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Discussing diet, nutrition, and body weight after treatment for gynecological cancer: a conversation analytic study of outpatient consultations. J Cancer Surviv 2024; 18:1016-1031. [PMID: 36897546 PMCID: PMC11081991 DOI: 10.1007/s11764-023-01345-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023]
Abstract
PURPOSE To generate direct observational evidence for understanding how diet, nutrition, and weight-related topics are discussed during follow-up after treatment for gynecological cancer, as recommended by survivorship care guidelines. METHODS Conversation analysis of 30 audio-recorded outpatient consultations, involving 4 gyne-oncologists, 30 women who had completed treatment for ovarian or endometrial cancer, and 11 family members/friends. RESULTS From 21 instances in 18 consultations, diet, nutrition, or weight-related talk continued beyond initiation if the issue raised was ostensibly relevant to the clinical activity being undertaken at the time. These instances led to care-related outcomes (i.e., general dietary recommendations, referral to support, behavior change counseling) only when the patient identified needing further support. Diet, nutrition, or weight-related talk was not continued by the clinician if it was not apparently related to the current clinical activity. CONCLUSIONS The continuation of diet, nutrition, or weight-related talk during outpatient consultations after treatment for gynecological cancer, and the subsequent delivery of care-related outcomes, depends on its immediate clinical relevance and the patient indicating needing further support. The contingent nature of these discussions means there can be missed opportunities for the provision of dietary information and support post-treatment. IMPLICATIONS FOR CANCER SURVIVORS If seeking information or support for diet, nutrition, or weight-related issues post-treatment, cancer survivors may need to be explicit regarding their need for this during outpatient follow-up. Additional avenues for dietary needs assessment and referral should be considered to optimize the consistent delivery of diet, nutrition, and weight-related information and support after treatment for gynecological cancer.
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Establishing the sensitivity and specificity of the gynaecological cancer distress screen. Psychooncology 2024; 33:e6328. [PMID: 38504431 DOI: 10.1002/pon.6328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/08/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE Nuanced distress screening tools can help cancer care services manage specific cancer groups' concerns more efficiently. This study examines the sensitivity and specificity of a tool specifically for women with gynaecological cancers (called the Gynaecological Cancer Distress Screen or DT-Gyn). METHODS This paper presents cross-sectional data from individuals recently treated for gynaecological cancer recruited through Australian cancer care services, partner organisations, and support/advocacy services. Receiver operating characteristics analyses were used to evaluate the diagnostic accuracy of the DT-Gyn against criterion measures for anxiety (GAD-7), depression (patient health questionnaire), and distress (IES-R and K10). RESULTS Overall, 373 individuals aged 19-91 provided complete data for the study. Using the recognised distress thermometer (DT) cut-off of 4, 47% of participants were classified as distressed, while a cut-off of 5 suggested that 40% had clinically relevant distress. The DT-Gyn showed good discriminant ability across all measures (IES-R: area under the curve (AUC) = 0.86, 95% CI = 0.82-0.90; GAD-7: AUC = 0.89, 95% CI = 0.85-0.93; K10: AUC = 0.88, 95% CI = 0.85-0.92; PHQ-9: AUC = 0.85, 95% CI = 0.81-0.89) and the Youden Index suggested an optimum DT cut-point of 5. CONCLUSIONS This study established the psychometric properties of the DT-Gyn, a tool designed to identify and manage the common sources of distress in women with gynaecological cancers. We suggest a DT cut point ≥5 is optimal in detecting 'clinically relevant' distress, anxiety, and depression in this population.
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Safety and feasibility of hyperthermic intraperitoneal chemotherapy during interval cytoreductive surgery in patients with advanced high-grade serous ovarian, fallopian tube, peritoneal cancer in an Australian context. Aust N Z J Obstet Gynaecol 2023; 63:702-708. [PMID: 37259677 DOI: 10.1111/ajo.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/16/2023] [Indexed: 06/02/2023]
Abstract
AIMS To assess the safety and feasibility of hyperthermic intraperitoneal chemotherapy (HIPEC) during cytoreduction surgery (CRS) in advanced high-grade serous ovarian, fallopian tube and peritoneal cancer within an Australian context. METHODS Data were collected from 25 consecutive patients undergoing CRS and HIPEC from December 2018 to July 2022 at the Peritoneal Malignancy Service at the Mater Hospital Brisbane, Australia. Data collected included demographics, clinical variables, surgical procedures and complications and intra-operative and post-operative indexes of morbidity. RESULTS Twenty-five women who underwent CRS and HIPEC from December 2018 to July 2022 were included in analysis. Findings indicate that CRS with HIPEC is associated with low morbidity. CONCLUSION While judicious patient selection is imperative, HIPEC during CRS was well tolerated by all patients and morbidity was comparable to results from the previously reported OVHIPEC-1 trial. HIPEC appears to be a safe and feasible addition to CRS for the treatment of advanced ovarian cancer in Australian practice.
