Home About us Contact
|
Home About us Contact | ||
|
|
||
Limited Experience (limited + experience)
Selected AbstractsPCI versus CABG for multivessel coronary disease in diabetics,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 1 2009Giuseppe Tarantini MD Abstract Objectives: To explore the clinical performance of a strategy of revascularization by percutaneous coronary intervention (PCI) with drug-eluting stent (DES) in diabetic patients with multivessel disease (MVD) compared with coronary artery bypass graft (CABG), when it is based on clinical judgment. Background: Diabetes mellitus (DM) is a major risk factor for poor outcome after PCI. However, PCI may result in better outcome if the choice of revascularization (PCI versus CABG) is based on the physician decision, rather than randomization. Limited experiences have compared revascularization by DES-PCI versus CABG in DM patients with MVD. Methods: From August 2004 to August 2005, 220 consecutive DM patients with MVD underwent DES-PCI (93) or CABG (127) at our Institution. The type of revascularization was dependent on patient and/or physician choice. Major adverse cardiac and cerebrovascular events (MACCE) included death, myocardial infarction, repeat coronary revascularization, and stroke. Results: Compared with PCI patients, CABG patients had higher prevalence of 3-vessel disease (P < 0.001), significant LAD involvement (P < 0.001), presence of total occlusions (P = 0.04), collateral circulation (P < 0.001). At 2-year follow-up, MACCE were not different between CABG group and DES-PCI group (OR 1.2; P = 0.6) and, only when the clinical judgment on the revascularization choice was excluded at propensity analysis, DES-PCI increased the risk of 24-month MACCE in total population (OR 1.8; P = 0.04). Conclusions: For patients with DM and MVD, a clinical judgment-based revascularization by DES-PCI is not associated with worse 2-year outcome compared with CABG. © 2008 Wiley-Liss, Inc. [source] ENDOSCOPIC SUBMUCOSAL DISSECTION IN THE UPPER GASTROINTESTINAL TRACT: PRESENT AND FUTURE VIEW OF EUROPEDIGESTIVE ENDOSCOPY, Issue 2009Horst Neuhaus In Western countries endoscopic mucosal resection (EMR) has been widely accepted for treatment of early Barrett`s neoplasia and flat or depressed colorectal adenomas. In contrast endoscopic submucosal dissection (ESD) is infrequently performed for several reasons. It seems to be difficult to overcome the learning curve of this difficult technique because of the low case volume of early gastric cancer. On the other hand ESD of esophageal or colorectal lesions is even more challenging and is considered to be inappropriate for learning. In addition the indication for esophageal or colorectal ESD is controversial in view of excellent results of the well established EMR technique which is less time-consuming and safer than ESD. A recent survey of leading Western endoscopy centers indicated the limited experience with ESD with a low number of cases for all potential indications. Only a few training courses have been established and the number of ongoing clinical studies is limited. Only 12 out of 340 published articles on "endoscopic mucosal dissection" were reported from Western countries. A better acceptance of ESD requires improvement of the technique to allow an easier, faster and safer approach. There is a strong demand for structured training courses and limitations of human cases to selected centers which participate in prospective trials. A close collaboration between Western and Asian centers is recommended for improvement of the ESD technique and its clinical application. [source] Acquiring knowledge with limited experienceEXPERT SYSTEMS, Issue 3 2007Der-Chiang Li Abstract: From computational learning theory, sample size in machine learning problems indeed affects the learning performance. Since only few samples can be obtained in the early stages of a system and fewer exemplars usually lead to a low learning accuracy, this research compares different machine learning methods through their classification accuracies to improve small-data-set learning. Techniques used in this paper include the mega-trend diffusion technique, a backpropagation neural network, a support vector machine, and decision trees to explore the machine learning issue with two real medical data sets concerning cancer. The result of the experiment shows that the mega-trend diffusion technique and backpropagation approaches are effective methods of small-data-set learning. [source] QoS experiences in native IPv6 networksINTERNATIONAL JOURNAL OF NETWORK MANAGEMENT, Issue 2 2009Athanassios Liakopoulos Deployment of IPv6 technology in research and commercial networks has accelerated in the last few years. Inevitably, as more advanced services take advantage of the new technology, IPv6 traffic gradually increases. Today, there is limited experience in the deployment of Quality of Service (QoS) for IPv6 traffic in backbone networks that support the Differentiated Services framework. As available software and hardware are designed to handle IPv4 packets, there is a need to accurately measure and validate performance of QoS