Impact of a digital training platform and tailored education on the chest image interpretation performance of healthcare professionals.

INTRODUCTION: With the use of expert consensus a digital training tool was developed which proved useful when teaching radiographers how to interpret chest images. The training tool included A) a search strategy and B) an educational video programme to communicate the search strategies using eye tracking technology. METHODS: A multi-reader multi-case study was undertaken to assess the effectiveness of a training tool and study day. The interventions were designed to cover a range of potential pathological presentations. Participants, physiotherapists and nurse practitioners working at a cardiothoracic Intensive Care Unit (ICU), were asked to interpret 20 chest images at the beginning of the study and following access to each intervention. Participants received access to the training tool at different times for a period of 4-6 weeks. A study day was then be provided to all participants and interpretations of a different dataset were completed by all. Each participant was asked to complete a questionnaire to gain perceptions of the training provided. RESULTS: Twenty-eight participants interpreted a total of 1680 chest radiographs. Improvements in specificity were noted across the participants. Sensitivity fell in both groups following both training interventions. CONCLUSION: Face to face learning and digital components are potentially useful in professional development and revision in chest x-ray interpretation for non-medical healthcare professionals working in an ICU setting. IMPLICATIONS FOR PRACTICE: The training tool and study day may be useful as image interpretation revision aids or to accompany formal methods of education.

Centralized medical monitoring in phase III clinical trials: the National Surgical Adjuvant Breast and Bowel Project (NSABP) experience.

BACKGROUND: There is a need for data quality assurance procedures in phase III cancer trials. At the National Surgical Adjuvant Breast and Bowel Project (NSABP) 'real-time' systems have been developed for quality assurance and study monitoring: (1) manual review and triage of data forms by data managers at the time of submission; (2) computerized edit checking of all submitted data forms; (3) systematic review of eligibility, treatment compliance and toxicity in the first 100 patients of a new protocol; (4) prospective centralized medical review of all reported serious adverse events, treatment failures, second primary cancers and deaths; (5) quarterly review and approval of study summary data files by project statistician; and (6) on-site auditing. PURPOSE: To assess the utility of an additional final comprehensive review of all patient records to confirm eligibility, disease status and vital status prior to manuscript submission. METHODS: Four phase III NSABP studies, which had been monitored using the triage-based quality assurance program described above, were selected for analysis (n = 7972). Charts for 5965 patients were identified that had not been previously medically reviewed for protocol events of recurrence, second primary cancer or death. Submitted source documents and data forms of these 5965 NSABP patient records underwent medical review to verify patient eligibility, disease status and vital status. RESULTS: This final comprehensive review found no additional treatment failures or deaths, identified seven additional cases of ineligibility, was time-intensive requiring enormous use of expensive resources, and was therefore judged not to add significantly to the integrity of the database. LIMITATIONS: Our findings are influenced by the procedures the NSABP employs for quality assurance and study monitoring for Phase III clinical trials and may have limited generalizability to other settings. CONCLUSION: In the presence of multiple quality assurance and data monitoring systems, the rare discrepancies found between the data forms and source documentation does not support the routine use of a final comprehensive chart review for phase III trials at the NSABP Biostatistical Center.

Update on systemic glucocorticosteroids in dermatology.

Although dermatology now has the most extensive group of systemic medications available for the treatment of skin diseases at any time, GCSs remain the most important agents for managing inflammatory disorders. It is important that the dermatologist have a broad knowledge of guidelines for clinical use, pharmacology, and adverse effects of these drugs. Acute and chronic side reactions should be well recognized. An understanding of the HPA axis and reasons for administering GCSs in different ways is of great value. A good medical history should be taken on any patient treated with GCSs, including knowledge of conditions that would make GCSs inadvisable and other concomitant systemic medications that might produce drug interactions. During the course of therapy, physical examination should include all systems pertinent to side effects caused by these agents, including frequent evaluations of weight and blood pressure. Blood chemistries should be performed on a regular basis, including glucose, electrolytes, and serum lipids. Osteoporosis is one of the most significant adverse affects to be evaluated, with bone mineral density studies recommended on an annual basis for persons continuing on GCS therapy. If hip or other joint pain develops, MR imaging is the most specific and sensitive radiologic examination for evaluating the possibility of osteonecrosis. An ophthalmology examination should be performed every 6 to 12 months to detect early cataract or glaucoma development. Any early signs of infection should be evaluated by appropriate smears, wet preparations, and cultures. Many other studies, including gastrointestinal and pulmonary examinations, may be dictated by specific acute situations. It is important to begin early prevention of the bone loss that occurs with GCS-induced osteoporosis. The 1996 guidelines of the American College of Rheumatology, including adequate calcium and vitamin D intake, should be followed. Hormonal replacement, a bisphosphonate, calcitonin, or a thiazide diuretic may be indicated. Restriction of sodium in the diet is important, as well as adequate potassium intake. The diet should be low in saturated fat and calories and should be high in vegetable protein. Because osteoporosis is so prevalent with GCSs, keeping the patient as active as possible with mild-to-moderate exercise is important. Whenever possible, exposure to persons with infectious processes should be avoided, and proper treatment should be instituted at the initial signs of systemic or cutaneous infection. Oral doses of GCSs are best taken with food to prevent gastrointestinal irritation, and agents for gastric acidity occasionally may be indicated. Significant trauma should be prevented, as should severe exposure to the sun. Many situations may call for consultation with other medical or surgical subspecialists. The patient must be aware of the importance of regular physician evaluations and reporting of any adverse effects while on long-term GCSs. A good relationship and understanding between the patient and physician are vital in minimizing potential problems from these agents. If the dermatologist maintains the proper guidelines of care, patients on GCSs have the highest benefits and lowest risks possible.

