Psychodynamic Psychiatry and the Care of Persons with Vision Loss and Blindness.

The authors describe the clinical relevance of the psychiatric concept of bidirectionality when caring for persons with comorbid disorders, and they propose a psychodynamic framework to guide the treatment of persons with vision loss and blindness. Since persons with vision loss have an increased risk of depressive and anxiety disorders, they recommend targeted screening, integrated services, and a biopsychosocial approach to clinical care. The psychoanalytic concept of aphanisis, first described by Ernest Jones and later developed by Lacan and Kohut, is briefly discussed. Common psychotherapy themes in the treatment of persons who experience vision loss from systemic illness include reactivation of memories of past traumas resulting in avoidance, social withdrawal, depressive states, catastrophic thinking, a sense of foreshortened future, anhedonia, and fear of disintegration and invisibility. Psychotherapy also serves to correct negative introjects from ableist societal attitudes.

Multi-Modal Neurorehabilitation for Persisting Post-Concussion Symptoms.

Treatment of the chronic sequela that persist after a mild traumatic brain injury has been challenging with limited efficacy. The aim of this work was to report outcomes obtained from persons who met the criteria of persisting post-concussive symptoms (PPCS), utilizing a novel combination of modalities in a structured neurorehabilitation program. This work was designed as a retrospective, pre-post chart review of objective and subjective measures collected from 62 outpatients with PPCS a mean of 2.2 years post-injury, before and after a multi-modal 5-day treatment protocol. The subjective outcome measure was the 27-item modified Graded Symptom Checklist (mGSC). Objective outcome measures were motor speed/reaction time, coordination, cognitive processing, visual acuity, and vestibular function. Interventions included non-invasive neuromodulation, neuromuscular re-education exercises, gaze stabilization exercises, orthoptic exercises, cognitive training, therapeutic exercises, and single/multi-axis rotation therapy. Pre-post differences in measures were analyzed using the Wilcoxon signed-rank test, with effect size determined by the rank-biserial correlation coefficient. Pre-post treatment comparisons for the subjective mGSC overall, combined symptom measures, individual components of the mGSC, and cluster scores significantly improved for all items. Moderate strength relationships were observed for the mGSC composite score, number of symptoms, average symptom score, feeling in a "fog," "don't feel right," irritability, and physical, cognitive, and affective cluster scores. Objective symptom assessment significantly improved for trail making, processing speed, reaction time, visual acuity, and Standardized Assessment of Concussion. Patients suffering from PPCS ∼2 years after injury may have significant benefits with some moderate effect sizes from an intensive, multi-modal neurorehabilitation program.

Subject Satisfaction of Wrinkle Reduction Following Treatment with Fractional Radiofrequency: A Prospective Study.

BACKGROUND: Fractional radiofrequency (FRF) technology reduces skin laxity and treats aging-related skin disorders such as wrinkles. The objective of this study was to evaluate participant satisfaction of FRF for the treatment of facial wrinkles. METHODS: A total of 25 male and female patients (average age 60.5 years) were enrolled in this prospective, single center study. Patients received 3 FRF treatments at 3- to 5-week intervals on both sides of the face, using 80-pin (up to 124 millijoule/pin) or the 160-pin tip (up to 62 millijoule/pin) applicator. Follow-up visits were conducted at 6 and 12 weeks after the last treatment. Participant satisfaction was evaluated by individual self-assessment of wrinkle reduction and a patient satisfaction questionnaire. Pain, tolerability, and safety were monitored throughout. RESULTS: The individual satisfaction was high with participants giving an average satisfaction score of 2.8 ("satisfied") out of 4. Pain was rated "mild" with an average of 4.0 on a 10-point Visual Analog Scale (VAS). Tolerability was rated 3.3 out of 4.0, correlating to "very tolerable." Ninety percent (90%) of subjects reported a mild or moderate improvement in their treatment area at 12-week follow-up. CONCLUSION: This study demonstrates that under the FRF pre-sets used, patients are satisfied with results of FRF modality for improvement of their wrinkles. No unanticipated side effects were observed. Treatment was tolerable, and individuals had high levels of satisfaction and tolerability with the results at last follow-up. J Drugs Dermatol. 2022;21(11):1221-1227. doi:10.36849/JDD.6986.

1,550 nm Erbium-Doped and 1,927 nm Thulium Nonablative Fractional Laser System: Best Practices and Treatment Setting Recommendations.

