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Clinical Scenarios (clinical + scenario)
Kinds of Clinical Scenarios Selected AbstractsEvidence-Based Diagnosis of Nontraumatic Headache in the Emergency Department: A Consensus Statement on Four Clinical ScenariosHEADACHE, Issue 6 2004Pietro Cortelli MD Objective.,To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches. Background.,Many patients present to an ED with the chief complaint of headache. Causes of nontraumatic headache include life-threatening illnesses, and distinguishing patients with such ominous headaches from those with a primary headache disorder can be challenging for the ED physician. Conclusion.,We present a consensus statement aimed to be a useful tool for ED doctors in making evidence-based diagnostic decisions in the management of adult patients with nontraumatic headache. Methods.,A multidisciplinary work performed an extensive review of the medical literature and applied the information obtained to commonly encountered scenarios in the ED. [source] Complementary and integrative medical therapies, the FDA, and the NIH: definitions and regulationDERMATOLOGIC THERAPY, Issue 2 2003Michael H. Cohen ABSTRACT: ,,The National Center for Complementary and Alternative Medicine (NCCAM) presently defines complementary and alternative medicine (CAM) as covering "a broad range of healing philosophies (schools of thought), approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available. The research landscape, including NCCAM-funded research, is continually changing and subject to vigorous methodologic and interpretive debates. Part of the impetus for greater research dollars in this arena has been increasing consumer reliance on CAM to dramatically expand. State (not federal) law controls much of CAM practice. However, a significant federal role exists in the regulation of dietary supplements. The U.S. Food and Drug Administration (FDA) regulates foods, drugs, and cosmetics in interstate commerce. No new "drug" may be introduced into interstate commerce unless proven "safe" and "effective" for its intended use, as determined by FDA regulations. "Foods", however, are subject to different regulatory requirements, and need not go through trials proving safety and efficacy. The growing phenomenon of consumer use of vitamins, minerals, herbs, and other "dietary supplements" challenged the historical divide between drugs and foods. The federal Dietary Supplements Health Education Act (DSHEA) allows manufacturers to distribute dietary supplements without having to prove safety and efficacy, so long as the manufacturers make no claims linking the supplements to a specific disease. State law regulates the use of CAM therapies through a variety of legal rules. Of these, several major areas of concern for clinicians are professional licensure, scope of practice, and malpractice. Regarding licensure, each state has enacted medical licensing that prohibits the unlicensed practice of medicine and thereby criminalizes activity by unlicensed CAM providers who offer health care services to patients. Malpractice is defined as unskillful practice which fails to conform to a standard of care in the profession and results in injury. The definition is no different in CAM than in general medicine; its application to CAM, however, raises novel questions. Courts rely on medical consensus regarding the appropriateness of a given therapy. A framework for assessing potential liability risk involves assessing the medical evidence concerning safety and efficacy, and then aligning clinical decisions with liability concerns. Ultimately research will or will not establish a specific CAM therapy as an important part of the standard of care for the condition in question. Legal rules governing CAM providers and practices are, in many cases, new and evolving. Further, laws vary by state and their application depends on the specific clinical scenario in question. New research is constantly emerging, as are federal and state legislative developments and judicial opinions resulting from litigation. [source] Fine-needle aspiration biopsy of metastatic malignant melanoma resembling a malignant peripheral nerve sheath tumorDIAGNOSTIC CYTOPATHOLOGY, Issue 10 2008Svetoslav Bardarov M.D. Abstract We report a case of metastatic malignant melanoma resembling a malignant peripheral sheath tumor, which posed a significant diagnostic challenge. The patient is a 76-year-old male, who presented in the emergency room with bilateral chest pain exacerbated by inspiration. The pain was present for 3 week and was not exacerbated by physical exercise. The diagnostic workup revealed bilateral parenchymal pulmonary infiltrates. The CT-scan guided fine-needle aspiration and the core biopsies of the largest pulmonary lesion revealed high-grade spindle cell neoplasm with individual cell apoptosis and necrosis. The immunohistochemical profile on the cell block showed that the cells are positive for Vimentin. The S-100 stain showed only focal positivity. The immunohistochemical stains for HMB45, Melan A, pancytokeratin, and smooth muscle actin were negative. Five years ago the patient was diagnosed with melanoma on the back with Clark level of IV. The melanoma was excised with clear margins and sentinel lymph nodes were negative. Careful examination of patient's previous slides revealed an area of spindle cell melanoma adjacent to a nodular type melanoma. Based on the patient's previous history, current clinico-pathologic presentation and immunohistochemical profile, the diagnosis of metastatic malignant melanoma resembling peripheral nerve sheath tumor was favored over the diagnosis of metastatic malignant spindle cell neoplasm of unknown primary site, which by itself is very rare clinical scenario. Diagn. Cytopathol. 