Systemic glucocorticosteroid therapy in dermatology.

Glucocorticosteroids (GCS) have been frequently used for a number of dermatologic conditions since the early 1950s. These drugs continue to be very efficacious, yet there are serious side effects associated with their long-term use. Significant complications produced by GCS can be minimized by proper management and precautions. All health care professionals should be aware of these strategies and nursing personnel can play a vital role in helping patients adhere to the guidelines of preventing adverse events.

Clozapine-associated elevation in serum triglycerides.

OBJECTIVE: This study was conducted to determine serum lipid level changes in patients who received clozapine or haloperidol. METHOD: Medical records of 222 inpatients treated with clozapine or haloperidol were reviewed. Age, weight, gender, daily antipsychotic dose, total cholesterol level, serum triglyceride level, and concurrent medications were recorded. RESULTS: Clozapine-treated men had significantly higher follow-up serum triglyceride concentrations over baseline than did haloperidol-treated men. Female patients experienced serum triglyceride level elevations regardless of antipsychotic treatment. Changes in total cholesterol levels were not significantly different between treatment groups. CONCLUSIONS: An increase in serum triglyceride levels occurred in clozapine-treated patients; screening for serum triglyceride elevations may be warranted before treatment with clozapine.

How to buy athletic shoes.

Although the right pair of athletic shoes may not enhance sports performance, it might help you avoid discomfort or even injury. Here are tips about what to look for in your next pair.

Correcting overpronation: help for faulty foot mechanics.

Foot pronation-inward tilting of the ankles and flattening of the arches-is a normal part of walking and running. But when it's excessive, it can lead to foot, ankle, or even knee pain. Properly designed shoe inserts, called orthoses, can help correct overpronation.

Platelet serotonin transporter in depressed children and adolescents: 3H-paroxetine platelet binding before and after sertraline.

OBJECTIVE: To evaluate serotonin transporter protein (5HTPR) binding in platelets from children and adolescents with major depression (MDD) compared to normal controls using the selective ligand 3H-paroxetine. METHOD: Children and adolescents with MDD (n = 24) defined by DSM-III-R criteria and normal controls (n = 22) were compared by platelet 5HTPR kinetic analysis with the hypothesis that 5HTPR is reduced in MDD. A subset of MDD subjects (n = 18) continued to participate in a fixed-dose, open-label sertraline trial for 6 weeks followed by drug-free washout and repeated 5HTPR analysis. RESULTS: Sex, prepubertal status, and age had no effect on 5HTPR. Medication-free MDD subjects differed from controls in reduced binding capacity (Bmax) (p < .001). Sertraline therapy decreased binding affinity from baseline non-selectively (p < .05), and Bmax elevation from baseline was associated with nonresponse and suicide attempt history. CONCLUSION: Earlier literature in this population is replicated with regard to reduced platelet 5HTPR Bmax in MDD. Findings support a continuum of 5HTPR involvement in MDD across the developmental spectrum.

Relative efficacy of haloperidol and pimozide in children and adolescents with Tourette's disorder.