BACKGROUND: The Fraxel Dual laser system (Solta Medical, Inc., Bothell, WA) contains a 1,550 and 1,927 nm wavelength single handpiece with different indications for each wavelength. OBJECTIVE: To discuss treatment setting recommendations and best practices for select on-label and investigational applications of the 1,550 and 1,927 nm dual laser system. MATERIALS AND METHODS: Eight board-certified dermatologists with 10 or more years of experience with the 1,550 and 1,927 nm laser system completed an online survey about their clinical experience with the system and then participated in a roundtable to share clinical perspectives and best practices for using the laser system. RESULTS: For all Fitzpatrick skin types, treatment recommendations were described for selected approved indications for the 1,550 and 1,927 nm laser system, including both lasers in combination. Treatment recommendations were also reached for investigational applications with the 1,550 nm laser and 1,927 nm laser. Best practices for using the lasers during the treatment session to achieve optimal outcomes and decrease the post-treatment recovery time were compiled. CONCLUSION: The 1,550 and 1,927 nm dual laser system is effective for a wide range of aesthetic and therapeutic applications, on and off the face and across all Fitzpatrick skin types.

Study of a 532/1064 Fractional Picosecond Laser for Facial Rejuvenation.

BACKGROUND AND OBJECTIVES: Picosecond (ps) fractional lasers create small wounds, presumably by laser-induced optical breakdown. We studied a ps fractional laser in the treatment of wrinkles and mottled pigment. MATERIALS AND METHODS: This was a single center, prospective, open-label clinical trial. Patients with at least 2 facial areas, with visible wrinkles and dyschromia, were enrolled in the study and received 3 treatments at monthly intervals and appeared at 3 follow-up visits at 1, 3, and 6 months after treatment. The laser is an 800 ps fractional system with nominal 10 mm macrospot diameter. Both 532 nm and 1,064 nm wavelengths were applied in each subject. Wrinkle and pigmentation clearance were assessed by 2 blinded investigators using a 5-point clearance scale. Skin improvement was assessed by investigators using the 5-point Global Aesthetic Improvement (GAI) Scale based on before/after photographs for the following categories: (1) fine lines/wrinkles and (2) pigmentation. RESULTS: A total of 18 healthy subjects at a single site were enrolled. At least moderate pigmentation and fine line/wrinkles improvement were observed in 93% and 79% of patients at 1 month after the last treatment according to GAI, respectively. Pigment clearance approached a mean of approximately 40%. CONCLUSION: A ps 1,064/532 fractional laser achieves reduction in fine lines and pigment.

Airborne particulate concentration during non-thermal nano-pulse stimulation wart clearance is negligible compared to thermal modalities.

OBJECTIVES: As clinicians continue to implement safety protocols amid the global pandemic, considerations to mitigate potential viral transmission of airborne particulates (plume) generated from certain dermatologic procedures are of growing interest. This study intended to measure the change in airborne particulate matter using a non-thermal energy modality called nano-pulse stimulation (NPS) and compare levels of concentration to common thermal modalities (CO2 laser and electrocautery). NPS is a new non-thermal modality that applies nanosecond pulses of electrical energy to induce regulated cell death in cellular structures while sparing the surrounding acellular structure of the dermis. MATERIALS AND METHODS: The study used a Condensation Particle Counter during four types of dermatologic procedures: (1) using non-thermal NPS for the clearance of cutaneous, nongenital warts; (2) an electrocautery treatment of warts; (3) a CO2 laser for facial resurfacing; and (4) an electrocautery procedure for a facelift. Four subjects and a total of 11 warts were treated with NPS while a particle counter was used to detect the average particles per cubic centimeter once per second. The same particle counter was used, for comparison, during a wart removal procedure using electrocautery for comparison, and for control, during a skin resurfacing procedure with a CO2 laser and a facelift in which electrocautery was used. RESULTS: Only one of the 11 NPS wart procedures generated any detectable change in the particulate concentration and that change was negligible in comparison to the increase in particulate concentration measured during the CO2 laser resurfacing and the electrocautery use during a facelift procedure. CONCLUSIONS: Procedures using non-thermal NPS technology do not generate significant plume when applied to eliminate warts, suggesting it is unlikely that this new energy modality would release viral DNA into the air.

"Photon recycling" can enhance cutaneous response to lasers: A pilot human study.