2008;36:754,757. © 2008 Wiley-Liss, Inc. [source] Achieving long-term compliance with colonoscopic surveillance guidelines for patients at increased risk of colorectal cancer in AustraliaINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 3 2007P. A. Bampton Summary We have previously demonstrated that we could improve colonoscopic surveillance practice for patients at increased risk of colorectal cancer by the adoption of guidelines, facilitated by a nurse co-ordinator. This study was to determine whether we could sustain this improvement over a longer period (4 years). All colonoscopic surveillance decisions made by the co-ordinated colorectal screening programme of our hospital between 2000 and April 2004 were reviewed. Reasons for variance were recorded, and surveillance decisions made in the last 4 months of the study time were compared with decisions made 4 years previously, both before and after the introduction of the co-ordinated programme. Between 2000 and 2004, 1794 surveillance decisions were made with variance occurring in 100. In the last 4 months of the period of study, 98% of decisions matched guidelines, suggesting that the improvement made following the adoption of the guidelines (45,96% p < 0.05) could be maintained. Reasons for variance from guidelines included a belief that the particular clinical scenario was not covered in the guidelines, disagreement with the guidelines or patient anxiety. Adherence to evidence based medicine guidelines for colonoscopy surveillance can be maintained over time at a high level. A number of clinical scenarios are not covered adequately by the existing guidelines and continue to generate disagreement amongst clinicians. [source] Delivering the choice agenda as a framework to manage adverse effects: a mental health nurse perspective on prescribing psychiatric medicationJOURNAL OF PSYCHIATRIC & MENTAL HEALTH NURSING, Issue 4 2007M. JONES rn msc The article describes the clinical management of a patient referred, with a diagnosis of schizophrenia, who experienced adverse effects associated with an elevated prolactin level. A reflective model was adopted to inform the new learning which emerged from the clinical scenario. It highlights that Mental Health Nurse Supplementary Prescribers need to develop a prescribing value base underpinned by choice in addition to advanced technical skills to manage unhelpful effects of medication. [source] Integrating the Principles of Evidence-Based Practice: Testing and DiagnosisJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 1 2004APRN-C, Mary Jo Goolsby EdD ABSTRACT The intention of the clinical practice guideline (CPG) column has included increasing readers' familiarity with the range of available evidence-based recommendations, while stimulating dialogue regarding application of those recommendations in practice. This column introduces the first article in a series of three written to describe a framework in which the principles of evidence-based practice can be applied. This article uses a clinical scenario to illustrate considerations relevant to the selection and application of a CPG in practice. [source] Living liver donor death related to complications of myelomaLIVER TRANSPLANTATION, Issue 3 2009Emmanuel Melloul We report a donor death after right hepatectomy for living donor transplantation due to an undiagnosed myeloma. The 47-year-old donor, who was the 147th case performed in our department, was in excellent health without any abnormalities in the preoperative investigations. Despite an uneventful right hepatectomy without transfusion, the patient developed a partial thrombus of the inferior vena cava with a right proximal pulmonary trunk embolism on postoperative day 6. Subsequently, he developed multiorgan dysfunction leading to a coagulopathy, respiratory distress, and renal failure requiring hemodialysis and mechanical ventilation. This clinical scenario led us to suspect a hematological disorder. Immune electrophoresis showed a monoclonal peak of immunoglobulin G (8.7 g/L), a myelogram revealed an abnormally high level of dystrophic plasmocytes (more than 7%), and biopsies of salivary glands confirmed the diagnosis of immunoglobulin G kappa myeloma. The patient progressively deteriorated because of simultaneous hemorrhagic and infectious pulmonary complications resulting in septic shock. Despite an adequate combination of antimicrobial therapy and pleural drainage, the donor died on postoperative day 57 from multiple organ failure. This unusual cause of donor death after right hepatectomy reinforces the need for an extensive preoperative assessment. We advocate the addition of urinary protein loss and electrophoresis to the standard donor assessment protocol. Liver Transpl 15:326,329, 2009. © 2009 AASLD. [source] Bilateral Squamous Cell Carcinoma of the External Auditory Canals,THE LARYNGOSCOPE, Issue 6 2002Stephen G. Wolfe Abstract Objectives To report a case of bilateral squamous cell carcinoma of the external auditory canals and to present a management algorithm for this difficult clinical scenario. Study Design Case report and literature review. Methods The study comprises a case report of a 69-year-old man who initially presented with complaints of bilateral otorrhea, left-sided otalgia, and a left-sided hearing loss. Following attempted treatment of a presumed case of otitis externa, biopsy of both external auditory canals revealed squamous cell carcinoma. A computed tomography scan demonstrated marked abnormal soft tissue in the left external auditory canal with no bony erosion and thickening of the soft tissue in the right external auditory canal. Results The left-sided lesion required a lateral temporal bone resection, a partial superficial and deep-lobe parotidectomy, and postoperative irradiation. The right-sided lesion was more limited and was managed with a lateral temporal bone resection and tympanoplasty for hearing preservation. Conclusions Bilateral squamous cell carcinoma of the external auditory canals is an extremely uncommon but aggressive malignancy that may present with symptoms similar to a case of otitis externa, and this can result in delays in proper diagnosis. Early recognition is essential because management and prognosis are determined by the extent