Search

Lower esophageal diverticula are frequently related to esophageal motor disorders. An epiphrenic esophageal diverticulum can also have a mechanical cause, such as an esophageal web, benign stricture, or leiomyoma. For a good therapeutic outcome, symptomatic patients with an esophageal diverticulum require a tailored approach. Therefore, it is important to evaluate motor disorders and other associated diseases in a patient with an esophageal diverticulum before devising a therapeutic strategy. We report a case of subphrenic diverticulum associated with an esophageal leiomyoma and motility disorder in a 58-year-old man who had suffered from intermittent regurgitation of food and epigastric soreness. (Korean J Med 2013;84:389-394)

In response to the existing undersupply of physical therapists and the projected changes of the health care reform era, it is prudent for the profession to consider implementing a training strategy that would bring the supply of physical therapists in line with requirements. Before such a training strategy could be developed, however, the physical therapy community would need to produce a requirements forecast. This article compares the uses and limitations of the two major methods for generating health professions requirements--the "need-based" and "demand-based" approaches--and recommends a pragmatic, tailored approach to determining physical therapist requirements that uses easily obtainable data on staffing patterns of managed care plans. The proposed method draws from both need-based and demand-based models to produce complementary data on which to base policy formation.

Background: The characteristics of biopharmaceuticals may require a tailored approach to their safety management. However, information on what tools and methods are employed to assess the safety of biopharmaceuticals post-authorization is lacking. Objective: This study investigates determinants that contribute to the post-authorization management of biopharmaceuticals. Methods: A cohort study was performed including all centrally approved biopharmaceuticals for which a Direct Healthcare Professional Communication (DHPC) was issued during 1997–2009. Safety-related regulatory actions were defined as updates of the summary of product characteristics through type II variations. Determinants of these actions were identified based on publicly available data. Urgent variations, defined as variations accompanied by a DHPC, were compared with other, ‘non-urgent’, safety-related variations. Results: We identified 133 variations relating to 15 products, 24 urgent and 109 other variations. For 55% of urgent variations, spontaneous reports were the sole source of regulatory action, post-approval studies accounted for 33%, and 12% were based on other sources or combinations of sources. For the non-urgent variations, spontaneous reports were the sole source for 36%, post-approval studies for 28%, and 36% were based on other sources or combinations. Overall, most variations included safety issues categorized as ‘infections and infestations’ (33.1%), ‘general disorders and administration site conditions’ (25.6%), and ‘neoplasms’ (14.3%). Conclusion: Determinants of urgent and non-urgent safety-related regulatory actions of biopharmaceuticals are largely similar. Spontaneous reports are an important pillar for both urgent and non-urgent actions and remain an important tool in the post-authorization safety management of biopharmaceuticals.

Kindler syndrome is a rare, blistering skin disease characterized by acral bullae, poikiloderma, and diffuse cutaneous atrophy. Kindler syndrome has been established as a separate entity from epidermolysis bullosa; however, controversy still remains as to whether Kindler syndrome can be differentiated from Weary's hereditary acrokeratotic poikiloderma. Fusion of the digits secondary to blistering and scarring, "pseudosyndactyly," has been reported in several patients with Kindler syndrome; however, surgical correction of the syndactylies in these patients has not been described. In this report, a patient with Kindler syndrome underwent surgical treatment of acquired syndactylies. Treatment included a tailored approach to preparation of the patient for surgery, surgical separation of fused tissues, selection of donor site for skin-graft harvest, postoperative dressings, splinting, and therapy. Results in our patient 2 years after correction demonstrate that syndactyly release in Kindler syndrome can be accomplished effectively, with improvement in both function and appearance.

PURPOSE To identify the technical and physical principles of extracorporeal biliary lithotripsy that are clinically relevant, and to review the patient series published to date. DATA IDENTIFICATION Studies published since 1983 identified through a computerized search of MEDLINE and extensive hand searching of bibliographies in identified articles. STUDY SELECTION Twenty-nine studies done in vitro or in animals and 21 studies in humans assessing biliary lithotripsy. DATA EXTRACTION Based on an understanding of experimental determinants of fragmentation, we assess and explain the differences in the results from the clinical studies. The conclusions concerning overall clinical efficacy and safety are emphasized. RESULTS OF DATA ANALYSIS Extracorporeal shock waves will safely fragment the gallstones of 80% to 100% of selected patients. However, the rate of satisfactory fragmentation (defined as the persistence of fragments only 3 to 5 mm in diameter or less) varies widely among the studies (22% to 78%); this discrepancy depends partly on differing characteristics of stone populations. For patients presenting with solitary stones of 20 mm in diameter or less, 90% will be stone-free within 6 to 9 months after lithotripsy; moreover, the success of lithotripsy determines the rapidity and extent of fragment dissolution. Bile-duct-stone lithotripsy is reserved for patients in whom endoscopic stone extraction and intracorporeal lithotripsy, with or without direct contact dissolution, have failed. Lithotripsy achieves ductal clearance in 55% to 85% of patients. CONCLUSIONS Extracorporeal lithotripsy is safe and effective in selected patients, and has a definite role to play in managing patients with biliary stone disease. Its role in the coming years will depend on technical improvements in the generators, a tailored approach to complementary dissolution or extraction, and effective prophylactic therapy for preventing gallstone recurrence.