mechanisms in an IPv6 environment. This paper discusses tests and technical challenges in the deployment of IPv6 QoS in core networks, namely the production dual stack gigabit-speed Greek Research and Education Network (GRNET) and the IPv6-only 6NET European test network, using both hardware and software platforms. In either case, we succeeded in delivering advanced transport services to IPv6 traffic and provided different performance guarantees to portions of traffic. The deployed QoS schema was common to IPv6 and IPv4; in most cases both v4 and v6 traffic exhibited comparable performance per class, while imposing no significantly different overhead on network elements. A major conclusion of our tests is that the IPv6 QoS mechanisms are efficiently supported with state-of-the-art router cards at gigabit speeds. Copyright © 2008 John Wiley & Sons, Ltd. [source] Uncovering the evidence of non-expert nephrology nursing practiceINTERNATIONAL JOURNAL OF NURSING PRACTICE, Issue 2 2006Ann Bonner BAppSc(Nurs) MA PhD RN MRCNA Expertise in nursing has been widely studied although there have been no previous studies into what constitutes expertise in nephrology (renal) nursing. This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, provides evidence of the characteristics and practices of non-expert nephrology nurses. Using the grounded theory method, the study took place in one renal unit in New South Wales, Australia, and involved six non-expert and 11 expert nurses. Sampling was purposive then theoretical. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semistructured interviews was undertaken. The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Non-expert nurses showed superficial nephrology nursing knowledge and limited experience; they were acquiring basic nephrology nursing skills and possessed a narrow focus of practice. [source] Liver transplantation in patients with severe portopulmonary hypertension treated with preoperative chronic intravenous epoprostenolLIVER TRANSPLANTATION, Issue 8 2001Henkie P. Tan MD Portopulmonary hypertension (PPHTN) is no longer an absolute contraindication to orthotopic liver transplantation (OLT). The pre-OLT management of patients with PPHTN requires early diagnosis and chronic therapy with intravenous epoprostenol to decrease pulmonary vascular resistance (PVR). Close follow-up is necessary to reassess pulmonary artery pressures (PAPs) and evaluate right ventricular (RV) function. This assists in the optimal timing of OLT. Successful management also necessitates reassessment of pulmonary artery hemodynamics just before OLT, with clearly defined parameters used to determine whether to proceed. Even with the intraoperative and postoperative availability of potent pulmonary vasodilators, clinical management may be suboptimal in reducing PAP. Adequate reduction in PVR and improvement in RV function in response to chronic epoprostenol therapy may facilitate successful OLT. We present a case report and review the limited experience with this treatment. [source] Penile resurfacing with vascularized fascia lataMICROSURGERY, Issue 6 2005Andreas I. Gravvanis M.D., Ph.D. Penis resurfacing is a challenging procedure, and should simultaneously ensure erectile function, tactile sensibility, sexual satisfaction, and aesthetic integrity. This article presents three cases with penile skin defects treated by means of a pedicled fascia lata attached either to the tensor fascia lata (one case) or an anterolateral thigh flap (two cases). The cause of the wounds included electrical burn, Fournier's gangrene, and self-mutilation. The size of flaps ranged from 10,13 cm in width and 15,30 cm in length. All flaps included vascularized fascia lata, which covered part or the circumference of the penis. All flaps survived completely. The lateral cutaneous nerve of the thigh was included in the designed flaps in all instances, and normal protective sensation was recorded postoperatively. The patients reported normal erectile function and ability to perform intercourse. The flaps, though relatively bulky and hairy, had a good color and texture match with the penis and suprapubic region. Based on our limited experience, we believe that the anterolateral thigh flap has greater dimensions with a longer pedicle, and allows for greater flexibility in flap design compared to the tensor fascia lata flap. An anterolateral thigh flap can be safely thinned in a second stage, and it is our flap of choice for penis resurfacing. © 2005 Wiley-Liss, Inc. Microsurgery 25:462,468, 2005 [source] Pacemaker Lead Extraction with the Needle's Eye Snare for Countertraction via a Femoral ApproachPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2002DIDIER KLUG KLUG, D., et al.: Pacemaker Lead Extraction with the Needle's Eye Snare for Countertraction via a Femoral Approach. Femoral approach pacemaker lead extraction is described as a safe and efficacious procedure. When the lead can not be removed from its myocardial insertion, the "Needle's eye snare" has become available, and it allows a femoral approach traction associated with a countertraction . Between May 1998 and May 2000, 222 lead extraction