of the lesion. [source] IS THE ANALYST A GOOD OBJECT?BRITISH JOURNAL OF PSYCHOTHERAPY, Issue 3 2006Warren Colman ABSTRACT This paper suggests that the prohibition against ,taking the role of the good object' may inhibit therapists from an appropriate recognition of loving relation between the patient and themselves. It is argued that the prohibition actually refers to a defensive attempt to get the analyst to take the role of the idealized object as a defence against the emergence of bad objects in the transference. This clinical scenario is contrasted with one where the patient needs to find in their therapist a real good object who genuinely cares for them. [source] 18 Graduate Medical Education and Knowledge Translation: One Problem-Specific Approach in ResidencyACADEMIC EMERGENCY MEDICINE, Issue 2008Christopher Carpenter Traditional graduate medical education approaches to improving clinical performance based upon the latest research have included Journal Club and didactic lectures. Unfortunately, these educational interventions have rarely been demonstrated to change practice behavior or improve patient-important outcomes. Using a structured approach to identifying a gap between best-evidence knowledge and clinical practice, an illustrative one-year residency-wide translational research project was developed in a four year emergency medicine training program. Step one (assigned to the second year residents): identify and quantitatively justify a Knowledge Translation (KT) deficit within our institution. They identified steroids in adult bacterial meningitis as an unequivocal therapeutic option. Based upon a structured one-year chart review, they next demonstrated that only 7% of meningitis patients received pre-antimicrobial steroids. The next step (assigned to the first year residents): identify and quantify the physician "leaks" within the pipeline of information from publication to bedside utilization via an online survey. The third year residents hypothesized plugs for these information leaks, including examples of other specialties or institutions which have successfully navigated this specific clinical scenario. Finally, at an end-of-year Journal Club, the fourth year residents formulated a protocol for the appropriate use of steroids in suspected adult meningitis and brought together individuals from within the institution contributing to the best-practice leak. Knowledge Translation involves multiple stages beyond simple evidence awareness and usually involves continuation beyond the emergency department. The Washington University KT project offers a structured, multidisciplinary example of moving beyond contemplation to implementation of an unequivocal therapy. [source] Variation in GH and IGF-I assays limits the applicability of international consensus criteria to local practiceCLINICAL ENDOCRINOLOGY, Issue 1 2007A. Pokrajac Summary Background, There is increasing reliance on consensus criteria for decision making. Recent criteria state that acromegaly is excluded by a nadir GH during an oral glucose tolerance test (OGTT) of < 1 µg/l and a normal level of IGF-I. Objective, To study GH and IGF-I assay performance close to cut-off values for active acromegaly. Design and methods, Two serum samples known to give borderline results were sent to all centres participating in the UK National External Quality Assessment Service (NEQAS). Sample A was assigned to be a nadir during an OGTT and sent for GH assessment to 104 centres. Sample B, with a clinical scenario, was sent to 23 centres that measure IGF-I, and these centres were asked to measure IGF-I, interpret the result and provide the source of their reference ranges (RRs). Results, For sample A, the median GH was 2·6 mU/l (range 1·04,3·5 mU/l). Applying a conversion factor (CF) of 2·0 (1 µg/l = 2 mU/l), the most negatively biased method classified 10% of the values consistent with acromegaly, while the most positively biased method classified all values as consistent with the diagnosis. Applying a CF of 3·0 (1 µg/l = 3 mU/l), only 11% of results were consistent with acromegaly. For sample B, the median IGF-I was 50·8 nmol/l (range 24·3,60·9 nmol/l). All centres used age-related RRs. There was a 50% variation in the upper limit of the RRs between centres. Overall, 30% of the IGF-I results were against the diagnosis. There was little agreement in the RRs quoted by centres using the same method. Conclusion, Variability in assay performance, coupled with use of inappropriate CFs and RRs, undermines the applicability of international consensus criteria to local practice. [source] Clinical pathologic correlations for diagnosis and treatment of nail disordersDERMATOLOGIC THERAPY, Issue 1 2007Olympia I. Kovich ABSTRACT:, Clinicopathologic correlation is crucial to the correct diagnosis of disorders of the nail unit. This chapter will explore four common clinical scenarios and how pathology can help differentiate between their various etiologies. These include: dark spot on the nail plate (melanin versus heme), subungual hyperkeratosis (onychomycosis versus psoriasis), longitudinal melanonychia (benign versus malignant), and verrucous papule (verruca versus squamous cell carcinoma). Consideration must be given to both when to perform a biopsy and the location of the biopsy site, which must be based on an understanding of the origin of the changes. An overarching principle is that lesions within the same differential diagnosis may be present concomitantly, such as malignant melanoma of the nail unit associated with hemorrhage. Therefore, even with a biopsy-proven diagnosis, the clinician must always monitor lesions of the nail unit for appropriate response to treatment and consider an additional biopsy for recalcitrant lesions. [source] Teaching Techniques in the Clinical Setting: the Emergency Medicine PerspectiveACADEMIC EMERGENCY MEDICINE, Issue 10 2004David A. Wald DO Abstract The emergency department (ED) provides a unique educational experience that is distinct from both inpatient and ambulatory care