Prehabilitation for medically frail patients undergoing surgery for epithelial ovarian cancer: a cost-effectiveness analysis / 부인종양

Objective@#To assess the potential cost-effectiveness of prehabilitation in medically frail patients undergoing surgery for epithelial ovarian cancer (EOC). @*Methods@#We created a cost-effectiveness model evaluating the impact of prehabilitation on a cohort of medically frail women undergoing primary surgical intervention for EOC. Cost was assessed from the healthcare system perspective via (1) inpatient charges from 2018–2019 institutional Diagnostic Related Grouping data for surgeries with and without major complications; (2) nursing facility costs from published market surveys. Major complication and non-home discharge rates were estimated from the literature. Based on published pilot studies, prehabilitation was determined to decrease these rates. Incremental cost-effectiveness ratio for cost per life year saved utilized a willingness-to-pay threshold of $100,000/life year. Modeling was performed with TreeAge software. @*Results@#In a cohort of 4,415 women, prehabilitation would cost $371.1 Million (M) versus $404.9 M for usual care, a cost saving of $33.8 M/year. Cost of care per patient with prehabilitation was $84,053; usual care was $91,713. When analyzed for cost-effectiveness, usual care was dominated by prehabilitation, indicating prehabilitation was associated with both increased effectiveness and decreased cost compared with usual care. Sensitivity analysis showed prehabilitation was more cost effective up to a cost of intervention of $9,418/patient. @*Conclusion@#Prehabilitation appears to be a cost-saving method to decrease healthcare system costs via two improved outcomes: lower complication rates and decreased care facility requirements. It represents a novel strategy to optimize healthcare efficiency. Prospective studies should be performed to better characterize these interventions in medically frail patients with EOC.

Comparison of ultrasound-measured properties of the common carotid artery to tobacco smoke exposure in a cohort of Indonesian patients / 世界急诊医学杂志（英文）

@#BACKGROUND:The purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated. METHODS:We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease. RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness. CONCLUSION:Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.

Michael J. Simmonds1, Herbert J. Meiselman2, Oguz K. Baskurt3 / 老年心脏病学杂志（英文版）

The flow properties of blood play significant roles in tissue perfusion by contributing to hydrodynamic resistance in blood vessels. These properties are influenced by pathophysiological processes, thereby increasing the clinical relevance of blood rheology information. There is well-established clinical evidence for impaired blood fluidity in humans of advanced age, including enhanced plasma and whole blood viscosity, impaired red blood cell (RBC) deformability and enhanced RBC aggregation. Increased plasma fibrinogen concentration is a common finding in many studies owing to the pro-inflammatory condition of aged individuals;this finding of increased fibrinogen concen-tration explains the higher plasma viscosity and RBC aggregation in elderly subjects. Enhanced oxidant stress in advanced age is also known to contribute to altered blood fluidity, with RBC deformability being an important determinant of blood viscosity. Several studies have shown that physical activity may improve the hemorheological picture in elderly subjects, yet well-designed observational and mechanistic studies are required to determine the specific effects of regular exercise on hemorheological parameters in healthy and older individuals.

An automated dispensing system for improving medication timing in the emergency department / 世界急诊医学杂志（英文）

BACKGROUND: Numerous medical conditions require timely medication administration in the emergency department (ED). Automated dispensing systems (ADSs) store premixed common doses at the point-of-care to minimize time to administration, but the use of such automation to improved time to medication administration has not been studied. Since vancomycin is a commonly used empiric antimicrobial, we sought to quantify the effect of using an ADS on time to drug delivery in patients presenting to the ED. The study aimed to determine the efficacy of utilizing an ADS to improve time to administration of vancomycin and determine any negative effects on dosing appropriateness.METHODS: The institional review board approved the retrospective quality improvement study took place in a single, urban academic tertiary care ED with an annual census of 80000. Study subjects were all patients receiving vancomycin for the management of sepsis between March 1 to September 30, 2008 and the same time period in 2009. The primary outcome was the proportion of patients who received vancomycin within one hour of bed placement and the secondary outcome was dosing appropriateness.RESULTS: Sixty-three patients had weight and dosing information available (29 before and 34 after intervention) and were included in the study. Before intervention, no patient received vancomycin in less than 60 minutes, while after intervention 14.7％ of the patients received it in less than 60 minutes (difference in proportions 14.7％, 95％ CI 0.39％-30.0％, P=0.04). A similar proportion of the patients received correct dosing before and after intervention (44.8％ vs. 41.2％, difference in proportions 3.7％, 95％ CI -20.0％-26.7％, P=0.770).CONCLUSION: The use of an ADS may improve the timing of medication administration in patients presenting to the ED without affecting dosing appropriateness.