Anecdotal evidence has shown that people vary greatly in their sensitivity to pain and in their response to analgesics. Now, new research indicates that there is a genetic basis for differences in pain perception. The findings may lead to a more tailored approach towards determining doses of analgesic and to a better understanding of opiate addiction. Working with mouse models, scientists from Johns Hopkins University in Baltimore and the National Institute of Drug Abuse in …

A tailored approach for evaluating patients with peripheral vascular disease has been developed using intravenous digital subtraction angiography (IV DSA). This approach includes a history, physical examination, and correlation with Doppler pressure measurements to predict the location of the dominant lesion. In 60 patients, two views of the aortoiliac segment plus three or four views of the femoral and runoff circulation in the most symptomatic leg were obtained. Of the 60 patients, 36% had percutaneous transluminal angioplasty as a primary form of therapy, 32% were treated surgically, and 32% were followed clinically. Only 10% of these patients required further evaluation by conventional angiography. By omitting inpatient arteriography, considerable financial savings and increased patient comfort result.

TODAY what is generally known as management development is in vogue as never before. Among reasons cited in various publications for this increased interest are the tremendous demand for managers caused by the growth and expansion of industry throughout the world, the increase in new knowledge which is occurring at a fantastic rate, and the recognition that in a world of rapid change the preparation and development of all managers to operate effectively in a changing world is essential for the survival and progress of the firm.

Considerable controversy exists regarding the optimal method of surgical relief of the pain of chronic pancreatitis. We previously made a retrospective study of 49 patients with chronic pancreatitis who were operated upon only for relief of pain. Those results indicated that patients who had an internal decompression had lower mortality, less morbidity, less postoperative pancreatic insufficiency, and better relief of pain (88% vs 76% improved). Since then, we have prospectively determined the operative treatment based upon the criteria outlined in that previous report. Seventeen patients had 19 operations (12 resections, seven internal drainage procedures). The patients' ages, duration of symptoms, and sex distribution are similar. Eight-five percent of patients with internal decompression had good to excellent relief of pain vs 60% of patients with resection. Pancreatic insufficiency occurred in 70% of patients who had resection and in only 14% of those who had drainage. Forty percent of patients who had resection had mild to severe postoperative morbidity vs 14% of those who had drainage. There was one postoperative death in the resection group. These preliminary results indicate that internal decompression in properly selected patients can provide superior relief of pain, with lower mortality, less morbidity, and less pancreatic insufficiency.

This paper describes the value of identifying and processing intuitive hunches and impressionistic ideas that arose amongst psychiatrist/clinicians on an inpatient unit. Through semistructured meetings, these hunches generated psychodynamic formulations and therapeutic approaches that were integrated into already existing models of treatment to yield a better understanding of, and a more tailored approach to, the borderline patient and his/her impact on staff.

Maize is the most important cereal and most widely cultivated staple that plays a key role in the food security of sub-Saharan Africa (SSA). Although some countries have achieved significant gains in maize productivity, the SSA average yields are far below what could be obtained with improved cultivars under good crop management. Low cultivar turnover is one among many contributing factors to low maize yields in SSA. At present, there is a critical knowledge gap on the identity, number, and age of maize cultivars currently grown by smallholder farmers on the continent. This study revealed that nearly 500 maize cultivars were grown in 13 African countries surveyed in the 2013/2014 main crop season. Sixty-nine percent of the cultivars each occupied 40% and four occupied >30% area. Approximately 32% of all the cultivars were hybrids, 23% were improved open-pollinated varieties (OPVs), and 46% were locals. Eastern Africa (EA) and southern Africa (SA) accounted for about 43 and 38%, respectively, of all the cultivars reported, whereas West Africa’s (WA) share was 19%. The average area planted to modern cultivars in the surveyed areas was estimated at 57%—with EA, SA, and WA estimates of 82, 55, and 36%, respectively; however, increased adoption was not necessarily always related to improved productivity, as the latter depends on many additional factors. Each household planted an average of 1.781 cultivars (range 1–8). The overall weighted average age of the cultivars was 15 years, with hybrids and OPVs being 13 and 18 years, respectively. Maize variety turnover in SSA is slower than what is practiced in the USA and other world regions such as Latin America and Asia. The substantial variations among regions and countries in all parameters measured suggest a tailored approach to mitigation interventions. Findings of this current study pave the way for replacing the old cultivars with more recent releases that are tolerant or resistant to multiple stresses and are more resilient.