settings. Because of the high acuity, interesting pathology, and rapid patient turnover, the ED is an ideal location to train medical students. Numerous teaching opportunities exist within the domain of the ED. In the preclinical years, the ED setting provides medical students with an introduction to clinical medicine and may serve as a venue for teaching basic history and physical examination skills. In the clinical years, medical students are exposed to a wide range of undifferentiated patients. Besides common medical and surgical complaints, many medical students will encounter clinical scenarios that they otherwise would have little direct contact with. Encounters such as the acutely poisoned or intoxicated patient, environmental emergencies, interaction with out-of-hospital providers, and patients requiring emergency procedures are just a few situations that make emergency medicine a distinct clinical specialty. These and other student,patient encounters can provide the teaching physician an opportunity to focus case-based teaching on a number of elements including complaint-directed medical interviewing and physical examination skills, development of case-specific differential diagnosis, diagnostic evaluation, implementation of patient management plans, and patient disposition. In this review article, the authors discuss various ways to approach and improve clinical teaching of medical students, including: opportunities for teaching in the ED, teaching procedural skills, student case presentations, clinical teaching styles, qualities of an effective clinical teacher, and barriers to effective clinical teaching. [source] Improving clinical assessment: evaluating students' ability to identify and apply clinical criteriaEUROPEAN JOURNAL OF DENTAL EDUCATION, Issue 3 2010C. Redwood Abstract Aim:, There is ongoing concern by health educators over the inability of professionals to accurately self-assess their clinical behaviour and standards, resulting in doubts over a key expectation of effective self-regulation in the health professions. Participation by students in the assessment process has been shown to increase the understanding of assessment criteria in written assessment tasks. How this might transfer to the clinical setting is the focus of this study. This paper is part of an ongoing investigation of the impact on learning of a series of activities that provides students with opportunities to discuss and apply criteria and standards associated with self-assessment in clinical dentistry. Our aim was to evaluate whether participation in these assessment activities improved the ability of first-year dental students to recognise behaviours demonstrated by ,peers' in videos of clinical scenarios and to relate these to the assessment criteria. Materials and methods:, A series of three workshops in conjunction with weekly clinical assessment activities in Semesters 1 and 2 were use to support first-year students' learning of clinical assessment criteria. The design of the workshops was based on the principles of social constructivist theories of learning and the concept of tacit knowledge. Accordingly workshop activities were planned around videos that were specifically constructed to illustrate procedures and behaviours typical of those observed by staff and tutors in the first year of the dental course at The University of Adelaide, Australia. First-year students viewed the videos prior to and after the workshops and recorded observed behaviours that related to the assessment criteria that were used in their clinical practice course. Student learning outcomes were assessed 10,14 weeks after the initial workshop and again up to 42 weeks later. To check whether learning resulted from repeated viewing of the videos without formal discussion, a reference group of third-year students who did not attend the workshops also viewed the videos two times, separated by 12 weeks, and recorded observations in the same way. Results:, There was no consistent evidence that repeat viewing of the videos in isolation resulted in improved recognition of ,peer' behaviours by third-year dental students. Results for the first-year students indicated that the workshops and clinical assessment activities had a significantly positive effect on the ability of students to identify ,peer' behaviours related to the criteria used for clinical assessment. In particular, students' recognition in others of knowledge and professional behaviours improved significantly. This improvement was retained over the year and students were able to recognise these behaviours in other scenarios relevant to their year level. Conclusions:, This early exposure to the process of clinical assessment, coupled with ongoing self-assessment and tutor feedback throughout first year, improved the ability of first-year students to identify and apply some key assessment criteria to observed ,peer' behaviour, and this ability was retained over time. [source] Achieving long-term compliance with colonoscopic surveillance guidelines for patients at increased risk of colorectal cancer in AustraliaINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 3 2007P. A. Bampton Summary We have previously demonstrated that we could improve colonoscopic surveillance practice for patients at increased risk of colorectal cancer by the adoption of guidelines, facilitated by a nurse co-ordinator. This study was to determine whether we could sustain this improvement over a longer period (4 years). All colonoscopic surveillance decisions made by the co-ordinated colorectal screening programme of our hospital between 2000 and April 2004 were reviewed. Reasons for variance were recorded, and surveillance decisions made in the last 4 months of the study time were compared with decisions made 4 years previously, both before and after the introduction of the co-ordinated programme. Between 2000 and 2004, 1794 surveillance decisions were made with variance occurring in 100. In the last 4 months of the period of study, 98% of decisions matched