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Dosimetric Impact of Systematic Mediastinal Staging via Endobronchial Ultrasound for Patients with Locally Advanced Lung Cancer: The SEISMIC Trial. Int J Radiat Oncol Biol Phys 2023; 117:S29. [PMID: 37784468 DOI: 10.1016/j.ijrobp.2023.06.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The SEISMIC trial aims to find the best method for mediastinal staging in patients with lung cancer receiving chemoradiotherapy. Currently, CT or PET-CT scans are standard in clinical practice, but histological evaluation of the mediastinum is performed on a case-by-case basis. The study will examine the effect of systematic histological evaluation using Endobronchial Ultrasound (EBUS) on radiotherapy target volumes. The hypothesis of this study is that differences in staging between the diagnostic PET-CT and EBUS would result in reduced tumor coverage and/or increased doses to organs at risk (OAR). MATERIALS/METHODS SEISMIC is a prospective multicenter international cohort study. Patients were enrolled from Australia, the Netherlands, USA and Canada after regional IRB approvals. Patients were treated with 4DCT simulation. Two iGTV and PTV target volumes were delineated for each patient with discordant staging according to both PET-CT and EBUS, as were OARs. Two VMAT plans were generated for each patient based on either PET-CT or EBUS target volumes using knowledge-based planning methodology. Plans aimed to achieve institutional guidelines for target coverage and OAR dose constraints, with a prescribed dose of 60 Gy in 30 fractions. Target coverage and OAR doses for the PET- and EBUS-defined volumes were compared. RESULTS In 156 patients, EBUS showed a larger extent of disease than PET in 18 (11.5%) and a smaller extent of lymph node (LN) involvement than PET in 49 (31.4%). Out of 67 patients with PET-EBUS discordant results, 25 underwent upfront radiotherapy and were included in the study. EBUS revealed PET-occult LN involvement in 11/25 patients (44%). In these patients, 10/11 patients received <95% of the prescribed dose to PET-occult LN iGTVs; the median [range] minimum dose to the EBUS iGTV was 9.2 Gy [0.1 - 57.9 Gy]. When planning based on EBUS LN involvement, all patients received ≥95% of the prescribed dose to the iGTV (the median [range] minimum dose to the EBUS iGTV was 58.9 Gy [58.1 - 60.5 Gy]). This resulted in increased median [range] doses to OARs; mean lung dose increased by 1.1 Gy [0.3 - 8.4 Gy], esophagus mean dose increased by 3.6 Gy [0.2 - 24.8 Gy], and mean heart dose increased by 0.5 Gy [-0.6 - 8.5 Gy]. CONCLUSION Systematic endoscopic evaluation of the mediastinum had a significant effect on tumor coverage in a clinically meaningful proportion of cases and consequent plan adaptation impacted on organ-at-risk (OAR) doses. Results suggest systematic mediastinal LN staging should be considered in all patients prior to curative-intent radiotherapy. CLINICAL TRIAL ID ACTRN12617000333314.
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Dietary practices after primary treatment for ovarian cancer: A qualitative analysis from the OPAL Study. J Acad Nutr Diet 2022; 122:1607-1628.e12. [PMID: 35595188 DOI: 10.1016/j.jand.2022.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/22/2022] [Accepted: 05/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Little is known about dietary practices of women who have completed primary treatment for ovarian cancer, many of whom will go on to experience cancer recurrence and have further treatment. Knowledge of dietary practices is needed to optimize care. OBJECTIVE To identify dietary practices after primary treatment for ovarian cancer and evaluate how these practices differ by disease recurrence and treatment status. DESIGN Women with invasive epithelial ovarian cancer were provided with an open-ended question after completing a food frequency questionnaire (FFQ): "Is there anything we haven't asked you about your diet in the last 1-2 months that you feel is important?" PARTICIPANTS/SETTING Participants in the Ovarian cancer Prognosis And Lifestyle (OPAL) Study in Australia. MAIN OUTCOMES Dietary practices after primary treatment for ovarian cancer and factors affecting these practices. ANALYSIS Participants' responses were analyzed using content analysis. Individual content codes were categorized and reported by recurrence and treatment status at questionnaire completion. RESULTS 286 women provided responses on 363 questionnaires. Those undergoing further treatment for recurrence commonly reported dietary regimens with clinical indications (e.g., low fiber to avoid bowel obstructions, high energy/protein to minimize nutritional deficits). Those not undergoing further treatment frequently reported 'popular' diets (e.g., organic, plant-based, alkaline). For women with cancer recurrence, dietary practices were affected by poor appetite and treatment late effects. For women without recurrence, other comorbidities, geographical location, family and friends appeared to influence dietary practices. In both groups, nutrition information sources and personal beliefs informed dietary practices. Participant responses that referenced media or online sources often included misinformation. CONCLUSIONS Following primary treatment for ovarian cancer, women report dietary practices that may not be captured in standard FFQs. Dietary practices and factors affecting these practices likely differ by treatment and recurrence status. Improved access to evidence-based dietary information and support is needed.
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Information needs of women undergoing gynaecological risk reduction surgery: Applying patient-reported findings to improve service delivery. Aust N Z J Obstet Gynaecol 2021; 62:286-293. [PMID: 34751946 DOI: 10.1111/ajo.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with genetic mutations including BRCA1, BRCA2 and Lynch syndrome are at increased risk of developing gynaecological cancers with management options including surveillance and/or risk reduction surgery. Little is known about the information women require to inform their decisions around having risk reduction surgery, the implication this surgery has for them and the timing preferences to receive this information. AIMS To identify the information needs of women who are considering or who have had risk reduction surgery due to having a diagnosed or suspected genetic mutation with subsequent increased risk of developing gynaecological cancer. MATERIALS AND METHODS A pilot survey was undertaken in a tertiary, metropolitan hospital as part of a service improvement project. Women referred to the gynaecology-oncology service for gynaecological risk reduction surgery between January to December 2018 were invited to participate through completing either online or hard copy versions of a 12-item survey. RESULTS A response rate of 60% (n = 32) was obtained from women between 27 and 77 years of age. Key information topics included sexuality and intimacy (90.6%; n = 29), the surgery itself (87.5%; n = 28) and surgical menopause (87.5%; n = 28). Over 90% (n = 31) of respondents stated they preferred to receive information about surgery pre-operatively and in written format (81.3%; n = 26). The importance of a multidisciplinary approach was recognised with women wanting information from allied health practitioners such as physiotherapists and social workers. CONCLUSIONS Findings have enabled a better understanding of the type, timing and content of information desired by women making complex decisions about risk reduction surgery. Results have contributed to developing an information resource which will more adequately assist women to meet their information needs when considering gynaecological risk reduction surgery in our hospital.
