in 26 indications. Thirty-two [50.79%] cases were considered appropriate, 12 [19.04%] cases uncertain and 19 [30.1%] cases inappropriate. The RAND appropriateness method is helpful in identifying the opinion of stakeholders in health care systems. Moreover, making practical use of clinical guidelines can improve patients' quality of care and prevent un-necessary costs
ABSTRACT
Background: The aim of this study is to assess of dose enhancement effect in tumour in presence of 10B, 157Gd, 10B nanoparticles and 157Gd nanoparticles in radiotherapy through neutron capture by Monte Carlo method.
Materials and Methods: A 252Cf brachytherapy source AT model was simulated by Monte Carlo method code MCNPX and its TG-43 parameters were calculated and compared with previous corresponding data. This 252Cf brachytherapy source was used as a neutron source in neutron capture therapy. Dose enhancement factor was compared in tumour in presence of 10B, 157Gd, 10B nanoparticles and 157Gd nanoparticles for the concentrations of 100, 200 and 500 ppm of each capture agents in neutron capture. For this aim, around the 252Cf source, a spherical soft tissue phantom and a tumour containing each capture agents were considered.
Results: Calculated air kerma strength and dose rate constant for 252Cf source equals to 0.306 cGycm2/hµg and 5.782 cGy/Uh respectively. Among examined agents, maximum DEF belonged to 10B and 10B nanoparticles in concentration of 500 ppm. These values were reported as 1.06 and 1.08 respectively.
Conclusion: IN this study, air kerma strength and dose rate constant indicate difference of %7.27 and %1.10 with other corresponding values. In dose enhancement point of view, capture agents containing 10B are more useful in neutron capture therapy. In the same concentrations, dose enhancement factor for capture agents in nanoparticles form is higher than the presence of capture agents in atomic form. So, it is preferable to use of nanoparticle capture agent rather than atomic form. However, it should be noted that before clinical usage of this agents, other medical, chemical and physical criteria should be considered, for their comparison, in selection of capture agents in neutron capture therapy.
ABSTRACT
DUE [Drug Utilization Evaluation] studies can help identify and correct problems associated with irrational use of drugs. Considering lack of data regarding how rational vancomycin is being used, we evaluated this DUE study in a referral infectious center to evaluate compliance with guidelines in terms of rational use of this valuable antibiotic. This retrospective study was done for 6 months from March to September 2012 at Razi hospital, an educational hospital affiliated to Mazandaran University of Medical Sciences. Data including patients' demographics, vancomycin dose, kidney function assessment, dose adjustments, sampling and culture were collected. Based on the HICPAC [Hospital Infection Control Practices Advisory Committee] and Up-to-date 2012 advices, the concordance of practice with standard guidelines was assessed. One hundred and forty six medical records were reviewed in this study. Fever and shortness of breath were the most common symptoms at the time of initiation of vancomycin. Skin infections, lower respiratory tract infection and septicemia were the most common initial diagnosis of patients. Sampling was done in almost one-third of patients. Most of patient with a specific order were received vancomycin in half an hour. Considering the indication, Vancomycin was administered appropriately in 58 percent of patients. Vancomycin was used irrationally in a great proportion of patients. The main observed drawbacks were empiric use of vancomycin without subsequent adjustment of antimicrobial agent according to culture and sensitivity data and lack of paying enough attention to calculation of creatinine clearance and dosage adjustment
ABSTRACT