OBJECTIVE: The authors evaluated the relative efficacy and safety of pimozide and haloperidol in the treatment of Gilles de la Tourette's syndrome in children and adolescents. METHOD: A double-blind, 24-week, placebo-controlled double crossover study of equivalent dose formulations of haloperidol and pimozide was conducted with 22 subjects, aged 7-16 years, with Tourette's disorder who were randomly assigned to first one active drug treatment and then the other. Biweekly assessment and flexible dose titration mimicked clinical practice. The primary outcome variable was total score on the Tourette Syndrome Global Scale. Final outcome was determined after 6 weeks of each treatment (placebo, pimozide, haloperidol), with a 2-week placebo baseline period and intervening 2-week placebo washout periods between treatments. RESULTS: Pimozide proved significantly different from placebo in affecting the primary outcome variable, whereas haloperidol failed to have a significant effect. Haloperidol exhibited a threefold higher frequency of serious side effects and significantly greater extrapyramidal symptoms relative to pimozide. Haloperidol-associated treatment-limiting adverse events were experienced by 41% of the patients. The therapeutic doses of pimozide and haloperidol were equivalent (mean = 3.4 mg/day, SD = 1.6, and mean = 3.5 mg/day, SD = 2.2, respectively). CONCLUSIONS: At equivalent doses, pimozide is superior to haloperidol for controlling symptoms of Tourette's disorder in children and adolescents.

Platelet serotonin transporter in children and adolescents with obsessive-compulsive disorder or Tourette's syndrome.

UNLABELLED: Previous studies of serotonin transporter protein (5HTPR) indexed in platelets by 3H-imipramine demonstrate reduction in children with comorbid obsessive-compulsive disorder (OCD) and Tourette's syndrome (TS). OBJECTIVE: To use the 5HTPR selective ligand 3H-paroxetine and homogeneous diagnostic groups to reevaluate these findings. METHOD: Platelet Kinetic binding parameters were evaluated using standard techniques from medication-free child and adolescent patients with OCD (n = 18), with TS (n = 10), and normal controls (n = 19). RESULTS: Baseline binding capacity (Bmax) was significantly reduced in patients with OCD (1,342 +/- 952 fmol/mg; protein p < .01) compared with normal controls (2,486 +/- 1309 fmol/mg) and TS patients (2,420 +/- 1,069 fmol/mg; p < .05). Among OCD patients who were subsequently treated on an open-label basis with selective serotonin reuptake inhibitor (SSRI), Bmax values at baseline differentiated between responders (1,718 +/- 1,041 fmol/mg) and nonresponders (802 +/- 713 fmol/mg protein; p < .05). Response to SSRI was greatest in patients with a positive family history of OCD. Among responders (n = 10), baseline Yale-Brown Obsessive Compulsive Scale and Bmax were positively correlated (r = .76, p = .01), as was Clinical Global Impression (r = .67, p = .03). CONCLUSIONS: Platelet 5HTPR capacity (Bmax) is reduced in children and adolescents with OCD, but not in those with TS. 5HTPR may be an indirect measure of basal serotonergic tone.

Minimizing complications from systemic glucocorticosteroid use.

For proper use of systemic GCS, a basic knowledge of the normal HPA axis, as well as knowledge of the pharmacology, clinical usage guidelines, and adverse reactions of these agents is imperative. Both short-term (acute) and long-term side effects should be well known by the physician. The pros and cons of oral and parenteral therapy for various disorders and in various situations should be recognized. For long-term therapy, an intermediate-acting agent such as prednisone in single, early morning doses is most commonly used to minimize suppression of the HPA axis. Alternate-morning doses produce even less suppression if the disease process will respond. A through patient history, including general medical history and medications the patient is taking, is important to anticipate any potential problems. Weight and blood pressure should be checked initially and every 1 to 3 months thereafter. Blood glucose, electrolytes, and lipid studies, including triglycerides, should be done approximately every 6 months. An ophthalmology examination should be performed every year, and stool examination for occult blood and chest radiography can be obtained as indicated. Bone density studies might be necessary in patients who are at high risk for osteoporosis. Specific acute situations may dictate other studies. The patient on long-term GCS should be kept as active as possible, as mild-to-moderate exercise helps prevent certain side effects, such as osteoporosis. The dose of oral GCS is best given with food to prevent gastrointestinal irritation, and agents to decrease gastric acidity might be needed in certain situations. Exposure to infections should be prevented, where possible, and treatment initiated at the first sign of systemic or cutaneous infection. Pain should be evaluated early, especially abdominal pain or bone pain; MRI is indicated if aseptic necrosis of bone is suspected. Both trauma and severe sun exposure should be avoided. Consultation with other specialists is strongly recommended when the situation dictates. Diet is one of the most important strategies to minimize side effects from long-term GCS therapy. Vegetable protein should be increased in the diet, and fats and carbohydrates limited. Adequate calcium is imperative, and calcium supplementation is recommended for high-risk osteoporosis patients. Small amounts of vitamin D may be necessary to increase absorption of calcium. Restriction of sodium is also important, as is maintainance of dietary potassium. Supplemental potassium may be necessary in some patients, and a thiazide diuretic might be useful in patients with hypertension, edema, or osteoporosis. Vitamin C can be given to promote wound healing. A good doctor-patient relationship is important in managing the patient on long-term GCS. The patient must return for regular visits and be encouraged to promptly report any adverse reactions to the physician. If these criteria are maintained and the strategies noted previously are followed, problems from long-term therapy with GCS will be minimized.