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OA05.06 Lessons Learned from the Victorian Lung Cancer Registry: Opportunities for Quality Improvement in Lung Cancer Management and Outcomes. J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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404MO Clinical relevance of MIR27A rs895819 polymorphism and its interaction with DPYD variants for predicting grade 4-5 fluoropyrimidine (FP) toxicity (tox) in the FUSAFE individual patient data meta-analysis (IPD-MA). Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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FUSAFE individual patient data meta-analysis (MA) to assess the performance of dihydropyrimidine dehydrogenase (DPD) gene polymorphisms for predicting grade 4-5 fluoropyrimidine (FP) toxicity. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz246.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Racial differences in intracerebral haemorrhage outcomes in patients with obesity. Obes Sci Pract 2018; 4:268-275. [PMID: 29951217 PMCID: PMC6010019 DOI: 10.1002/osp4.167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/18/2018] [Accepted: 03/19/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE This study was conducted to determine the role of obesity and race in intracerebral haemorrhage (ICH) outcomes. METHODS The Get with the guideline-Stroke database was queried for all admitted patients with spontaneous ICH. Secondary causes of ICH were excluded. Body mass index (BMI) was classified using the Center for Disease Control guidelines. Race was classified as White or non-White. Demographics, clinical, imaging data were retrieved. Outcome measures were hematoma expansion at 24 h and discharge disposition. RESULTS A total of 428 patients were included in our analysis. Female gender, past history of congestive heart failure, diabetes mellitus, HbA1c, blood pressure, ICH volume, ICH location, intraventricular haemorrhage and hospital length of stay deferred across BMI categories. On multivariate analysis, along with obese categories, age, ICH location and ICH volume were independent predictors of poor outcomes (hematoma expansion and poor discharge disposition). After adjusting for these variables, obesity remained a predictor of poor disposition outcome compared with normal and overweight subjects; Normal vs. Obese OR 0.26 CI 0.115-0.593 p = 0.0014; Obese vs. Overweight OR 3.79 CI 1.68-8.52 p = 0.0013. Nonetheless, obesity did not influence hematoma expansion. Overall, BMI-race classification did not influence outcomes. However, among non-Whites, the obese category had higher odds of a poor disposition outcome than normal (OR 6.84 CI 2.12-22.22 p = 0.0013) or overweight (OR 8.45 CI 2.6-27.49 p = 0.0004) categories. CONCLUSION An obesity paradox in ICH was not observed in our cohort. In the non-White population, patients with obesity were likely to be associated with poor disposition outcome. Similar findings were not observed in White population.
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DEMENTIA AND THE HUMAN GOOD: RECOGNITION, SOLIDARITY, AND FLOURISHING. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.2221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract 16: Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy. Gynecol Oncol 2015. [DOI: 10.1016/j.ygyno.2015.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Relational Liberty Revisited: Membership, Solidarity and a Public Health Ethics of Place. Public Health Ethics 2015. [DOI: 10.1093/phe/phu045] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Colour mixing and apparent motion: the effect of luminance contrast. J Vis 2014. [DOI: 10.1167/14.10.991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Spatial integration of orientation-defined texture. J Vis 2014. [DOI: 10.1167/14.10.1427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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O-002 Single Center Experience Comparing Outcomes of Strokes Treated with Mechanical Thrombectomy vs Without Mechanical Thrombectomy Using CTP for Patient Selection. J Neurointerv Surg 2014. [DOI: 10.1136/neurintsurg-2014-011343.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Outreach obstetrics training in Western Australia improves neonatal outcome and decreases caesarean sections. J OBSTET GYNAECOL 2010; 30:6-9. [DOI: 10.3109/01443610903276409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Homocysteine and Peripheral Arterial Disease: Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2009; 38:316-22. [DOI: 10.1016/j.ejvs.2009.05.007] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Accepted: 05/09/2009] [Indexed: 01/29/2023]
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Randomized clinical trial of folate supplementation in patients with peripheral arterial disease. Br J Surg 2009; 96:990-8. [PMID: 19672935 DOI: 10.1002/bjs.6670] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD). METHODS Individuals with PAD were randomly assigned to receive 400 microg folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF) (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle : brachial pressure index (ABPI) and pulse wave velocity (PWV). Secondary outcomes were changes in plasma inflammatory markers. RESULTS Plasma tHcy was significantly reduced in folic acid and 5-MTHF groups compared with controls: median difference: - 2.12 (95 per cent confidence interval - 3.70 to - 0.75) micromol/l (P = 0.002) and - 2.07 (-3.48 to - 0.54) micromol/l (P = 0.007) respectively. ABPI improved significantly: median difference 0.07 (0.04 to 0.11) (P < 0.001) and 0.05 (0.01 to 0.10) (P = 0.009) respectively. Brachial-knee PWV (bk-PWV) decreased significantly in individuals receiving 5-MTHF and tended to be reduced in those taking folic acid compared with controls: median difference: - 1.10 (-2.20 to - 0.20) m/s (P = 0.011) and - 0.90 (-2.10 to 0.00) m/s (P = 0.051) respectively. Plasma levels of inflammatory markers were not affected. CONCLUSION Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.