Assessment of glomerular filtration rate [GFR] by common creatinine-based methods is potentially inaccurate in patients with cirrhosis. Cirrhotic patients have several underlying conditions that contribute to falsely low serum creatinine concentrations, even in the presence of moderate to severe renal impairment. Therefore creatinine-based methods usually overestimate true GFR in these patients. Cystatin-C is a low molecular weight protein and an endogenous marker of GFR. We compared the accuracy of plasma cystatin-C and creatinine in assessing renal function in cirrhotic patients. We serially enrolled cirrhotic patients with stable renal function admitted in our ward if they met the inclusion criteria and consented to participate. Child-Pugh [CP] score was calculated for all patients. GFR was calculated using serum creatinine, serum cystatin-C, and 99m TC-DTPA clearance with the last one serving as the gold standard. The area under curve [AUC] on receiver-operating characteristic curves [ROC] were used to assess the diagnostic accuracy of each calculated GFR with that measured by DTPA. Fourty-eight patients were enrolled [32 males, 66.7%]. Nine were in class-A, 20 in class-B and 19 in class-C of CP. Cystatin-C did not perform well in predicting the true GFR, while serum creatinine performed relatively accurately at GFR<80ml/min [AUC=0.764, p=0.004]. Serum creatinine at a cutoff of 1.4 mg/ dl was 20% sensitive and 92% specific and with at a cutoff of 0.9 mg/dl was 77% sensitive and 72% specific for diagnosis of impaired renal function. Cystatin-C could not predict GFR effectively even after stratification for CP score, gender, and BMI. Serum creatinine could predict GFR<65ml/min in females [ROC curve AUC=0.844,p=0.045]. In those with BMI>20 kg/m2 a GFR<80 ml/min could also be predicted by serum creatinine [ROC curve AUC=0.739,p=0.034]. It also could predict GFR<80ml/min in patients with CP class A and B [ROC curve AUC=0.795,/7=0.01], but not in patients with CP class C. Neither serum creatinine nor Cystatin-C are good predictors of GFR in cirrhotic patients, although serum creatinine seems to perform better in selected subgroups
Subject(s)
Humans , Male , Female , Cystatin C/blood , Creatinine/blood , Reference Standards , Technetium Tc 99m Pentetate , Sensitivity and SpecificityABSTRACT
Many factors have been proposed to be associated with higher mortality in patients on continuous ambulatory peritoneal dialysis [CAPD]. However, the relative importance of these factors may differ among patients with different characteristics. We evaluated survival of patients on CAPD and its influencing factors in Iran. We enrolled 282 patients on CAPD between 1996 and 2006 at 2 major CAPD centers in Tehran. Patient survival was investigated during this period. Demographic characteristics, laboratory data, dialysis adequacy parameters, residual renal function, peritoneal transport characteristics, and nutritional status were assessed as potential predictors of the outcome. The mean duration of follow-up was 18.4 +/- 14.5 months. Sixty patients [21%] died during the studied period. In univariate analysis, age, body mass index, history and duration of hemodialysis before CAPD, diabetes mellitus, blood pressure, patient selection criteria, edema, peritonitis, renal residual function, urine volume, dialysis adequacy, and serum levels of cholesterol, triglyceride, intact parathyroid hormone, calcium, and albumin were predictors of patient survival. Multivariate analysis demonstrated that old age, diabetes mellitus, prior hemodialysis longer than 7 months, low serum albumin, calcium, trigelyceride, and parathyroid hormone levels independently predicted mortality, while the use of angiotensin-converting enzyme inhibitors was associated with a better survival. This study showed that older patients on CAPD and diabetics are at a higher risk of mortality. On the other hand, nutritional and metabolic factors are other predictors of mortality. Especial concern should be applied to good nutrition and treatment of comorbidities in these patients
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Adolescent , Aged , Prognosis , Risk Assessment , Survival Analysis , Age Factors , Diabetes ComplicationsABSTRACT