BACKGROUND: Depending on wavelength and pigmentation, human skin can reflect up to 70% of incident laser light. AIMS: We tested the hypothesis that returning ("recycling") this diffusely reflected light to the site of laser exposure would increase cutaneous response. MATERIALS AND METHODS: Thirteen adult volunteers with Fitzpatrick skin types I-IV participated in this IRB-approved study. Matched contralateral test sites on the volar forearms were exposed to a pulsed dye laser operated at 585 nm, 450 microseconds pulse duration in a uniform 5 mm circular exposure spot without skin cooling. On one arm, the laser handpiece was fitted with an aluminized hemispherical mirror with a reflectance of 67%. The minimum fluence causing skin purpura, and the purpura lesion diameter were measured. RESULTS: The mean purpura threshold fluence with the reflector was 3.1 J/cm2 (0.5 SD), and 3.7 J/cm2 without the reflector (0.36 SD) (p < 0.001). The mean laser-induced purpura lesion diameter was approximately 5.3 mm with the reflector and 5.0 mm without the reflector. CONCLUSION: Consistent with a theoretical model and in vitro measurements, this human study confirms that "recycling" reflected laser light can increase skin response. Potentially, the therapeutic response can also be improved with "photon recycling."

Intrarectal Xyloglucan Administration Reduces Disease Severity in the Dextran Sodium Sulfate Model of Mouse Colitis.

BACKGROUND: The pathophysiology of inflammatory bowel diseases remains poorly understood and treatment remains suboptimal for many patients. We hypothesize that the inflammatory milieu secondarily prolongs the injury and attenuates healing. We propose primary or adjuvant therapy with biocompatible adhesives to restore a barrier to protect submucosal structures, particularly stem cells. METHODS: We used the well-described mouse dextran sodium sulfate (DSS) model of colitis resembling human ulcerative colitis to test the therapeutic efficacy of intrarectal administration of the tamarind plant-derived xyloglucan (TXG) polymer adhesive which underwent extensive analytic characterization. Mice in control, DSS-only, TXG-only, and DSS + TXG groups were studied for gross (weight, blood in stool, length of colon) and multiple histologic parameters. RESULTS: Compared to DSS-only mice, TXG prevented the weight loss, occurrence of blood in the stool and colon shortening, with all those parameters not being statistically different from treatment naïve animals. Histologically, there was dramatic and highly statistically significant reduction in the total inflammatory index and protection from goblet cell loss, cellular infiltration, crypt abscess formation, epithelial erosion, granulation tissue, epithelial hyperplasia crypt irregularity and crypt loss. The TXG purity and characterization were established by nuclear magnetic resonance, infrared spectroscopy, differential scanning calorimetry, and texture analysis. CONCLUSION: The striking attenuation of disease severity by intrarectal TXG use warrants future investigations of natural bioadhesives with well-established high safety profiles, and which could potentially be derivatized to include therapeutically active moieties for local drug delivery.

Hair Removal With Blended 755/1064 nm Laser Energy.

BACKGROUND AND OBJECTIVES: The 1064 nm wavelength is optimized for dark skin, but within the range of available fluences for commercially available 1064 nm devices, may not provide effective treatment for lighter hair. The 755 nm alexandrite wavelength can treat a full range of hair colors but is not ideal for darker skin. The hypothesis is that a new laser system capable of emitting 755/1064 nm wavelengths simultaneously allows for safer, effective, and less painful hair reduction over a range of skin and hair types. STUDY DESIGN/MATERIALS AND METHODS: We completed treatment in 36 patients in this institutional review board approved prospective randomized study. Ages ranged from 20 to 55 and the distribution of skin types was: I (14% of patients), II (50% of patients), III (18% of patients), IV (18% of patients). Areas included the axilla and lower extremity. A prototype laser system emitted 755/1064 nm simultaneously. The spot size was 12 mm and the pulse duration was 3 milliseconds. The percentage of each wavelength in the mixture varied from 0% to 100%. Total radiant exposure ranged from 20 to 50 J/cm2 . Test spots were performed with escalating doses of light for each category (alexandrite alone, Nd YAG alone, and blended). Patients returned within 1 week for evaluation of side effects. The highest fluence without side effects for each category was then applied in two sessions 1 month apart. Final hair counts were performed 2 months after the final treatment. RESULTS: Optimal light doses (in J/cm2 ) for the range of skin types were as follows: for alexandrite alone, YAG alone, and blended. (Skin type I) 40, 70, 40-10; (II) 40, 70, 40-10; (III) 34, 60, 30-20; (IV) 26, 60, 20-30; (V) 18, 50, 14-36. After 2 months, there was greater than 50% hair reduction in 40%, 24%, and 60% of subjects on the lower extremity for the alexandrite, Nd YAG, and blended groups, respectively, and 20%, 25%, and 24% for the axilla. Our data show that for "challenging" cases, that is, darker skin types or tanned skin with lighter hairs, a 70/30 mixture of Nd:YAG and alexandrite wavelengths tended to produce the greatest hair reduction and least epidermal compromise while maintaining a lower pain level than Nd YAG alone. CONCLUSIONS: Modeling and data suggest that 755/1064 nm mixture is useful in lighter hair removal treatment for darker skin types. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Enhanced Pulsed Dye Laser for Facial Rejuvenation.