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Folate supplementation improves arterial function in patients with peripheral arterial disease: a randomised double-blind, placebo-controlled clinical trial. Br J Surg 2009. [DOI: 10.1002/bjs.6533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Do novel risk biomarkers reflect the severity of peripheral arterial disease? Br J Surg 2009. [DOI: 10.1002/bjs.6498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Method Modification (2004.08) to Field Testing of Visible Powders on a Variety of Nonporous Environmental Surfaces: Field Study. J AOAC Int 2006. [DOI: 10.1093/jaoac/89.6.1622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
The RAMP® Anthrax Test Cartridge for detecting Bacillus anthracis was validated for use in the field for detection of B. anthracis spores in visible powder residues on 7 nonporous environmental surfaces. Six teams of trained first responders and civil support personnel in Class C personal protective equipment sampled visible powder residues on plastic, stainless steel, ceramic tile, wood, rubber, sealed concrete, and food-grade painted wood and analyzed the samples on the RAMP Anthrax Test System. The accuracy for each surface was at least 97% and the overall average was 98.8%. The overall average false-positive rate was 1.79% and false-negative rate was 1.07% for all surfaces. There were no significant differences between surfaces or between spore levels.
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Ecological notes on Crowned SnakesElapognathus coronatusfrom the Archipelago of the Recherche in southwestern Australia. ACTA ACUST UNITED AC 2001. [DOI: 10.7882/az.2001.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Relating bioethics to the philosophy of the city creates the possibility for developing the field along paths not yet explored. In the Western tradition, the city has been understood as the venue for two quite different forms of activity and two different types of moral possibility. In one guise, the city is an urbs, a center of commerce, market exchange, and social individualism. In another guise, the city is a civitas or polis, the space of active democratic citizenship, equality under law, and civic virtue. As civitas, classical philosophers regarded the city as the place of moral growth and full human self-realization. These two possibilities of human moral and political experience in the city have given rise to distinct traditions of political theory--liberalism and civic republican and democratic theory. This article traces these conceptual configurations into the domain of contemporary bioethics, arguing that most work in the field has drawn on the liberal tradition and hence has been insufficiently critical of the moral paradigm of market individualism and unduly inattentive to the values of civitas and the civic tradition. It argues for the creation of a form of civic bioethics and explores some of the theoretical foundations that type of bioethics would require.
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Freedom fading: on dementia, best interests, and public safety. GEORGIA LAW REVIEW (ATHENS, GA. : 1966) 2001; 35:593-619. [PMID: 15119325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Abstract
Activating mutations in the Met receptor tyrosine kinase, both germline and somatic, have been identified in human papillary renal cancer. Here we report a novel germline missense Met mutation, P1009S, in a patient with primary gastric cancer. The dosage of the mutant Met DNA was elevated in the tumor when compared to its matched normal DNA. Therefore, as with hereditary renal papillary cancer, the mutant Met allele may also be selectively duplicated in the tumor. Different from previously reported Met mutations, which occur in the tyrosine kinase domain, this missense mutation is located at the juxtamembrane domain, and is not constitutively activated. However, following treatment with HGF/SF, the P1009S mutant Met protein, expressed in NIH3T3 cells, displays increased and persistent tyrosine phosphorylation compared to the wild-type Met. Importantly, these cells also form colonies in soft agar, and are highly tumorigenic in athymic nude mice. A second nucleotide change in this region of Met, T1010I, was found in a breast cancer biopsy and a large cell lung cancer cell line. Although this previously reported 'polymorphism' did not stimulate NIH3T3 cell growth in soft agar, it was more active than the wild-type Met in the athymic nude mice tumorigenesis assay, suggesting that it may have effects on tumorigenesis. Met has been shown to be highly expressed in human gastric carcinoma cell lines, and our results raise the possibility that activating missense Met mutations could contribute to tumorigenesis of gastric cancer.
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Abstract
BACKGROUND Risk factors for 30-day hospital readmission following coronary artery bypass grafting (CABG) have not been established. METHODS We prospectively followed 485 consecutive patients who underwent isolated primary CABG at our institution in 1997. Patients were contacted by telephone at 30 days following operation to determine readmission status. RESULTS The overall readmission rate was 16% (76 of 485). Female gender (25% versus 11%, p = 0.001) and diabetes (22% versus 12%, p = 0.005) were associated with significantly higher readmission rates. The relationship between female gender and readmission persisted after correcting for age and other comorbidities. Congestive heart failure trended towards a significant relationship with increased readmission rate (22% versus 14%, p = 0.09). There were no significant associations between 30-day readmission rate and age, hypertension, chronic obstructive pulmonary disease, history of myocardial infarction, peripheral vascular disease, creatinine level of > or = 1.4 mg/dL, or decreased left ventricular ejection fraction (< 40%). CONCLUSIONS These data show that most of the classic risk factors for postoperative mortality are not necessarily associated with increased readmission. However, female gender and diabetes are associated with greater than twice the risk of 30-day readmission following CABG.
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Screening for diabetic retinopathy using computer based image analysis and statistical classification. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2000; 62:165-75. [PMID: 10837904 DOI: 10.1016/s0169-2607(00)00065-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Diabetic retinopathy is one of the most common causes of blindness in Europe. However, efficient therapies do exist. An accurate and early diagnosis and correct application of treatment can prevent blindness in more than 50% of all cases. Digital imaging is becoming available as a means of screening for diabetic retinopathy. As well as providing a high quality permanent record of the retinal appearance, which can be used for monitoring of progression or response to treatment, and which can be reviewed by an ophthalmologist, digital images have the potential to be processed by automatic analysis systems. We have described the preliminary development of a tool to provide automatic analysis of digital images taken as part of routine monitoring of diabetic retinopathy in our clinic. Various statistical classifiers, a Bayesian, a Mahalanobis, and a KNN classifier were tested. The system was tested on 134 retinal images. The Mahalanobis classifier had the best results: microaneurysms, haemorrhages, exudates, and cotton wool spots were detected with a sensitivity of 69, 83, 99, and 80%, respectively.