guidelines, suggesting that the improvement made following the adoption of the guidelines (45,96% p < 0.05) could be maintained. Reasons for variance from guidelines included a belief that the particular clinical scenario was not covered in the guidelines, disagreement with the guidelines or patient anxiety. Adherence to evidence based medicine guidelines for colonoscopy surveillance can be maintained over time at a high level. A number of clinical scenarios are not covered adequately by the existing guidelines and continue to generate disagreement amongst clinicians. [source] Management of advanced HIV disease with no other complications in women and in AfricansINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 1 2007I. Williams Summary The number of patients who present with advanced human immunodeficiency virus (HIV) disease [defined as a helper lymphocyte (CD4) count <50 cells/mm3 or the presence of an acquired immunodeficiency syndrome (AIDS)-defining illness] is increasing. In the USA during 1994,1999, a relatively stable proportion of 43% of people diagnosed with HIV infection were tested late in the infection (had AIDS diagnosed within 1 year of diagnosis). A recent review of newly diagnosed infections in 2003 found that 301/977 (31%) of patients in the UK and Ireland presented late (<200 CD4 cells/mm3). Before a diagnosis is made, patients with advanced disease do not benefit from antiretroviral therapy and may continue to transmit the infection to others. Furthermore, when antiretroviral therapy is initiated in patients with CD4 counts of 201,350 cells/mm3, the risk of death is lower than when treatment is started at lower CD4 cell counts. With the increasing prevalence of HIV in women and African immigrants, some doctors are concerned that different management approaches need to be used in these groups. This article reviews the evidence and some clinical scenarios for patients with advanced disease without complications and women and Africans who may present with advanced HIV disease. The aim is to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease on the basis of available clinical evidence. [source] Thromboprophylaxis in ENT patients: a national surveyINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 10 2006S. O'HANLON Summary The aim of this survey was to establish whether ENT departments in England follow British Medical Journal guidelines on thromboprophylaxis. A telephone survey of doctors in 80 ENT departments was used to present six clinical scenarios. The participants were asked what their local department routinely did. They were also asked whether they were aware of a local or national thromboprophylaxis policy. For patients undergoing procedures other than major head and neck procedures, compliance was poor and ranged between 7.5% and 37.5%. For laryngectomy, the rate was 82.6%. There was no statistical difference in answers given by doctors of different levels of seniority. Where local thromboprophylaxis guidelines exist, compliance is found to be statistically better. These results suggest that most ENT departments do not follow national or local guidelines on thromboprophylaxis. Greater awareness of existing guidelines is required. [source] Genetics education in the nursing profession: literature reviewJOURNAL OF ADVANCED NURSING, Issue 2 2006Sarah Burke BA MA Aim., This paper reports a literature review exploring genetics education for nursing professionals. The aim was to contribute to the debate about the future direction of such education. Background., Advances in genetics science and technology have profound implications for health care and the growing importance and relevance of genetics for everyday nursing practice is increasingly recognized. Method., A search was conducted in February 2005 using the CINAHL and Google Scholar databases and the keywords nurse, midwife, health visitor, education and genetics. Papers were included if they were published in English between 1994 and 2005 and included empirical data about genetics education in nursing. In addition, attempts were made to access the grey literature, with requests for information on research, for example, to members of the Association of Genetic Nurses and Counsellors and searches of relevant websites. Findings., Agreement on the relevance of genetics for nursing practice is extensive. Empirical evidence of the learning needs of practitioners highlights widespread deficits in knowledge and skills, and low confidence levels. Provision of nursing education in genetics is patchy and insubstantial across a number of countries, further hampered by lack of strategic development. Significant progress has been made in the identification of learning outcomes for nurses. Research on the delivery of genetics education is limited, but the role of skills-based training, use of clinical scenarios, and importance of assessment have all been identified as factors that can promote learning. Conclusion., Whilst areas of good performance were revealed, many studies identified gaps in professional competence and/or education. New initiatives are underway to support genetics education and its integration into professional practice, but further research is needed on the most effective forms of educational delivery, and an international collaborative approach to this should be considered. [source] Vignettes in Osteoporosis: A Road Map to Successful Therapeutics,JOURNAL OF BONE AND MINERAL RESEARCH, Issue 1 2004Clifford J Rosen Abstract The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. Introduction: The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. Materials and Methods: Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). Results: A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. Conclusions: A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas. [source] Basal cell carcinoma of the nose: An Australian and New Zealand Radiation Oncology patterns-of-practice studyJOURNAL OF MEDICAL IMAGING AND RADIATION ONCOLOGY, Issue 4 2008MJ Veness Summary