procedures were performed in 99 patients using the femoral approach. This article reports the results of the 70 lead extractions requiring the use of the Needle's eye snare for femoral approach countertraction in 39 patients with a total of 82 leads. The indications were infection, accufix leads and lead dysfunction in 56, 1 and 6 leads, respectively. The age of the leads was 113 ± 56 months. Sixty-one (87.2%) leads were successfully extracted, the extraction was incomplete in 3 (4.3%) cases and failed in 6 (8.5%) cases. The failures were due to leads totally excluded from the venous flow for four leads, the impossibility of advancing the 16 Fr long sheath through the right and left iliac veins for one lead and one traction induced a nontolerated ventricular arrhythmia. In these cases, an extraction by a simple upper traction had been attempted in another center several months before. The complications included two deaths and one transient ischemia of the right inferior limb. Despite the selection of a series of leads for which an extraction by a simple traction on the proximal end of the lead was impossible or unsuccessful, femoral countertraction seems to be a safe and efficacious procedure. The failure of this technique occurred in patients with damaged leads due to a previous extraction procedure performed in centers with limited experience in lead extraction. [source] Single-center experience with mycophenolate mofetil in pediatric renal transplant recipientsPEDIATRIC TRANSPLANTATION, Issue 4 2001Mumtaz Virji Abstract: Mycophenolate mofetil (MMF), a potent and specific inhibitor of guanosine nucleotide synthesis, is a new immunosuppressive drug used to prevent rejection in transplant patients. Extensive data on its utility and efficacy exists in adult patients but there is limited experience in pediatrics. Twenty-four children (14 male, 10 female; 2,19 yr of age), eight of whom had received living-related donor (LRD) transplants and 16 of whom had received cadaveric donor (CD) transplants, have been treated with MMF in our institution since September 1996. MMF was administered for a duration ranging from 13 weeks to 38 months, at an average dose of 600 mg/m2 (range: 200,1,000 mg/dose) every 12 h, for a total experience of 304 patient months. MMF capsules were used in 16 patients and/or pediatric suspension in eight. Five patients were switched to MMF from azathioprine as a result of rejection episodes or inability to taper prednisone, between 5 weeks and 3.5 yr post-transplant. All patients received prednisone, cyclosporin A (CsA), and induction therapy with anti-lymphocyte globulin (19 patients), anti-thymocyte globulin (one patient) or daclizumab (four patients). In 12 patients started on MMF at the time of CD transplant, five (42%) had an acute rejection episode. In seven who received a LRD transplant, one (14%) had an acute rejection episode. No patients who were converted to MMF were treated for acute rejection following conversion to MMF. One LRD graft was lost at 19 days following injury to the donor artery at the time of retrieval. At the last follow-up, the average creatinine level was 93 µmol/L and average urea level was 8.6 mmol/L. One patient developed epigastric distress. Three patients developed diarrhea/abdominal pain requiring dose adjustment. Five episodes of leukopenia and one episode of thrombocytopenia required dose adjustment. Two patients developed symptomatic cytomegalovirus (CMV) infection, one while on acyclovir prophylaxis. No malignancy has been encountered to date. Hence, MMF can be administered safely to children with good effect and with an acceptable side-effect profile. [source] Endoscopic Laryngotracheal Cleft Repair Without Tracheotomy or IntubationTHE LARYNGOSCOPE, Issue 4 2006Kishore Sandu MD Abstract Objectives: The objectives of this study are to present the technique and results of endoscopic repair of laryngotracheoesophageal clefts (LTEC) extending caudally to the cricoid plate into the cervical trachea and to revisit the classification of LTEC. Methods: The authors conducted a retrospective case analysis consisting of four infants with complete laryngeal clefts (extending through the cricoid plate in three cases and down into the cervical trachea in one case) treated endoscopically by CO2 laser incision of the mucosa and two-layer endoscopic closure of the cleft without postoperative intubation or tracheotomy. Results: All four infants resumed spontaneous respiration without support after a mean postoperative period of 3 days with continuous positive airway pressure (CPAP). They accepted oral feeding within 5 postoperative days (range, 3,11 days). No breakdown of endoscopic repair was encountered. After a mean follow up of 48 months (range, 3 mos to 7 y), all children have a good voice, have no sign of residual aspiration, but experience a slight exertional dyspnea. Conclusion: This limited experience on the endoscopic repair of extrathoracic LTEC shows that a minimally invasive approach sparing the need for postoperative intubation or tracheotomy is feasible and safe if modern technology (ultrapulse CO2 laser, endoscopic suturing, and