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Collaboration in disability policies--collaboration between stakeholders of disability policies in the South and in the North. Int J Rehabil Res 2000; 23:81-9. [PMID: 10929660 DOI: 10.1097/00004356-200023020-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Four studies have been recently undertaken at the Centre for International Child Health on the collaboration between the stakeholders of disability policies, in Southern and Northern countries. Informed by the literature, the authors have explored the roles disabled people's organizations, non-governmental organizations, government and professionals play in the design, provision and evaluation of services for disabled people. They also highlight the different forms participation can take and their most relevant features. The main factors influencing collaboration processes are then classified in three different categories: social factors, ideology-related factors and project-related factors. They are subsequently analysed. The first group encompasses the societal framework in which collaboration may take place, while the identity of the stakeholders is reflected in the ideology-related factors. The nature of the activities undertaken by stakeholders is characterized by the third group of factors. In the conclusion it is suggested that stakeholders, and especially disabled people's counterparts, should increase their awareness of the social model of disability, adopt participatory practices and promote participation at higher levels. However, they should acknowledge that it implies more trust between partners and an alteration of their structures.
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The liberal neutrality of living and dying: bioethics, constitutional law, and political theory in the American right-to-die debate. THE JOURNAL OF CONTEMPORARY HEALTH LAW AND POLICY 2000; 16:97-126. [PMID: 10695247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J 2000; 7:61-7. [PMID: 10700672 DOI: 10.1155/2000/587957] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Prednisone (PRED) is recommended at discharge to reduce the relapse rate following emergency treatment for an asthmatic attack. However, PRED has systemic side effects. Inhaled anti-inflammatory medications, such as budesonide (BUD), are well tolerated. This study was designed to compare the effectiveness of PRED and BUD on relapse rate. DESIGN A prospective, randomized, double-blind, double dummy, parallel group design. SETTING Tertiary referral emergency departments. POPULATION STUDIED One hundred and eighty-five patients with acute asthma who received standard treatment with bronchodilators and systemic glucocorticosteroids in the emergency department, had a forced expiration volume in 1 s (FEV1) greater than 50% predicted and who were deemed well enough to be discharged from the emergency department. INTERVENTION Patients were randomized to receive either BUD Turbuhaler 600 microg qid or PRED 40 mg in the morning for seven to 10 days. At discharge and final visit, symptoms, medication use, FEV1, peak expiratory flow (PEF) and quality of life (QoL) were assessed. Relapse rate to the emergency department during the follow-up was determined by a yes and/or no questionnaire. MAIN RESULTS The PRED (n=85) and BUD (n=90) treatment groups were comparable at baseline (emergency department discharge) for age (mean +/- SD; 27.6+/-8.5 years and 29. 2+/-8.7 years) and prebronchodilator FEV1 (1.77+/-0.79 L and 1. 75+/-0.78 L), respectively. BUD was at least as effective as PRED in preventing a relapse to the hospital; relapse rate was 10 (11.8%) during PRED treatment and nine (10.0%) for BUD treatment (95% CI PRED-BUD, -7.5% to 11.0%). Improvements in FEV1, asthma symptoms, PEF and QoL were not significantly different between treatments. CONCLUSIONS In patients whose acute asthma has been stabilized in the emergency department, high dose BUD may be an alternate to PRED as a follow-up treatment.
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Hospital readmission after cardiac surgery. Does "fast track" cardiac surgery result in cost saving or cost shifting? Circulation 1998; 98:II35-40. [PMID: 9852877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Intense medical and economic pressures have created "fast track" cardiac surgery in which clinical services are streamlined and early discharge is encouraged. Does this strategy promote significant cost saving or merely cost shifting? In a global system of reimbursement, the economic benefit of decreasing patient length of stay may be offset by high rates of patient readmission. This study was undertaken to determine the 30-day readmission rate after cardiac surgery and to analyze trends of readmission diagnoses. METHODS AND RESULTS From October 1, 1996 to July 31, 1997, 460 consecutive cardiac surgical operations were performed at 1 institution. There were 25 deaths and 8 patients who remained as inpatients at the 30-day postoperative deadline for readmission. Two patients had 2 operations. Therefore, 527 operations were performed on 525 patients. There were 110 readmissions after 527 operations for a readmission rate of 20.9%. A significant number of readmissions (49%) were to outside hospitals. Readmission diagnoses were: atrial fibrillation (23%); angina, congestive heart failure, or ventricular tachycardia (20%); leg wound (15%); sternal wound (5%); pneumonia (5%); gastrointestinal complaints (5%); neurologic event (2%); and miscellaneous (25%). Patients discharged > or = 7 days postoperatively were twice as likely to be readmitted as those discharged on postoperative days 4, 5, or 6. CONCLUSIONS Readmission after cardiac surgery is common and frequently (49%) to outside institutions. Patients discharged > or = 7 days postoperatively represent the patients at greatest risk of readmission and, therefore, warrant closer scrutiny before discharge.