Abnormal uterine bleeding (AUB) is an extremely common problem and represents a clinical area of unmet need. It has clinical implications and a high cost for the healthcare system. The PALM-COEIN acronym proposed by FIGO may be used as a foundation of care; it improves the understanding of the causes of AUB, and in doing so facilitates effective history taking, examination, investigations, and management. Heavy menstrual bleeding, a subset of AUB, is a subjective diagnosis and should be managed in the context of improving the woman's quality of life. Available evidence suggests that there is poor satisfaction with standard treatment options often resulting in women opting for major surgery such as hysterectomy. Such women would benefit from a tailored approach, both for diagnosis and treatment, highlighting the deficiency of biomarkers in this area. This article focuses on the causes of AUB as per the PALM-COEIN acronym, the researched biomarkers in this area, and the potential pathogenetic mechanisms. In the future, these approaches may improve our understanding of AUB, thereby enabling us to direct women to most suitable current treatments and tailor investigative and treatment strategies to ensure best outcomes, in keeping with the principles of personalized or precision medicine.

Background Cardiac resynchronization therapy (CRT) is ineffective in approximately 30% of recipients, in part due to sub-optimal left ventricular (LV) pacing location. The Quartet LV lead, with 2 additional electrodes proximal to conventional bipolar lead electrodes, enables 10 different pacing configurations at four independent LV locations. In a CRT patient cohort, we sought to evaluate the spectrum of echocardiographic and electrocardiographic response over these 10 configurations, to select the optimal one in each patient. Moreover, we sought to evaluate the 6-months clinical and echocardiographic response to a "tailored approach" in which the optimal LV pacing configuration for CRT was determined by echocardiographic measures, QRSd and pacing capture thresholds. Methods Twenty-two consecutive CRT indicated patients were implanted with a quadripolar CRT system (St. Jude Medical). Optimal LV pacing configuration was determined by echocardiographic measures, including velocity time integral (VTI), myocardial performance index (MPI) and mitral regurgitation (MR), and an electrocardiographic measure (QRS duration) during pacing from each of the configurations at pre-discharge. The optimal LV pacing vector was chosen for every patient. Clinical and echocardiographic assessment was repeated after 6 months. Results Various configurations provided different VTI, MPI, MR and QRSd values. Conventional bipolar vectors (ie, D1-M2, D1-RVc, M2-RVc) were rarely associated with the best echocardiographic improvements and provided significantly worse VTI, MR, MPI, and QRSd values than the best configuration for every patient ( P = .005, P = .05 and P = .03 for VTI; P = .01, P = .005 and P = .001 for MPI; P = .003, P = .01 and P = .005 for MR, P > .5, P = .01 and P = .05 for QRSd) Conversely, "unconventional" proximal configurations (ie, making use of P4 and M3 electrodes) were generally characterized by higher acute VTI, MR and MPI improvements. CRT devices were reprogrammed with an "unconventional" LV pacing configuration in 50% of patients. A significant improvement in New York Heart Association class (81%), LV ejection fraction (76%), end-diastolic and end-systolic volumes was observed after 6 months ( P = .02, P P = .02 and P = .003, respectively). Conclusions In this study, conventional bipolar vectors of quadripolar-CRT were rarely associated with the best echocardiographic improvements. Quadripolar CRT utilizing optimal LV pacing configuration was associated with a significant improvement in New York Heart Association class and LV ejection fraction after 6 months.

Objective We investigated for the first time the presence of chronic changes in the functional organization of sensorimotor brain areas induced by prolonged training with a bidirectional hand prosthesis. Methods A multimodal neurophysiological and neuroimaging evaluation of brain functional changes occurring during training in five consecutive amputees participating to experimental trials with robotic hands over a period of 10 years was carried out. In particular, modifications to the functional anatomy of sensorimotor brain areas under resting conditions were explored in order to check for eventual changes with respect to baseline. Results Full evidence is provided to demonstrate brain functional changes, and some of them in both the hemispheres and others restricted to the hemisphere contralateral to the amputation/prosthetic hand. Conclusions The study describes a unique experimental experience showing that brain reactions to the prolonged use of an artificial hand can be tracked for a tailored approach to a fully embedded artificial upper limb for future chronic uses in daily activities., Brain and Behavior, 10 (11), ISSN:2162-3279