postoperative use of CPAP in the intensive care unit) is available. [source] Fibreoptic intubation through the laryngeal mask airway: effect of operator experience,ANAESTHESIA, Issue 10 2009I. Hodzovic Summary In a randomised crossover study, we compared times and success rates for tracheal placement of a fibrescope and railroading of a tracheal tube through the classic laryngeal mask airway by anaesthetists with limited experience in fibreoptic intubation (trainees) and those who were experts. Thirty-two patients, 32 trainees and three experts took part. The median (IQR [range]) times to fibrescope placement for trainees and experts were 21 (18,30 [12,58]) s and 17 (14,24 [9,55]) s, respectively (95% CI for the difference 2,8 s; p = 0.023). There were no significant differences between trainees and experts in the times to placement of the laryngeal mask airway (41 (33,47 [31,105]) s and 36 (33,43 [30,52]) s, respectively; p = 0.24), railroading times (43 (40,58 [33,87]) s and 44 (38,57 [31,83]) s, respectively; p = 0.96) and total intubation time (114 (97,127 [80,213]) s and 95 (89,116 [74,139]) s, respectively; p = 0.13). There was no significant difference in the number of attempts needed for successful placement of the fibrescope (p = 0.12) and railroading the tracheal tube (p = 0.22). The differences between experts and trainees when using fibrescope assisted intubation via the classic laryngeal mask airway were not clinically important. [source] Opportunistic infections and other risks with newer multiple sclerosis therapies,ANNALS OF NEUROLOGY, Issue 4 2009Joseph R. Berger MD The introduction of newer therapies for the treatment of multiple sclerosis has generated considerable optimism. That optimism has been tempered by the potential risks of these therapies, such as the risk for progressive multifocal leukoencephalopathy. A review of the possible causes of reactivation of JC virus in this population has illustrated the need to better understand the untoward effects of monoclonal antibody therapies and other immunomodulatory therapies currently being contemplated for use in multiple sclerosis. These drugs alter the immune response at different sites, and most, if not all, affect more than one aspect of host immunity. Drawing from existing experience with the use of these immunomodulatory therapies in other conditions and that available from the limited experience with multiple sclerosis, we review their potential untoward effects. The latter include a predisposition to opportunistic and community-acquired infections, an altered response to vaccination, the development of cancers, and the appearance of autoimmune diseases. The identification of progressive multifocal leukoencephalopathy as a risk of therapy is relatively straightforward in light of its rarity and high morbidity and mortality, but a relatively slight increased risk for more common and less disabling disorders may be overlooked. Determining the actual risk frequency for many of these complications will likely require careful postmarketing surveillance. Ann Neurol 2009;65:367,377 [source] Clinical characteristics and outcomes for a modern series of primary gliosarcoma patientsCANCER, Issue 5 2010Seunggu J. Han BS Abstract BACKGROUND: Primary gliosarcoma (PGS) is a rare central nervous system tumor with limited experience reported in the literature. In the current study, the authors present a modern series of confirmed PGS cases treated in the era of magnetic resonance imaging (MRI), after the accepted glioblastoma management of resection, radiation, and temozolomide. METHODS: Using a retrospective review, patients with confirmed PGS were identified (1996-2008). Cases were determined to be PGS by central pathology review using the 2007 World Health Organization criteria. Extensive chart review was performed to gather clinical and pathologic data on these cases. RESULTS: All but 1 patient had undergone a preoperative MRI, with 1 patient receiving a computed tomography scan due to a cardiac pacemaker. A total of 10 patients received radiotherapy with concurrent and adjuvant temozolomide chemotherapy, and 8 patients received radiotherapy alone or in combination with other chemotherapeutic agents. In 2 patients, the history of adjuvant treatment could not be confirmed. The overall median survival was 13.9 months (range, 2.2-22.9 months). Patients with gliosarcomas resembling meningioma were found to have a significantly prolonged median survival compared with patients harboring gliosarcoma resembling glioblastoma multiforme (16 months vs 9.6 months; P = .011). However, no difference in survival was noted between patients who received concurrent radiotherapy and temozolomide compared with those who did not (10.4 months vs 13.9 months; P = .946). CONCLUSIONS: The results of the current study support previous hypotheses that there are 2 distinct types of PGS. The type mimicking the appearance of a meningioma appears to carry a significantly more favorable prognosis, most likely due to an increased chance at achieving macroscopic total resection. Cancer 2010. © 2010 American Cancer Society. [source] | |||||||||||||||||||