PDpoietin is a recombinant erythropoietin alfa that has been introduced by a manufacturer in Iran. We assessed the effectiveness and complications of PDpoietin in comparison with Eprex in anemic patients on hemodialysis. This clinical trial was performed in a multicenter setting. Patients with a hemoglobin level less than 12 g/dL were assigned into 2 groups in order to receive either Eprex [Janssen Cilag] or PDpoietin [Pooyesh Darou] for 3 months. Forty-one and 34 patients completed the study in the PDpoietin and Eprex groups, respectively. The mean hemoglobin levels at baseline were not significantly different between the two groups of patients with PDpoietin and Eprex. In both groups, hemoglobin levels increased significantly, but there were no significant differences between the two groups at months 1, 2, and 3. At the end of the study, the mean hemoglobin levels reached 11.6 +/- 1.7 g/dL and 11.8 +/- 1.9 g/dL, respectively [P = .002; P = .01]. The mean hemoglobin per cumulative of drug dose index [hemoglobin/[erythropoietin dose/1000 x injections per month]] was not significantly different between the two groups at different treatment stages, and it did not change significantly in each group during the course of the study. No serious complications were reported. Eprex and PDpoietin could equally increase the hemoglobin levels with no significant complication. Therefore, PDpoietin can be used for treatment of anemia in patients on dialysis, and the patients will have the advantages of its availability and low price
Subject(s)
Humans , Male , Female , Erythropoietin , Epoetin Alfa , Renal Dialysis , Hemoglobins/drug effectsABSTRACT
The conventional treatment of acute kidney allograft injection consists of high-dose corticosteroids and polyclonal antibodies. We report our experience of tacrolimus rescue therapy in patients with acute rejections refractory to corticosteroids and polyclonal antibodies. A total of 34 patients with a mean age of 42.3 years and clinical diagnosis of acute kidney allograft rejection underwent tacrolimus rescue therapy when treatment with corticosteroids and polyclonal antibodies failed. Kidney allograft biopsy results were available in 21 patients. All of the patients received tacrolimus, 0.1 mg twice daily, and in those who responded to the therapy after 4 to 6 months, tacrolimus was replaced with cyclosporine. Pathologic examination of 21 biopsy specimens of the kidney allografts showed acute vascular rejection in 7 patients [33.3%, acute humoral rejection in 6 [28.6%], acute cellular rejection in 3 [14.3%], and accelerated acute rejection in 3 [14.3]. Twenty-six patients [76.5%] responded to rescue therapy with tacrolimus and discharged with a mean serum creatinine level of 1.4 mg/dL [range, 1.1 mg/dL to 1.7 mg/dL]. Allograft nephrectomy was done in 8 patients [23.5%] because of no response to treatment of rejection, the pathology reports of which consisted of acute vascular rejection in 5 patients and extensive necrosis in 3. Tacrolimus therapy is able to salvage kidney allograft with acute refractory injection. We recommend that tacrolimus be used as an alternative to the conventional drugs used for antirejection therapy. However, severe infectious complications as a result of overt immunosuppression must be considered
Subject(s)
Humans , Male , Female , Graft Rejection/drug therapy , Immunosuppression Therapy/adverse effects , Kidney Transplantation/adverse effects , Graft Survival , Treatment Outcome , SteroidsABSTRACT
The incidence of acute rejection of the kidney allograft in the world has been around 15% during the period between 2001 and 2003. It is clinically defined as an elevation in the level of serum creatinine by more than 0.3 mg/dL and is diagnosed by kidney biopsy. On pathologic examination, the interstitium of the allograft is diffusely edematous and infiltrated by CD4 and CD8 lymphocytes. Tubulitis occurs when the lymphocytes and monocytes extend into the walls and lumina of the tubules. Presence of leukocytes determines infection or antibody-mediated rejection. Typically C4d staining is negative. Other causes of acute allograft dysfunction included prerenal factors, interstitial nephritis, infection, acute tubular necrosis, toxicity by drugs, and obstruction in the urinary tract. The primary diagnostic assessments include history, especially adherence to immunosuppressive therapy, physical examination, blood and urine laboratory tests, measurement of the serum levels of the drugs, and ultrasonography. Diagnosis of acute cellular rejection depends on biopsy, CD20 staining