Patients with a basal cell carcinoma (BCC) of the nose may be recommended radiotherapy (RT) with a wide variation in techniques and prescribed dose fractionation schedules between clinicians. The aim of this study was to ascertain variability in the patterns of practice among Australian and New Zealand radiation oncologists (ROs) when treating BCC arising on the nose. A postal survey was sent to 222 practising ANZ ROs detailing 12 different clinical scenarios of a BCC arising on the nose. The treatment selected for each scenario was analysed according to clinician's attitudes, training, experience and the availability of resources. The response rate was 74% (165/222) with 90 respondents treating non-melanoma skin cancer. Training was perceived to have a marked influence on treatment practice by most (79%). In total, 72% of ROs were ,very certain' in their choice of a dose fractionation schedule for obtaining local control and 61% for a satisfactory cosmetic outcome, respectively. Most (76%) favoured low-voltage photons over electrons as the optimal method of treatment, although for certain clinical scenarios most would use electrons. Dose fractionation schedules were highly variable with a lower total dose and hypofractionation favoured for older patients. Low-voltage photons were favoured for the T1 BCC and electrons for the T2 and T4 BCC. Nearly one-third of the ROs chose megavoltage photons for the T4 lesion. There is marked variation in treatment practices in terms of recommending RT over other treatment options, the choice of RT method, the dose fractionation schedule, the extent of field margins and the point of dose prescription. [source] Intended management of children with acute idiopathic thrombocytopenic purpura: A national surveyJOURNAL OF PAEDIATRICS AND CHILD HEALTH, Issue 1-2 2005MK Marks Objective: In Australia acute idiopathic thrombocytopenic purpura (ITP) is mainly treated by paediatricians (either general paediatricians or paediatric haematologists/oncologists). A survey was conducted to gauge the current practice of treating children with acute ITP in Australia. Methods: All practising Australian paediatricians registered by the Royal Australasian College of Physicians were surveyed regarding their intended management of children with acute ITP. The questionnaire, adapted from a study of paediatric haematologists/oncologists in North America, presented four clinical scenarios of children with acute ITP with a platelet count of 3000 × 109/L, with and without mucosal bleeding (wet and dry purpura, respectively). Questionnaires were returned by mail or filled in online at a dedicated webpage. Results: Five hundred and sixty-three of 1097 (51%) paediatricians responded to the survey. Data from 140 who had treated at least one child with ITP in the previous 12 months were analysed. Respondents indicated that children with acute ITP are usually or always hospitalised (58,92%) and that 48% would be given active treatment, even with dry purpura. Various regimens of i.v. immunoglobulin or corticosteroids are used when treatment is administered. In comparing Australian and North American management of acute ITP there were many similarities, although Australian paediatricians were less likely to arrange a bone marrow aspirate if corticosteroids were prescribed. Conclusions: There is great variation in the intended management of children with acute ITP in Australia. Previously published management recommendations regarding investigation and treatment have had little impact on intended practice. Prospective studies are required to evaluate hypotheses so as to produce evidence-based recommendations for treatment of patients with acute ITP. [source] Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task ForceJOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 4 2005U. MARTINOWITZ Summary.,Background:,Recombinant activated factor VII (rFVIIa) has been approved by the U.S. Food and Drug Administration (FDA) for almost a decade for hemophilic patients with inhibitors. Its off-label use as a hemostatic agent in massive bleeding caused by a wide array of clinical scenarios is rapidly expanding. While evidence-based guidelines exist for rFVIIa treatment in hemophilia, none are available for its off-label use. Objectives:,The aim of this study is to develop expert recommendations for the use of rFVIIa in patients suffering from uncontrolled bleeding (with special emphasis on trauma) until randomized, controlled trials allow for the introduction of more established evidence-based guidelines. Methods:,A multidisciplinary task force comprising representatives of the relevant National Medical Associations, experts from the Medical Corps of the Army, Ministry of Health and the Israel National Trauma Advisory Board was established in Israel. Recommendations were construed based on the analysis of the first 36 multi-trauma patients accumulated in the prospective national registry of the use of rFVIIa in trauma, and an extensive literature search consisting of published and prepublished controlled animal trials, case reports and series. The final consensus guidelines, together with the data of the first 36 trauma patients treated in Israel, are presented in this article. Results:,Results of the first 36 trauma patients: The prolonged clotting assays [prothrombin time (PT) and partial thromboplastin time (PTT)] shortened significantly within minutes following administration of rFVIIa. Cessation of bleeding was achieved in 26 of 36 (72%) patients. Acidosis diminished the hemostatic effect of the drug, while hypothermia did not affect it. The survival rate of 61% (22/36) seems to be favorable compared with published series of similar, or less severe, trauma patients (range 30%,57%). Conclusions:,As a result of the lack of controlled trials, our guidelines should be considered as suggestive rather than conclusive. However, they provide a valuable tool for physicians using rFVIIa for the expanding off-label clinical uses. [source] Decision analysis: an aid to the diagnosis