Clinical applications of amphibian antimicrobial peptides

Frog skin constitutes a rich source of peptides with broad spectrum antimicrobial activity against strains of antibiotic-resistant bacteria and fungi and several hundred such peptides from diverse species have been described. However, their therapeutic potential remains to be realized and no anti-infective peptide based upon their structures has yet been adopted in clinical practice. This review assesses potential clinical applications of nine antimicrobial peptides isolated from frog skin [alyteserin- 1c, ascaphin-8, brevinin-1BYa, brevinin-2PRa, brevinin-2- related peptide, brevinin-2-related peptide-ERa, kassinatuerin- 1, pseudin-2, and temporin-DRa]. The multidrug-resistant microorganisms targeted include the Gram-negative bacteria Acinetobacter baumannii, Escherichia coli, Klebsiella pneumonia, and Pseudomonas aeruginosa, the Gram-positive bacterium Staphylococcus aureus, and the opportunistic yeast pathogens Candida spp. Although the naturally occurring peptides show varying degrees of cytotoxicity towards mammalian cells such as erythrocytes, analogs have been developed that retain high antimicrobial potency but are non-hemolytic. Treatment and prevention of acne and periodontal disease are identified as areas in which frog skin antimicrobial peptides might find future applications

Standard carotid endarterectomy with dacron patch angioplasty, risks and outcomes

The aim of this study was to assess the different risk factors and their impact on the final outcome of standard carotid endarterectomy with dacron patch angioplasty. From January 1998 to December 2002, 805 [488 males, 317 females] patients underwent standard carotid endarterectomy with dacron patch angioplasty at Texas Heart Institute. The mean age was 69.5 years [range 34-93 years]. The primary outcomes were combined same-admission stroke/death and 30-day mortality rate. While the secondary outcomes were same-admission perioperative transient ischemic attack, cranial nerve injuries, myocardial infarction and take back to secure hemostasis. There were 13 [1.6%] cases of same-admission stroke/death, and a total of 5 [0.6%] 30-day deaths. Ten [1.2%] patients had postoperative transient ischemic attack. Furthermore, 7 [0.9%] patients had cranial nerve injury. Two patients experienced acute myocardial infarction, and 14 [1.7%] patients were taken back to the operating theater to secure hemostasis. Standard carotid endarterectomy with dacron patch angioplasty is associated with low rates of morbidity and death, with reasonable outcomes in most patients

Estados de hipercoagulabilidad y obstrucción de la vena central de la retina / States of hypercoagulability and obstruction of the central retinal vein

Central retinal vein occlusion (CRVO) is a common cause of severe vision loss. Workup for all patients who present with CRVO includes evaluation for hypertension, diabetes, hyperlipidemia, glaucoma, and atherosclerosis. Those patients without the common risk factors are often subjected to extensive evaluation for hypercoagulable states. We review the current literature regarding which thrombophilias are actually associated with central renital vein occlusion. Current data suggests that tests for antiphospholipid antibodies and hyperhomocysteinemia are most often associated with CRVO. Widespread screening for hypercoagulable states on all patients with CRVO is not recommended. A hypercoagulable state workup should be considered in certain groups of patients presenting with CRVO including those patients who are young without known risk factors, those with a positive family history for thrombosis at an early age, and/or those with recurrent or bilateral retinal venous occlusive disease. Careful patient selection increases the likelihood for positive tests.

La obstrucción de la vena central de la retina (OVCR) es una causa común de perdida grave de la visión. El examen de todos los pacientes con OVCR incluye evaluación de hipertensión, diabetes, hiperlipidemia, glaucoma y aterosclerosis. Los pacientes sin factores de riesgo habituales a menudo son sometidos a una evaluación extensa para descartar estados de hipercoagulabilidad. Hemos revisado la bibliografía actual respecto de cuales trombofilias están asociadas con obstrucción de la vena central de la retina. La información presente sugiere que las pruebas de anticuerpos antifosfolípidos e hiperhomocisteinemia se asocian con mas recurrencia de OVCR. No se recomiendan las pruebas indiscriminadas de detección de estados hipercoagulables en todos los pacientes con OVCR. Se debe considerar la investigación de estados hipercoagulables en ciertos grupos de pacientes que presenta OVCR, incluyendo a aquellos que son jóvenes y sin factores de riesgo conocidos, los que tienen antecedente familiar de trombosis a edad temprana y los que tienen enfermedad retiniana oclusiva venosa bilateral. La selección cuidadosa de pacientes aumenta la probabilidad de obtener pruebas positivas.

The role of B-type natriuretic peptide in the diagnosis and treatment of decompensated heart failure / 老年心脏病学杂志（英文版）

Heart failure (HF) is a common disease associated with increasing age. B-type natriuretic peptide (BNP), is a cardiac neurohormone, and is released as prepro BNP and then enzyrnatically cleaved to the Ntenninal-proBNP (NT-proBNP) and BNP upon ventricular myocyte stretch. Blood measurements of BNP have been used to identify patients with I-IF. The BNP assay is currently used as a diagnostic and prognostic aid in HF. In general, a BNP level below 100 pg/mL excludes acutely decompensated HF and levels ＞ 500 pg/ml indicate decompensation. Recombinant human BNP (hBNP, nesiritide) is an approved intravenous treatment for acute,decompensated -HF. Nesiritide given in supraphysiologic doses causes vasodilation, natriuresis, diuresis, and improved symptoms over the course of a 48-hour infusion. This paper will sort out the literature concerning the use of this peptide both as a diagnostic test and as an intravenous therapy.