BACKGROUND AND OBJECTIVES: To evaluate the efficacy of an enhanced pulsed dye laser (PDL) for treatment of facial-dyschromia. STUDY DESIGN/MATERIALS AND METHODS: Thirteen patients were enrolled in the study. Nine patients were female, four were male, with a mean age of 61 years. All patients presented with either facial telangiectasia, rosacea, pigment, or a combination thereof. At the initial evaluation, test spots were performed to determine the subject's response to selected treatment parameters. In the study, the enhanced 595 nm PDL deployed a spot size range of 5-12 mm with fluences ranging from 8 to 18 J/cm2 . Pulse duration was 10 milliseconds. Enhancements in this device included the option for contact or cryogen spray cooling, increased maximum pulse energy, increased repetition rate, option for addition of radiofrequency (RF), an option for a 15 mm spot size, and longer dye life. The smaller spots were used only for focal low contrast pigmented lesions that persisted after overall facial treatment with the larger spot. Smaller fluences were applied for general rejuvenation with the 12 mm spot (mean ~9 J/cm2 ). Sapphire contact cooling was applied at 10°C. A smaller area of the skin was reserved (typically pre-auricular area) for addition of RF energy just before the pulse (40-70 J/cm3 ) over 100 milliseconds with a 20 milliseconds delay between the end of the RF pulse and beginning of the laser pulse. The minimum fluence that achieved vessel closure/vessel bluing and/or slight immediate pigment darkening was applied based on test spots performed just before treatment to the entire face. Determinations of improvement were made by evaluation of photographs with standard settings using polarized and nonpolarized images. Up to three treatments were performed approximately 1 month apart with follow-up visits 1 and 3 months after the final treatment. RESULTS: Evaluation by a panel of blind observers determined a mean clearance of at least 50% in all lesions, while 77% of lesions had 50-75% clearance, and 23% of lesions had 76-100% clearance. Pain was approximately 4/10. Subjective lesion improvement and satisfaction rates were 3 out of 4 and 3.6 out 4, respectively. CONCLUSION: An enhanced PDL is effective in one pass treatments for facial rejuvenation with considerably less operative time than previous commercially available systems. A second pass applied to focal challenging lesions results in even more improvement, in a single treatment session. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Laser Rejuvenation of Nonfacial Skin: A Review and a Personal Approach.

BACKGROUND: Laser skin rejuvenation historically has emphasized facial photodamage. In this review, we examine energy-based rejuvenation for nonfacial skin. OBJECTIVE: The purpose of this review is to summarize past and current energy-based rejuvenation off the face. RESULTS: Many energy-based interventions can address pigment, tone, and texture irregularities of nonfacial skin. CONCLUSION: With conservative settings, current devices can be applied safely for nonfacial skin rejuvenation.

Understanding the Science Surrounding Environmental Consequences and Rehabilitation Actions Stemming from Brazil's Fundão Tailing Dam Rupture.

Collapse of the Fundão tailings dam in November 2015 in Minas Gerais, Brazil, resulted in the release of approximately 36 million cubic meters of primarily clay and fine sand-sized particles to the environment. The spill event extended over 600 km of the Rio Doce catchment and affected terrestrial and aquatic ecosystems and compromised socioeconomic activities throughout the watershed. Numerous monitoring programs and research investigations in the catchment since that time contribute to better understanding of the environmental consequences and plans for rehabilitation of the landscape. The Society of Environmental Toxicology and Chemistry (SETAC) Latin America Geographic Unit hosted the Fundão Dam Rupture Science Meeting in Brasilia, Brazil, in June 2019 to report on the findings from these studies. Fourteen technical papers from that meeting are presented in this Integrated Environmental Assessment and Management (IEAM) special series. These papers and the technical discussions at the meeting reflect the consensus opinions of scientists who attended the symposium. Delegates generally agreed that society must commit to rehabilitation after disasters based on the best available evidence describing the structure and function of affected ecosystems. Scientists can play a crucial role in prioritizing and facilitating rehabilitation actions, as well as monitoring for progress toward achieving goals. Integr Environ Assess Manag 2020;16:569-571. © 2020 SETAC.