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Comparison of budesonide Turbuhaler with budesonide aqua in the treatment of seasonal allergic rhinitis. Rhinocort Study Group. Can Respir J 1998; 5:455-60. [PMID: 10070173 DOI: 10.1155/1998/639710] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare the effect of budesonide Turbuhaler 400 microg/day with budesonide aqua 256 microg/day in the treatment of seasonal allergic rhinitis (SAR). Secondarily to ascertain patients' preferences for the two nasal devices and to assess quality of life. DESIGN Randomized, multicentre, double-blind, double- dummy, parallel groups study. SETTING Private practices and hospital clinics in Ontario, Quebec and Manitoba. POPULATION Two hundred and eighty-four out-patients with SAR, who were symptomatic during the ragweed season, volunteered for enrolment (243 randomized). RESULTS Mean daily nasal symptom scores were significantly reduced with treatment. There were no statistically significant changes from baseline for eye symptoms. Most patients (more than 80%) achieved substantial control of their symptoms with budesonide. The most common nasal and non-nasal adverse events for both groups were epistaxis and headache. Turbuhaler was easier to use and more convenient to carry, had less of an unpleasant taste, and caused less nasal irritation than the aqua spray. More than twice as many patients preferred Turbuhaler to the aqua spray (69% versus 31%). Improvement in quality of life from baseline to clinic visits was statistically significant in both groups. CONCLUSION Once daily use of 256 mg of budesonide aqua and 400 mg of budesonide Turbuhaler are equally safe and efficacious in the treatment of SAR. Patients preferred the budesonide powder formulation delivered via Turbuhaler two to one over the aqua formulation.
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Commentary: reconciling hospice benefits and needs. J Pain Symptom Manage 1998; 16:265-7. [PMID: 9803057 DOI: 10.1016/s0885-3924(98)00078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Many screening methods are available for detecting diabetic retinopathy. However, once patients develop retinopathy, it is unclear as to what method should be used for their review. We describe a novel and integrated system for the screening and treatment of diabetic retinopathy using high street optometrists for primary screening and digital imaging as a secondary screening tool, with referral to a joint retinal clinic only where ophthalmological intervention may be required. Of 3586 patients screened by optometrists, 328 were classified as having moderate/severe pre-proliferative retinopathy or diabetic maculopathy. Patients with proliferative retinopathy (1% of the total) were recalled directly to the joint retinal clinic. A consecutive sample (281) of these patients, together with a further 100 classified by the optometrists as having no or background retinopathy were compared using digital images and standard 35 mm colour transparencies. These, together with the original optometrist reports, were reviewed independently and individually by an ophthalmologist. A further sample of 124 patients who had undergone both digital imaging and ophthalmologist slit-lamp examination were also compared. Comparison of 35 mm colour transparencies with optometrist reports showed the latter had a sensitivity for detecting sight-threatening retinopathy (STR) of 62%, a specificity of 84%, and a kappa score of 0.62. The results for digital images were 90%, 97%, and 0.90, respectively, although the extent of retinopathy was under-reported in 10 patients. With ophthalmologist slit-lamp examination as the gold standard, the sensitivity of digital imaging was 90% with a substantial level of agreement between them (kappa 0.61). We conclude that digital images provide an efficient method for the follow-up of patients with established or previously treated retinopathy.
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Comparison of 3 different doses of budesonide and placebo on the early asthmatic response to inhaled allergen. J Allergy Clin Immunol 1998; 102:363-7. [PMID: 9768574 DOI: 10.1016/s0091-6749(98)70121-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A simple laboratory method to evaluate relative potency of inhaled corticosteroids in asthma would be valuable. Single-dose studies with the allergen-induced late asthmatic response have failed to show a useful dose-response relationship. Treatment for several days with inhaled corticosteroids will also inhibit the allergen-induced early asthmatic response. METHODS Twelve atopic asthmatic subjects were studied during a season when no medications were required except ipratropium bromide as needed. These subjects had positive allergen and methacholine inhalation tests and FEV1 greater than 70% of predicted value. A double-blind, randomized, cross-over study compared placebo and budesonide 100, 200, and 400 microg administered by means of Turbuhaler twice daily for 7 days with 6-day washout periods. Methacholine PC20 was measured before and after 6 days of treatment, and allergen PC15 was measured after 7 days of treatment. RESULTS The allergen PC15 (n = 11) was significantly larger (P = .0001) for all doses of budesonide compared with placebo, but there was no significant difference between the 3 doses of budesonide, and no dose response was demonstrated. The methacholine PC20 was significantly larger after all budesonide treatments compared with placebo (P = .024), but there was no difference between the 3 doses. There was a progressive increase in the allergen PC15 chronologically (sequence effect) that was not explained by improvement in FEV1 or airway responsiveness; sequence effects were not seen for FEV1 or for pretreatment or posttreatment methacholine PC20. Statistical adjustment for sequence effect did not alter allergen PC15 statistics. CONCLUSION A 7-day course of budesonide administered by means of Turbuhaler at 200, 400, or 800 microg per day provided marked and significant inhibition of the allergen-induced early asthmatic response compared with placebo. There was, however, no difference between the 3 doses. Therefore this method with these doses is not useful for providing assessment of relative potency.
