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The use of Complementary and Alternative Medicine (CAM) in primary care is growing, but still not widespread. Little is known about how CAM can/should be integrated into mainstream care. Objectives: To assess primary care health professionals' perceptions of need and of some ways to integrate CAM in primary care. Method: Questionnaire survey of primary health care workers in Northwest London. General Practitioners (GPs) were targeted in a postal survey, other members of the primary care team, such as district and practice nurses, were targeted via colleagues. The questionnaire assessed health care professionals' perspective on complementary medicine, referrals, ways to integrate complementary medicine into primary care and interest in research on CAM. Results: Responses were obtained from 149 GPs (40% response rate after one reminder) and 24 nurses and 32 other primary care team members. One hundred and seventy-one (83%) respondents had previously referred (or influenced referral) for CAM treatments, the main reasons cited were: patients request (68%), conventional treatments failed (58%) and evidence (36%) (more than one reason could be given). Acupuncture and homoeopathy were the therapies for which patients were most frequently referred, followed by manual therapies. There was a significant interest in more training/information on CAM (66%). Only 12 respondents (6%) were against any integration of CAM in mainstream primary care. Most respondents felt that CAM therapies should be provided by doctors (66%) or other health professionals trained in CAM (82%). Twenty-six percent of respondents agreed with provision of CAM by non-state-registered practitioners. It was felt that the integration of CAM could lead to cost savings (70%), particularly in conditions involving pain, but also cost increases (55%) particularly in 'poorly defined conditions'. Fifty-six percent of respondents would consider participating in studies investigating CAM. The greatest interest was in acupuncture (41% of those who expressed an interest in research), homoeopathy (30%) and therapeutic massage/aromatherapy (26%). Conclusions: There is considerable interest in CAM among primary care professionals, and many are already referring or suggesting referral. Such referrals are driven mainly by patient demand and by dissatisfaction with the results of conventional medicine. Most of our respondents were in favour of integrating at least some types of CAM in mainstream primary care. There is an urgent need to further educate/inform primary care health professionals about CAM. KEYWORDS Complementary and Alternative Medicine; Primary care; Primary care workers

Left ventricular assist devices (LVADs) are excellent therapies for advanced heart failure patients either bridged to transplant or for lifetime use. LVADs also allow for reverse remodeling of the failing heart that is often associated with functional improvement. Indeed, growing enthusiasm exists to better understand this population of patients, whereby the LVAD is used as an adjunct to mediate myocardial recovery. When patients achieve benchmarks suggesting that they no longer need LVAD support, questions related to the discontinuation of LVAD therapy become front and center. The purpose of this review is to provide a surgical perspective on the practical and technical issues surrounding LVAD deactivation., (Copyright © 2024 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: In academic surgery publications, self-reporting of conflicts of interest (COI) has often proved to be inaccurate. Here, we review the accuracy of COI disclosures for studies related to the use of robotic technology in cardiothoracic surgery and evaluate factors associated with increased discrepancies., Methods: A literature search identified robotic surgery-related studies with at least 1 American author published between January 2015 and December 2020 from 3 major American cardiothoracic surgery journals (The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and Annals of Cardiothoracic Surgery). Industry payments from Intuitive Surgical (Intuitive) were collected with use of the Centers for Medicare and Medicaid Open Payments database. COI discrepancies were identified by comparing author declaration statements with payments found for the year of publication and the year prior (24-month period)., Results: A total of 144 studies (764 authors) were identified. At least 1 author of 112 studies (78%) had received payments from Intuitive. At least 1 author of 98 studies (68%) had received an undeclared payment from Intuitive. Authors who accurately disclosed payments received significantly higher median payments compared with authors who did not ($16,511 [interquartile range, $6389-$159,035] vs $1762 [interquartile range, $338-$7500]; P < .0001). Last authors were significantly more likely to have a COI discrepancy compared with middle and first authors (P = .018; P = .0015)., Conclusions: Most studies investigating the use of robotic technology in cardiothoracic surgery did not accurately declare COI with Intuitive. This study highlights the need for improved accuracy of reporting industry sponsorship by publishing authors., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Enhanced recovery pathways (ERPs), used across multiple surgical subspecialties, is a multidisciplinary delivery of perioperative care designed to lessen the psychological stress of patients undergoing surgery. Thoracic ERP has been implemented but is not widespread, and variations exist between programs. Evidence of the benefit of thoracic ERP is emerging. This article presents common components of a thoracic surgery ERP and reviews contemporary outcomes., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Cancer types with lower mutational load and a non-permissive tumor microenvironment are intrinsically resistant to immune checkpoint blockade. While the combination of cytostatic drugs and immunostimulatory antibodies constitutes an attractive concept for overcoming this refractoriness, suppression of immune cell function by cytostatic drugs may limit therapeutic efficacy. Here we show that targeted inhibition of mitogen-activated protein kinase (MAPK) kinase (MEK) does not impair dendritic cell-mediated T cell priming and activation. Accordingly, combining MEK inhibitors (MEKi) with agonist antibodies (Abs) targeting the immunostimulatory CD40 receptor results in potent synergistic antitumor efficacy. Detailed analysis of the mechanism of action of MEKi shows that this drug exerts multiple pro-immunogenic effects, including the suppression of M2-type macrophages, myeloid derived suppressor cells and T-regulatory cells. The combination of MEK inhibition with agonist anti-CD40 Ab is therefore a promising therapeutic concept, especially for the treatment of mutant Kras-driven tumors such as pancreatic ductal adenocarcinoma.