Experiencias de la instauración de normas relativas al contenido de plomo en aire y el agua, en los Estados Unidos de América / Establishing lead in air and water standards in the United States of America

En los Estados Unidos de América se ha logrado una disminución de la exposición a plomo de la población en general, gracias al establecimiento de diversas normas. En este artículo se destaca parte de los conocimientos adquiridos a través de la experiencia obtenida en este país en materia de plomo, en particular respecto al aire y al agua. Uno de los aspectos fundamentales es la posibilidad de contar con una base científica sólidamente establecida y claramente entendida, a partir de la cual se tomarán las medidas correspondientes. Los efectos secundarios de ciertas normas concernientes al aire ponen de manifiesto de qué manera los esfuerzos orientados a solucionar un problema pueden aportar beneficios en otras áreas, si bien pueden surgir consecuencias no deseadas, debido a la falta de previsión y de evaluación. Asimismo, en este documento se discuten las diferencias entre los enfoques centralizados y los descentralizados para el manejo de la exposición a plomo.

Combined Modality Therapy for Locally Advanced Non-Small Cell Lung Cancer / Journal of the Korean Cancer Association, 대한암학회지

The majority of non-small cell lung cancer patients present with locally advanced disease that may not be resectable. A single modality treatment such as thoracic radiotherapy often results in an inferior outcome when compared to combined modality treatment. Various combinations of radiotherapy, chemotherapy, and surgery have been tested in patients with locally advanced non-small-celllung cancer with promising results. The favorable results of the combined modality treatment are accompanied by a corresponding increase in treatment related morbidity. In this article, the results of the application of combined modality treatments in the management of locally advanced non-small cell lung cancer are reviewed.

Bioelectrical Impedance Analysis (BIA) of the Estimation of Total Body Water and Lean Body Mass in Patients with Renal Failure / 대한신장학회잡지

Bioelectrical impedance analysis (BIA) was used to determine total body water (TBW) and lean body mass (LBM) in patients with renal failure. The body's electrical resistance (R) was measured by the voltage to current ratio, injecting an 800microA alternating current with a frequency of 50KHZ and detecting a voltage drop between the wrist and the ankle. Impedance index (Height2/Resistance) compared favorably with TBW measured by deuterium (D2O) dilution method as the reference, giving the correlation coefficient (r) of 0.966 and standard error estimation (SEE) of 2.71 liter. The index was compared with LBM determined by dual-energy x-ray absorptiometry (DEXA) as the reference, giving r of 0.970 and SEE of 3.00kg. The r of 0.985 and SEE of 2.15kg were found between the reference method. BIA appeared to have a somewhat lower accuracy than those of the reference method. However, it is a useful clinical tool for estimating body composition, because it is easy, rapid and non-invasive. The existing BIA method is based on an extremely simple conductor model of the body. The accuracy may be improved further, based on a more realistic model for the body.

Determinación de los alcaloides de la coca y de las sustancias relacionadas / Determination of coca alkaloids and related substances

Como en todos los productos naturales, los procedimientos de extracción de todos los componentes interesantes de la planta matriz son de primera importancia y determinan a menudo la habilidad de identificar y cuantificar las sustancias de interés. En el caso de los productos de la coca, en particular en el de las hojas, se ha utilizado varios procedimientos de extracción evaluando la totalidad de la extracción y la integridad de los componentes extraídos, basándose en partidas de cocaína recuperadas. Los métodos clásicos de extracción han utilizado un cierto número de mezclas de solventes, Obviamente, los métodos más simples de extracción, por ejemplo, los que emplean éter o un medio básico, como los que adoptan Plowman y al (1989), son eficientes y efectivos para identificar algunos alcaloides de plantas, pero, al mismo tiempo, pueden no ser cuantitativos. Farnsworth y al (1974) utilizaron una mezcla de 10 por ciento de cloroformo de amoníaco para la determination de cocaína en las hojas. Turner y Elsohy (1979 y 1981) emplearon etanol para la primera extracción total de cocaína de nuestras hojas, seguida por la repartición del residuo en tampones y cloroformo. Rivier (1981) describió los resultados del estudio de una serie de procedimientos diseñados para extraer toda la gama de sustancias presentes en las hojas de coca.En comparación con los métodos clásicos de extracción, la extracción de fluidos, sumamente importante, es un método en el cual una sustancia, generalmente un gas como dióxido de carbono o amoníaco, es licuada a presión y utilizada como un solvente de extracción de componentes de plantas. Comporta la ventaja de una menor manipulación de los estractos de plantas y de un fácil eliminación del solvente de extracción, despues de la realización de esta última.

Cardiac transplantation in Puerto Rican patients at the Texas Heart Institute

Cardiac transplantation is the treatment of choice for patients suffering from end-stage cardiac disease unamenable to conventional medical or surgical treatment. More than 390 patients have undergone heart transplantation at the Texas Heart Institute in Houston, and nine were Puerto Rican. Overall survival of these patients is 88%. Our experience with patients from Puerto Rico is described