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Evaluation of single-dose inhaled corticosteroid activity with an allergen challenge model. J Allergy Clin Immunol 1997; 100:65-70. [PMID: 9257789 DOI: 10.1016/s0091-6749(97)70196-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inhaled corticosteroids are the most commonly used antiinflammatory agents for asthma. There is no simple way to compare objectively the relative potency of inhaled corticosteroids. The allergen-induced late asthmatic response (LAR) can be suppressed by a single dose of inhaled corticosteroid. OBJECTIVE This study was undertaken to evaluate LAR as a model for the determination of the relative potency of single doses of inhaled corticosteroids. METHODS We compared doses of 200 and 800 microg of a highly active inhaled corticosteroid (budesonide) with placebo and a marginally active investigational inhaled corticosteroid (D5159). Ten atopic patients with asthma completed a randomized, double-blind, double-dummy, multicenter, four-way, crossover trial. A standardized allergen challenge with the identical dose of allergen was performed 10 minutes after each of four blinded, single-dose treatments: 200 microg of budesonide, 800 microg of budesonide, 8 mg of D5159, and placebo, all administered from Turbuhaler. The LAR was recorded as the maximum percent fall in FEV1 between 4 and 7 hours, and the allergen-induced increase in methacholine airway responsiveness at 24 hours was recorded as the A log PC20 from the day before to the day after allergen challenge. RESULTS There were no significant differences in the early asthmatic responses during the 4 days; the mean maximum percent in FEV1 fall ranged between 19.5% and 22%. D5159 produced a slight inhibition of the LAR with maximum percent fall in FEV1 recorded as 28.8% +/- 5.0% for D5159 versus 34.1% +/- 4.8% for placebo (p < 0.05). There was a greater reduction recorded after administration of the two doses of budesonide. The mean LAR was 15.1% +/- 3.8% for 200 microg of budesonide and 11.2% +/- 2.3% for 800 microg of budesonide (p < 0.01 compared with placebo and D5159). The two doses of budesonide were not statistically different. Airway responsiveness to methacholine increased by 1.07 doubling doses 24 hours after allergen challenge. This increased airway responsiveness was slightly, but not significantly, reduced by the three active treatments (0.6 to 0.91 doubling doses). CONCLUSION The allergen-induced LAR model was able to differentiate a single dose of an active inhaled corticosteroid from placebo and a highly potent inhaled corticosteroid from a weak inhaled corticosteroid. The model did not differentiate between 2 fourfold doses of the highly active inhaled corticosteroid (at the doses used in this study), neither for the fall in FEV1 nor for the increase in airway hyperresponsiveness.
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Comparison of the antiasthmatic, oropharyngeal, and systemic glucocorticoid effects of budesonide administered through a pressurized aerosol plus spacer or the Turbuhaler dry powder inhaler. J Allergy Clin Immunol 1997; 99:186-93. [PMID: 9042043 DOI: 10.1016/s0091-6749(97)70094-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To determine therapeutically and systemically equivalent dosages of budesonide inhaled through the Turbuhaler dry powder inhalation device (Astra Pharma Production AB, Södertälje, Sweden) or pressurized metered-dose inhaler (pMDI) plus Nebuhaler spacer (Astra Pharma Production AB), we compared these devices in a randomized, open, parallel-group trial. Adults with moderate to severe asthma inhaled budesonide (0.4, 0.8, 1.6, and 2.4 mg/day), for 2 weeks at each dose level, through the Turbuhaler (n = 30) or pMDI + Nebuhaler (n = 28). Dose-dependent effects were demonstrated on asthma symptoms (p = 0.0001), daily peak expiratory flow (p = 0.02), blood eosinophils (p = 0.0001), urinary cortisol output per day (p = 0.0001), serum cortisol (p = 0.006), serum osteocalcin (p = 0.0001), and the oropharyngeal Candida colony count (p = 0.0007. analysis of covariance). The ratio of the responses to the two inhalation devices approximated 1.0 for each index measured; that is, no significant between-device difference was found (p > or = 0.29). However, the 95% confidence limits for the ratio of their respective systemic effects on osteocalcin production were 0.83 to 1.48. Thus in adults who use inhalation devices efficiently and have optimally controlled asthma, conversions from the pMDI + Nebuhaler to the Turbuhaler may reasonably be made at milligram equivalent doses of budesonide, then down-titrated to minimize possible systemic effects. Because earlier studies have shown that the Turbuhaler can double intrapulmonary drug delivery in comparison with a pMDI without a spacer, a 50% dose reduction may be indicated when converting from a pMDI to the Turbuhaler.
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Abstract
The phi X174 J protein is 37 amino acids in length and contains 12 basic residues. There are no acidic amino acids in the protein. The basic residues are concentrated in two clusters in the N-terminus which are separated by a proline-rich region. To investigate the morphogenetic functions of the J protein and possible mechanisms by which it may bind DNA, a genetic analysis was conducted. Lysine --> leucine and arginine --> leucine substitutions were generated within the basic amino acid clusters. At least three substitutions were required to eliminate viability in vivo. Lethal mutants with three or four substitutions exhibit dominant lethal phenotypes, indicating that the mutant proteins retain enough function to interfere with productive assembly. In cells infected with a dominant lethal mutant, noninfectious packaged particles were produced. Infectivity can be restored by second-site suppressors in the viral coat protein which disrupt polar interactions atop the threefold axis of symmetry in the capsid. The viability of strains containing compensating frameshift mutations within the proline-rich region suggests that only the proline residues in this segment are critical for efficient function.
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Abstract
Hospice care today faces economic, cultural, and social challenges that will force it to rethink its basic ethical mission and its basic values if it is to grow and prosper. Three different values can be said to inspire the hospice movement: palliation and the relief of suffering, enhancing individual control and autonomy at the end of life, and the value of healing or maintaining meaning and personal integrity in the dying process. An emphasis on palliation alone will not be sufficient to sustain a comprehensive hospice benefit in the future. An emphasis on patient autonomy alone is not in keeping with the history or spirit of the hospice movement, which in fact has had a vision of "good" dying. The notion of healing or making whole provides the richest and most adequate concept upon which to ground the social and ethical case for hospice care in the future.