O colapso da barragem de rejeitos de Fundão em novembro de 2015 em Minas Gerais, Brasil, resultou na liberação de aproximadamente 36 milhões de metros cúbicos de partículas do tamanho de argila e areia fina para o meio ambiente. O derramamento se estendeu por mais de 600 km na bacia hidrográfica do Rio Doce, afetou os ecossistemas terrestres e aquáticos e comprometeu as atividades socioeconômicas em toda a bacia hidrográfica. Numerosos programas de monitoramento e pesquisas na bacia, desde então, contribuem para uma melhor compreensão das consequências ambientais e para os planos de reabilitação da paisagem. A Sociedade de Toxicologia e Química Ambiental (SETAC) da América Latina sediou o Encontro Científico sobre a Ruptura da Barragem do Fundão em Brasília, Brasil, em junho de 2019, para relatar os resultados desses estudos. Quatorze artigos técnicos dessa reunião são apresentados nesta série especial da revista Integrated Environmental Assessment and Management (IEAM). Esses artigos e as discussões técnicas do encontro refletem as opiniões consensuais dos cientistas que participaram do simpósio. Os delegados em geral concordaram que a sociedade deve se comprometer com a reabilitação após desastres com base na melhor evidência disponível que descreva a estrutura e a função dos ecossistemas afetados. Os cientistas podem desempenhar um papel crucial na priorização e facilitação de ações de reabilitação, bem como no acompanhamento da evolução do cumprimento das metas. Integr Environ Assess Manag 2020;16:569-571.

Ecotoxicological Assessment of the Doce River Surface Water After the Fundão Dam Collapse.

On 5 November 2015, the Samarco Fe ore mining operations released approximately 50 million cubic meters of mining waste into the environment, due to a dam collapse. Aiming at understanding the potential effects on the Doce River, different regions of the course of tailings were monitored using acute and chronic ecotoxicological tests with 4 species: Ceriodaphnia dubia, Daphnia similis, Danio rerio, and Vibrio fischeri. The results showed no acute toxicity for water column organisms. However, chronic toxicity was observed with the tests with the microcrustacean C. dubia, mainly related to the physical effects of the passage of flood wave and increased suspended solids, given that toxicity was reduced after filtering the samples. The results showed different magnitudes of impact among the upper, middle, and lower Doce River, with greater impact close to the dam failure area. Integr Environ Assess Manag 2020;16:608-614. © 2020 SETAC.

Em 5 de novembro de 2015, aproximadamente 50 milhões de m3 de resíduos provenientes da barragem de rejeitos das operações de mineração de minério de ferro da Samarco atingiram o meio ambiente decorrente do seu rompimento. Com o objetivo de compreender os potenciais efeitos sobre o rio Doce, o monitoramento foi realizado, através de testes ecotoxicológicos com quatro espécies de diferentes, das regiões atingidas pela pluma de turbidez. Os resultados demonstraram, de modo geral, ausência de ecotoxicidade aguda para organismos de coluna de água. Entretanto, foi evidenciada ecotoxicidade crônica com o microcrustáceo Ceriodaphnia dubia, que esteve relacionada principalmente aos efeitos físicos da passagem da onda de cheia e ao aumento de sólidos em suspensão na coluna d'água. Os resultados mostraram que a magnitude do impacto foi diferente nas três regiões do rio Doce (alta, média e baixa), com maior intensidade na região mais próxima da área do rompimento da barragem. Integr Environ Assess Manag 2020;16:608-614.

Rio Doce Acoustic Surveys of Fish Biomass and Aquatic Habitat.