Hypopigmented macules in acantholytic disorders.

BACKGROUND: Widespread hypopigmented macules are rarely seen in heavily pigmented patients with Darier's disease. Previous hypotheses concerning the cause of decreased pigmentation suggest it is a postinflammatory phenomenon or that the hypomelanosis is evidence of subclinical acantholysis. PATIENTS: This report presents 2 patients: a new case of disseminated guttate leukoderma in a black patient with Darier's disease and the first such case in a patient with transient acantholytic dermatosis (Grover's disease). Direct immunofluorescence and electron-microscopic studies were carried out on lesional biopsies. OBSERVATIONS: Numerous small hypopigmented macules were observed in two black patients followed for acantholytic disorders. Three biopsies of the hypopigmented macules revealed acantholysis, while one showed only decreased melanin. Direct immunofluorescence studies were negative. Electron-microscopic studies of the leukodermic macules showed sparse melanocytes and melanosomes that were mostly pigmented stage IV melanosomes. CONCLUSIONS: Disseminated guttate leukoderma can occur in transient acantholytic dermatosis, as well as in Darier's disease. It is readily apparent on darkly pigmented skin because of contrast. The etiology of this phenomenon is still unknown.

Head growth in cocaine-exposed infants: relationship to neonate hair level.

Intrauterine brain growth retardation is the most common brain abnormality in infants of cocaine-abusing mothers. We report a cross-sectional study of "at-risk" pregnancies with 34 infants born to mothers urine positive for cocaine at delivery compared to 33 infants born to urine-negative mothers from the same clinic. Degree of cocaine exposure was assessed by radioimmunoassay of combined cocaine and benzoylecgonine (BE) levels in neonatal hair samples. Twenty-eight neonates were hair-positive for BE (mean 2507.40 +/- 1248.88 ng/g hair; range 716 to 5440 ng/g) and differed significantly from the control infants (n = 33) in head circumference and head growth percentiles. A negative correlation approaching significance was found between mean BE and head circumference (r = -.36; p < .06) in the group of newborns with hair positive for BE (n = 28). The study demonstrates for the first time head growth abnormalities in association with levels of cocaine exposure.

Lymphocyte glucocorticoid receptor: predictor of sertraline response in adolescent major depressive disorder (MDD).

Major depressive disorder (MDD) in adolescents demonstrates resistance to tricyclic antidepressants and absence of hypercortisolemia. The efficacy of serotonin reuptake inhibitors (SRIs) is uncertain, and response predictors are unavailable. Abnormal fast feedback and negative feedback of the hypothalamic-pituitary-adrenal axis implicates a dampened limbic-hippocampal glucocorticoid type II receptor (GCII). We hypothesized that lymphocyte GCII is altered in adolescent MDD and could serve as a marker for response to SRIs. In an open-label study, adolescents (n = 20) meeting DSM-III-R criteria for MDD showed baseline lymphocyte GCII sites per cell (sites/cell) values of 793 +/- 106 versus 2,563 +/- 499 (+/- SEM) for matched controls (n = 18) (t = 3.5; df = 36; p < .001). GCII was bimodally distributed, with SRI responders differing from nonresponders (t = 3.9; df = 14; p < .001). GCII accurately classified 90 percent of sertraline responders and 80 percent of nonresponders. Only SRI responders showed GCII sites/cell upregulated after 6 weeks of treatment (t = 2.1, df = 10; p < .05).

Update on immunofluorescent testing in bullous diseases and lupus erythematosus.

One of the earliest methods for investigating the immunologic basis of disease was the use of immunofluorescence (IF) on skin biopsy specimens and serum. IF can be used to detect immunoglobulins, complement components, and fibrin. In some diseases, the IF findings are disease specific and diagnostic, especially in certain bullous diseases. The use of IF testing has increased with the recent development of the salt split skin technique. The newer IF findings in some well-established immunodermatologic diseases and several recently described diseases are discussed. A brief description of the techniques involved in direct and indirect IF is also presented.