for refractory cases, negative C4d staining, presence of markers of activating lymphocyte, and proteomic study. Treatment of acute cellular rejection in kidney transplant recipients include pulse steroid for the first rejection episode. It can be repeated for recurrent or resistant rejection. Thymoglobulin and OKT3 are used as the second line of treatment if graft function is deteriorating. Changing the protocol from cyclosporine to tacrolimus or adding mycophenolate mofetil or sirolimus might be effective. Prognosis depends on number of rejection episodes, the use of potent drugs, time of rejection from transplantation, and response to treatment
Subject(s)
Humans , Kidney Transplantation , Immunity, Cellular , Acute Disease , CD4 Antigens , CD8 Antigens , Antigens, CD20 , Immunosuppression Therapy , Treatment OutcomeABSTRACT
The pharmacokinetic behavior of amikacin and predictive performance of Sawchuk-Zaske dosing method, have been prospectively evaluated in 31 [16 male, 15 female] critically ill septic patients of mean [ +/- SD] age of 58 +/- 23 years, mean ideal body weight of 59.6 +/- 6.4 kg, mean creatinine clearance of 52 +/- 21.5 ml/min, mean serum albumin of 3.1 +/- 0.5 mg/dl and median APACHE [acute physiology and chronic health evaluation] II score of 26 [with a range of 18 to 33]. In this cross-sectional study, critically ill patients who met the Bone criteria for spesis but had stable creatinine clearance [serum creatinine change <0.5 mg/dl of the baseline] received the ordered dose of amikacin in one hour infusions. Blood sample were collected 30 minute after the third dose, half an hour before the fourth dose which was 1.5 times of the predicted half life of amikacin after the third dose. Cirrhotic patients and patients with renal failure requiring any mode of dialysis were excluded. Vital signs were recorded at each time of blood sampling; serum Mg+, serum albumin and APACHE score were recorded at the time of the first blood sampling. Mean [ +/- SD] of the pharmacokinetic key parameters of amikacin in this population was as follow: Vd=0.390.045 l/kg; Ke=0.141 +/- 0.057 /h; half-life=5.7 +/- 2.06 h; Clearance=54.2 +/- 25.2 ml/min. There was a good correlation between Vd and serum albumin and also APACHE score II [r2=0.83, P=0.033;r2=0.82, P<0.001 respectively]. Mean measured peak and trough amikacin concentrations were 20.9 and 3.2 micro g/ml respectively which were significanthy different [P<0.05 paired t test] from levels, predicted by Sawchuk-Zaske method [33.5 and 4.6 micro g/ml respectively]. Ke, t0.5 and cledrane did not show any statistically significant changes [P>0.05 repeated measure test] amongst three times of blood sampling, but Vd was significanly different [P<0.05]. The overall predictive performance of Sawchuk-Zaske method was poor; in spite of good correlation between predicted and measured parameters when using pooled data
Subject(s)
Humans , Male , Female , Critical Illness , Sepsis , Intensive Care Units , Prospective Studies , Kidney Function TestsABSTRACT
The high mortality rate associated with significant bleeding from stress ulceration has promoted efforts to prevent this complication in critically ill patients. Gastric pH is a key factor in the pathogenesis of stress ulceration and maintaining a pH of 4 or greater reduces the risk for development of the gastric ulceration. Our aim was to compare effects of intravenous bolus administration and continuous intravenous infusion of ranitidine on gastric pH in critically ill patients at the intensive care unit [ICU]. Twenty patients who met the inclusion criteria were entered this prospective, randomized, cross over study. A total of 1500 gastric pH measurement was obtained for each phase of the study. Continuous infusion of ranitidine maintained a gastric pH greater than 4 over a longer period than that of bolus administration [22.1 hrs vs. 14.2 hrs, respectively; P<0.001]. The pH-monitoring device which was made locally, was comparable to a standard international device. This study showed that continuous infusion of ranitidine was more effective than administration of an equivalent dose of the drug by bolus in maintaining the appropriate gastric pH required for the prevention of stress ulceration