Following the failure of the Fundão mine tailings dam in Brazil, approximately 32 million cubic meters of Fe ore tailings were released into the downstream riverine system. The postevent monitoring surveys implemented the use of noninvasive acoustic methods to improve the understanding of the fish biomass distribution patterns and aquatic habitat condition of the impacted reaches of the Rio Gualaxo do Norte, Rio do Carmo, and Rio Doce. The primary focus of the program was to collect hydroacoustic measurements of fish biomass, which was accompanied by sonar imaging of aquatic habitats using high-resolution side scan and downward imaging sonar at each site visited. The biannual surveys began in April 2017 and were fundamentally a multiple control-impact design because before data (prior to the dam failure event) were not available. Up to 22 sites were visited for each survey, including reservoir and river sites. Results indicate similar levels of instream habitat between control and impact river and reservoir sites. Average volumetric biomass was not significantly different between impact sites and their corresponding controls in the August 2018 survey (latest to date). Preliminary temporal analysis of the biomass data set collected indicates that either stable or increasing levels of biomass are detected at tailings impacted sites within the Rio Doce. Integr Environ Assess Manag 2020;16:615-621. © 2020 Hydrobiology QLD Pty Ltd. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Após o rompimento da barragem de rejeitos da mina do Fundão no Brasil, cerca de 32 milhões de metros cúbicos de rejeitos de minério de Fe foram libertados no sistema fluvial a jusante. Monitoramentos pós-evento foram implementados com a utilização de métodos acústicos não invasivos visando ampliar a compreensão dos padrões de distribuição da biomassa de peixes e condições dos habitat aquáticos em trechos impactados do Rio Gualaxo do Norte, Rio do Carmo e Rio Doce. A aquisição de medições hidroacústicas sobre a biomassa de peixes foi o foco principal do programa, seguido pela obtenção de imagens dos habitats aquáticos através da utilização de um sonar de varredura lateral de alta resolução e um sonar de imagem vertical, em cada local visitado. Os levantamentos de campo semestrais tiveram início em Abril de 2017 e seu design amostral foi baseados na concepção "trechos controle - trechos impactados" uma vez que não existem dados disponíveis para o período anterior ao evento (rompimento da barragem). Em cada levantamento foram visitados até 22 pontos de amostragem, incluindo vários reservatórios e rios. Os resultados indicaram níveis de habitat similares entre os pontos controle e impacto, de rios e reservatórios. No monitoramento mais recente (Agosto/2018) a biomassa volumétrica média não foi significativamente diferente entre os locais de impacto e os seus correspondentes pontos controles. A análise temporal preliminar do conjunto de dados sobre a biomassa indicou níveis estáveis ou crescentes deste parâmetro nos locais impactados pelos rejeitos, no Rio Doce. Integr Environ Assess Manag 2020;16:615-621.

Use of the esa resistance index to guide dosing for anaemia management.

BACKGROUND: Identifying erythropoiesis-stimulating agent (ESA) resistance is important for treating reversible causes, reaching target haemoglobin levels with minimal dosing, avoiding adverse effects and reducing costs. The resistance index (RI, dose/kg weight/g haemoglobin/dl) is reportedly superior to absolute or weight-based dosing. OBJECTIVES: With the growing number of ESA classes and medications, our goal was to develop methodology to establish RI ranges in otherwise healthy haemodialysis patients as a structured approach to identify remediable causes of anaemia. DESIGN: We retrospectively studied anaemia management with darbepoetin in 100 chronic haemodialysis patients and a subgroup of 48 without identifiable conditions that impair erythropoiesis. Data included inflammatory and bone marrow conditions, medications with hematologic effects, catheter use, iron, parathyroid and dialysis measures. RESULTS: The haematologically healthy group was aged 57.1 ± 1.9 SEM years, 33% diabetic, with haemoglobin 10.4 ± 0.2 g/dl. The darbepoetin RI (DRI) values were 0.05 ± 0.01, absolute dose 38.5 ± 3.5 mcg/week and weight-based 0.50 ± 0.05 mcg/kg. Regression analyses included iron saturation, ferritin, parathyroid hormone and urea reduction ratio. DRI was superior to other dosing approaches based on the distribution of results (kurtosis) and discordance between the measures that occurred in 17% of patients at haemoglobin target. CONCLUSIONS: We demonstrate the value of determining the RI for use with expanding ESA choices, using as an example how DRI values can be established for healthy haemodialysis patients so as to guide dosing. When elevated, the RI can trigger evaluation for remediable factors causing hyporesponsiveness even when haemoglobin goals have been reached.

Improved outpatient haemodialysis adequacy using queued schedules.