of Whipple's diseaseALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 6 2006M. OLMOS Summary Background Diagnosis of Whipple's disease, a rare systemic infection affecting predominantly the small bowel, is based on the identification of the bacterium Tropheryma whipplei. Aims To make explicit diagnostic uncertainties in Whipple's disease through a decision analysis, considering two different clinical scenarios at presentation. Methods Using appropriate software, a decision tree estimated the consequences after testing different strategies for diagnosis of Whipple's disease. Probabilities and outcomes to determine the optimum expected value were based on MEDLINE search. Results In patients with clinically-predominant intestinal involvement, diagnostic strategies considering intestinal biopsy for histology (including appropriate staining) and the polymerase chain reaction testing for bacterial DNA were similarly effective. In case of failure of one procedure, the best sequential choice was a polymerase chain reaction analysis after a negative histology. Of the five strategies tested for cases with predominant focal neurological involvement, the stereotaxis cerebral biopsy evidenced the highest expected value. However, using quality-adjusted life-years considering the morbidity of methods, intestinal biopsy for PCR determination was the best choice. Conclusions In patients with Whipple's disease having predominant digestive involvement, intestinal biopsies for histology should be indicated first and, if negative, a bacterial polymerase chain reaction determination should be the next option. Although the molecular polymerase chain reaction assessment of cerebral biopsies has the highest diagnostic yield in neurological Whipple's disease, its associated morbidity means that analyses of intestinal samples are more appropriate. [source] Liver transplantation and pancreatic resection: A single-center experience and a review of the literatureLIVER TRANSPLANTATION, Issue 12 2009John A. Stauffer Liver transplantation may occasionally be indicated in patients with unique clinical scenarios. Little is known regarding the outcomes of patients who have had a pancreatic resection prior to, in combination with, or after liver transplantation. A retrospective review of all patients undergoing liver transplantation from March 1998 to March 2008 identified 17 patients who also underwent pancreatic resection. An additional literature review was performed. Five underwent pancreatic resection prior to liver transplantation (1.7, 3.6, 3.8, 6.8, and 8.1 years), another 9 underwent pancreatic resection together with liver transplantation, and 3 underwent pancreatic resection after liver transplantation (2.2, 2.6, and 3.8 years). Indications for pancreatic resection included cholangiocarcinoma (n = 6), neuroendocrine tumor (n = 5), pancreatic cancer (n = 2), gastrointestinal stromal tumor (n = 1), periampullary adenocarcinoma (n = 1), duodenal adenomas (n = 1), and benign pancreatic mass (n = 1). Indications for liver transplantation were metastatic neuroendocrine tumor disease (n = 5), primary sclerosing cholangitis (n = 5), hepatitis C virus (n = 2), metastatic gastrointestinal stromal tumor (n = 1), Klatskin tumor (n = 1), alcohol cirrhosis (n = 1), alpha-1 antitrypsin deficiency (n = 1), and chemotherapy-induced cirrhosis (n = 1). One patient died intraoperatively, 7 patients died of tumor recurrence, 2 patients died from transplant complications, and 7 patients are still alive. Pancreatic resection,related complications included 4 pancreatic fistulas. A literature review confirmed liver transplantation/pancreatic resection,related complications. In conclusion, liver transplantation and pancreatic resection remain uncommon, and a good outcome can be achieved. Recurrence of malignant disease is the main factor limiting survival, and specific morbidity may be related to pancreatic resection and liver transplantation. Liver Transpl 15:1728,1737, 2009. © 2009 AASLD. [source] A technique for rapid single-echo spin-echo T2 mappingMAGNETIC RESONANCE IN MEDICINE, Issue 2 2010Marshall S. Sussman Abstract A rapid technique for mapping of T2 relaxation times is presented. The method is based on the conventional single-echo spin echo approach but uses a much shorter pulse repetition time to accelerate data acquisition. The premise of the new method is the use of a constant difference between the echo time and pulse repetition time, which removes the conventional and restrictive requirement of pulse repetition time , T1. Theoretical and simulation investigations were performed to evaluate the criteria for accurate T2 measurements. Measured T2s were shown to be within 1% error as long as the key criterion of pulse repetition time/T2 ,3 is met. Strictly, a second condition of echo time/T1 , 1 is also required. However, violations of this condition were found to have minimal impact in most clinical scenarios. Validation was conducted in phantoms and in vivo T2 mapping of healthy cartilage and brain. The proposed method offers all the advantages of single-echo spin echo imaging (e.g., immunity to stimulated echo effects, robustness to static field inhomogeneity, flexibility in the number and choice of echo times) in a considerably reduced amount of time and is readily implemented on any clinical scanner. Magn Reson Med, 2010. © 2010 Wiley-Liss, Inc. [source] Review: Neutrophil gelatinase-associated lipocalin: A troponin-like biomarker for human acute kidney injuryNEPHROLOGY, Issue 4 2010PRASAD DEVARAJAN ABSTRACT Acute kidney injury (AKI) is a common and serious condition, the diagnosis of which currently depends on functional markers such as serum creatinine measurements. Unfortunately, creatinine is a delayed and unreliable indicator of AKI. The lack of early biomarkers of structural kidney injury (akin to troponin in acute myocardial injury) has hampered our ability to translate promising experimental therapies to human AKI. Fortunately, understanding the early stress response of the kidney