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Beyond distributive justice in health reform. Hastings Cent Rep 1996; 26:14-5. [PMID: 8970788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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A conceptual model of Army nursing practice. Nurs Manag (Harrow) 1996; 27:33-6. [PMID: 8932105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This conceptual model of Army nursing incorporates all of the components of nursing practice to include research, education and administration. The pyramid of clinical practice emphasizes that Army nursing maximizes the clinical expertise and graduate education of advanced practice nurses while depending on the foundation of traditional nursing.
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Abstract
National rates of unintended births are a major public health concern. The availability of highly effective long-acting contraceptives has prompted some public officials to promote the coercive use of these methods to reduce such problems as intergenerational poverty and child abuse. Broad-brush public policies that require long-term contraceptive use are unethical. However, persuasion to use these methods can be appropriate. One place for exerting ethically justified influence is in family planning counseling. The dominant nondirective counseling model, which excludes the possibility of vigorous persuasion, is overly rigid. Family planning professionals should develop practice protocols that permit and guide the exercise of directive counseling to use long-acting contraception.
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The SUPPORT project and improving care for seriously ill patients. JAMA 1996; 275:1229-31. [PMID: 8601950 DOI: 10.1001/jama.1996.03530400015024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Comparison of four-times-a-day and twice-a-day dosing regimens in subjects requiring 1200 micrograms or less of budesonide to control mild to moderate asthma. Respir Med 1995; 89:537-43. [PMID: 7480986 DOI: 10.1016/0954-6111(95)90154-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The aim of this study was to compare the efficacy, compliance and side-effects of budesonide administered twice daily (b.d.) and four times a day (q.d.) with a Turbuhaler device in asthmatic subjects requiring < or = 1200 micrograms daily. The randomized, parallel group study design included a 2-week baseline period followed by a 6-12-month treatment period. Subjects were assessed at regular intervals in hospital through FEV1, PC20 methacholine, adrenal function and throat swabs. They were asked to record their symptoms and PEF values morning and evening at home. An asthmatic flare-up, which was the main outcome resulting in a patient's termination of the study, was defined beforehand as (a) 25% or greater diurnal variability in PEF for 2 consecutive days, and/or (b) nocturnal awakenings due to asthma symptoms 2 days or more in the same week and/or (c) an increase (doubling or more) in the need for inhaled bronchodilator 2 days in the same week. Fifty-eight adult asthmatic subjects (20 males and 38 females) entered the study, one-half being randomly assigned to the b.d. regimen and one half to the q.d. regimen. Fourteen subjects were on 400 micrograms, 15 subjects on 800 micrograms and 29 subjects on 1200 micrograms of budesonide daily. Seventeen flare-ups were recorded in the b.d. regimen group as opposed to 11 in the q.d. regimen (P = 0.05), significant differences being found in the 800 and 1200 micrograms groups (a total of 13 flare-ups in the b.d. group and eight flare-ups in the q.d. group for the two doses, P = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
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Bone mineral density and the risk of fracture in patients receiving long-term inhaled steroid therapy for asthma. J Allergy Clin Immunol 1995; 96:157-66. [PMID: 7636052 DOI: 10.1016/s0091-6749(95)70003-x] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
To determine whether high-dose or prolonged inhaled steroid therapy for asthma increases a patient's risk of osteoporosis and fracture, we measured bone density in 26 men and 43 women (41 postmenopausal, all of whom had received supplemental estrogen therapy) after treatment with an inhaled steroid for 10.1 +/- 5.5 years and oral prednisone for 10.7 +/- 9.7 years (mean +/- SD). Most had stopped receiving prednisone since commencing the inhaled steroid therapy. We found that bone densities (adjusted for age and sex to yield a z score) were lower in association with higher daily doses of inhaled steroid (p = 0.013 ANCOVA) and with the duration of past prednisone therapy (p = 0.032). Larger cumulative inhaled steroid doses were associated with higher bone densities (p = 0.002) and a reduction in the numbers of patients at risk of fracture. Bone density also increased with the amount of supplemental estrogen therapy (p = 0.058) and, at equivalent levels of inhaled and oral steroid use, women showed higher bone density z scores than did men. Women with a lifetime dose of inhaled steroid greater than 3 gm had normal bone density regardless of the amount of past or current prednisone use or the current dose of inhaled steroid. These data indicate that the daily dose, but not the duration, of inhaled steroid therapy may adversely affect bone density, and that estrogen therapy may offset this bone-depleting effect in postmenopausal women.
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Long-acting contraceptives. Ethical guidance for policymakers and health care providers. Hastings Cent Rep 1995; 25:S1-8. [PMID: 7730035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Realizing the promise of long-acting contraceptives depends on continuing efforts to distinguish appropriate from inappropriate policies and practices. The current debates concerning Norplant and other long-term methods generally have based ethical judgment on too slim a reed. It is insufficient and overly divisive to limit the tools of analysis to questions of freedom and coercion. A richer perspective is needed. We have sketched out an alternative approach that rests on a close, case-by-case analysis attentive to the social dimension and consequences of contraceptive decisionmaking, as well as to the individual interests at stake. The approach also takes special note of the need for access to long-acting contraceptive, the possibility for mistaken nonuse as well as mistaken use, and our country's past and present biases and power imbalances. We do not claim that this method will make judgments about justifiable or unjustifiable influence easy or automatic. However, it should prove adept at underscoring the factors that require particular scrutiny. Perhaps more importantly, the approach highlights that influences for the use of long-acting contraceptives ought to be judged, not merely dismissed.
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Cultural diversity meets end-of-life decision making. THE VOLUNTEER LEADER 1994; 35:15. [PMID: 10139904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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