BACKGROUND: Although technical advances help achieve haemodialysis adequacy, we hypothesise remediable non-therapy factors exacerbate patient dissatisfaction, non-adherence to treatment time and failure to meet dialysis goals. Scheduling inefficiencies lead to the total time in the unit far greater than actual treatment time, impacting facility efficiency and patient frustration. OBJECTIVES: We used queuing theorem principles to optimise schedules by incorporating timing and workflow for every dialysis process step to design a new schedule, rather than the whole-shift blocks at baseline. DESIGN: The goals were to: (1) craft schedules that maximised efficiency and economics from a facility perspective, and (2) minimise total time in the dialysis unit from a patient viewpoint. As dialysis units are held to a national standard of urea clearance, reduction ratios (URRs) were measured for the 3 months before and after the new scheduling was implemented. RESULTS: Dialysis staff and process parameters were measured to craft queued schedules of staggered small groups of patients instead of baseline blocks of 2 large shifts, 24 each. A total of 65 patients changed to groups of 8, with entry-to-exit at 290 minutes for four hours treatments. The URRs improved from 72.8 ± 6.9 to 75.2 ± 5.4% (p < 0.001). Before implementation, only 89% of subjects reached the URR facility compliance target of 65%, and afterwards 97% (p < 0.001). CONCLUSION: Queuing theorem principles can be successfully adopted to optimise haemodialysis scheduling. The resultant staggered timing increases facility efficiency, minimises the long wait time dissatisfier, and is associated with improved URRs with more patients reaching target clearance thresholds.

Iodine quantification and detectability thresholds among major dual-energy CT platforms.

OBJECTIVES: To estimate the minimum detectable iodine concentration on multiple dual-energy CT (DECT) platforms. METHODS AND MATERIALS: A phantom containing iodine concentrations ranging from 0 to 10 mg ml-1 was scanned with five dual-energy platforms (two rapid kilo volt switching (r-kVs), one dual source (DS), one sequential acquisition and one split-filter). Serial dilutions of 300 mg ml-1 iodinated contrast material were used to generate concentrations below 2 mg ml-1. Iodine density and virtual monoenergetic images were reviewed by three radiologists to determine the minimum visually detectable iodine concentration. Contrast-to-noise ratios (CNRs) were calculated. RESULTS: 1 mg mL-1 (~0.8 mg mL-1 corrected) was the minimum visually detectable concentration among the platforms and could be seen by all readers on the third-generation r-kVs and DS platforms. CONCLUSIONS: At low concentrations, CNR for monoenergetic images was highest on the DS platform and lowest in the sequential acquisition and split-filter platforms. ADVANCES IN KNOWLEDGE: The results of this study corroborate previous in vivo estimates of iodine detection limits at DECT and provide a comparison for the performance of different DECT platforms at low iodine concentrations in vitro.

Clinician Job Searches in the Internet Era: Internet-Based Study.

BACKGROUND: Traditional methods using print media and commercial firms for clinician recruiting are often limited by cost, slow pace, and suboptimal results. An efficient and fiscally sound approach is needed for searching online to recruit clinicians. OBJECTIVE: The aim of the study was to assess the Web-based methods by which clinicians might be searching for jobs in a broad range of specialties and how academic medical centers can advertise clinical job openings to prominently appear on internet searches that would yield the greatest return on investment. METHODS: We used a search engine (Google) to identify 8 query terms for each of the specialties and specialists (eg, dermatology and dermatologist) to determine internet job search methodologies for 12 clinical disciplines. Searches were conducted, and the data used for analysis were the first 20 results. RESULTS: In total, 176 searches were conducted at varying times over the course of several months, and 3520 results were recorded. The following 4 types of websites appeared in the top 10 search results across all specialties searched, accounting for 52.27% (920/1760) of the results: (1) a single no-cost job aggregator (229/1760, 13.01%); (2) 2 prominent journal-based paid digital job listing services (157/1760, 8.92% and 91/1760, 5.17%, respectively); (3) a fee-based Web-based agency (137/1760, 7.78%) offering candidate profiles; and (4) society-based paid advertisements (totaling 306/1760, 17.38%). These sites accounted for 75.45% (664/880) of results limited to the top 5 results. Repetitive short-term testing yielded similar results with minor changes in the rank order. CONCLUSIONS: On the basis of our findings, we offer a specific financially prudent internet strategy for both clinicians searching the internet for employment and employers hiring clinicians in academic medical centers.