to acute injuries has revealed a number of potential biomarkers. The discovery, translation and validation of neutrophil gelatinase-associated lipocalin (NGAL), possibly the most promising novel AKI biomarker, is reviewed. NGAL is emerging as an excellent stand-alone troponin-like structural biomarker in the plasma and urine for the early diagnosis of AKI, and for the prediction of clinical outcomes such as dialysis requirement and mortality in several common clinical scenarios. The approach of using NGAL as a trigger to initiate and monitor therapies for AKI, and as a safety biomarker when using potentially nephrotoxic agents, is also promising. In addition, it is hoped that the use of sensitive and specific biomarkers such as NGAL as endpoints in clinical trials will result in a reduction in required sample sizes, and hence the cost incurred. Furthermore, predictive biomarkers like NGAL may play a critical role in expediting the drug development process. However, given the complexity of AKI, additional biomarkers (perhaps a panel of plasma and urinary biomarkers) may eventually need to be developed and validated for optimal progress to occur. [source] Utility of Noninvasive, Mobile, Continuous Outpatient Rhythm Monitoring to Diagnose Seizure-Related ArrhythmiasPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2009KEVIN DRIVER M.D. The identification of patients with a diagnosis of seizure disorder who are also at risk for clinically significant bradycardia and/or tachycardia may require long-term cardiac rhythm monitoring. Noninvasive, continuous, outpatient cardiac rhythm monitoring may be useful for such clinical scenarios. The study group consisted of two male patients with a history of seizure disorder involving loss of consciousness. Clinical data and results of electrocardiography, echocardiography, electroencephelography, and continuous, mobile, outpatient cardiac rhythm monitoring are described. In the first patient, while cardiac bradyarrhythmias were secondary to seizures, sinus arrest most likely complicated the episodes by leading to more prolonged states of unconsciousness. In the second patient, permanent pacemaker implantation for AV block averted all clinical events previously attributed to seizures. Despite the different causal relationships between seizures and bradyarrhythmias in these two patients, mobile, cardiac outpatient telemetry was successful in diagnosing the contribution of cardiac dysrhythmia, leading to permanent pacemaker implantation. A diagnostic strategy that incorporates mobile, noninvasive, continuous, outpatient cardiac rhythm monitoring can effectively be utilized to diagnose significant seizure-related arrhythmias. [source] B-type natriuretic peptide monitoring in the Pediatric ICU populationPEDIATRIC ANESTHESIA, Issue 8 2007JOSEPH D. TOBIAS MD Summary The natriuretic peptide system plays an active role in the regulation of fluid balance and systemic vascular resistance. Assays of these peptides are now available and may be used for both diagnostic and prognostic purposes. Despite its primary use in adults, it may have a diagnostic role in the Pediatric ICU as well. The basic physiology of the natriuretic system is discussed and the potential applications of B-type natriuretic peptide (BNP) monitoring as a diagnostic tool in various clinical scenarios in infants and children in the Pediatric ICU setting is reviewed. [source] REVIEW ARTICLE: The Immune System in Pregnancy: A Unique ComplexityAMERICAN JOURNAL OF REPRODUCTIVE IMMUNOLOGY, Issue 6 2010Gil Mor Citation Mor G, Cardenas I. The immune system in pregnancy: a unique complexity. Am J Reprod Immunol 2010 Abstract Placental immune response and its tropism for specific viruses and pathogens affect the outcome of the pregnant woman's susceptibility to and severity of certain infectious diseases. The generalization of pregnancy as a condition of immune suppression or increased risk is misleading and prevents the determination of adequate guidelines for treating pregnant women during pandemics. There is a need to evaluate the interaction of each specific pathogen with the fetal/placental unit and its responses to design the adequate prophylaxis or therapy. The complexity of the immunology of pregnancy and the focus, for many years, on the concept of immunology of pregnancy as an organ transplantation have complicated the field and delayed the development of new guidelines with clinical implications that could help to answer these and other relevant questions. Our challenge as scientists and clinicians interested in the field of reproductive immunology is to evaluate many of the ,classical concepts' to define new approaches for a better understanding of the immunology of pregnancy that will benefit mothers and fetuses in different clinical scenarios. [source] Variation in rapid sequence induction techniques: current practice in WalesANAESTHESIA, Issue 1 2009J. P. Koerber Summary A questionnaire survey examining rapid sequence induction techniques was sent to all anaesthetists in Wales. The questionnaire presented five common clinical scenarios: emergency appendicectomy; elective knee arthroscopy with a symptomatic hiatus hernia; elective knee arthroscopy with an asymptomatic hiatus hernia; elective Caesarean section; and emergency laparotomy for bowel obstruction. Completed surveys were received from 421 anaesthetists, a 68% response rate. Rapid sequence induction was chosen by 398/400 respondents (100%) for bowel obstruction, 392/399 (98%) for Caesarean section, 388/408 (95%) for appendicectomy, 328/395 (83%) for symptomatic hiatus hernia but only 98/399 (25%) for asymptomatic hiatus hernia (p < 0.001). Trainees were more likely to use a rapid sequence induction technique than consultants and staff grades for the appendicectomy (p = 0.025), symptomatic hiatus hernia (p = 0.004) and asymptomatic hiatus hernia (p = 0.001) scenarios and were also more likely to use a thiopental,suxamethonium combination for rapid sequence induction (p < 0.001). [source] | ||||||||||