Context: Insulin resistance plays a significant role in the pathogenesis of the polycystic ovary syndrome (PCOS) and represents a link to the unfavorable cardiovascular risk profile frequently found in affected patients. The endogenous nitric oxide synthase inhibitor asymmetrical dimethyl-L-arginine (ADMA) is associated with atherosclerosis and represents an independent marker for cardiovascular morbidity and mortality., Objective: We investigated ADMA levels among other cardiovascular, metabolic, and hormonal parameters in women with PCOS and the effects of metformin treatment on these parameters., Design: A cross-sectional study and clinical trial were performed., Patients and Participants: Women with PCOS (n = 83) compared with a control group of healthy women (n = 39) were studied., Interventions: In a subgroup of patients with PCOS (n = 21), the effect of metformin was assessed after 6 months of treatment., Main Outcome Measures: ADMA, intima media thickness (IMT), metabolic and hormonal parameters, and markers of inflammation were investigated., Results: ADMA levels were significantly higher in the PCOS group compared with controls (0.57 +/- 0.15 vs. 0.50 +/- 0.11; P = 0.024). Androgens, C-reactive protein, fasting C-peptide, area under the curve (AUC) insulin, AUC glucose, homeostatic assessment of insulin resistance, fasting insulin, glycosylated hemoglobin, cholesterol, low-density lipoprotein cholesterol, triglycerides, and IMT were significantly higher in women with PCOS compared with controls. In PCOS patients ADMA was found to be positively correlated with body mass index (BMI), waist to hip ratio, parameters of insulin sensitivity, hyperandrogenemia (free testosterone, free androgen index), and IMT. Treatment with metformin ameliorated hyperandrogenemia and decreased ADMA levels (0.53 +/- 0.06 vs. 0.46 +/- 0.09, P = 0.013). Decrease in ADMA levels subsequent to metformin treatment did not correlate with change in BMI or metabolic parameters., Conclusions: ADMA amd parameters of insulin sensitivity are elevated in women with PCOS and the degree of insulin resistance confers the greatest influence on ADMA level. Metformin treatment led to improvement of hormonal and metabolic parameters and decreased ADMA levels possibly independent of BMI and metabolic changes.

Rationale and Objectives: A statistical based iterative single-photon emission-computed tomography (SPECT) reconstruction algorithm (OSEM) modeling the depth-dependent collimator response in three dimensions has recently been introduced (OSEM3D). The aim of this study was to evaluate the axial shape fidelity of OSEM3D in comparison to OSEM, not taking this variable into account (OSEM2D)., Materials and Methods: SPECT and separate spiral CT were performed in a phantom containing spheres filled with In-111. In-111-pentetreotide-SPECT and separate spiral-CT imaging were also performed in 22 patients with neuroendocrine tumors. Using window settings adapting the transversal size of the SPECT hot spots to that on CT and the 50% isocontour as boundary, the three-dimensional extensions (dx, dy, dz) of the SPECT representation of the structures under study were measured. These variables were also determined for CT. Furthermore, an index of eccentricity was calculated by averaging the ratios between dz and dx and dz and dy (IE). For isotropically imaged spheres, IE is 1., Results: For OSEM2D, IE was significantly different from 1 in the phantom data (P < .05); this was not the case for OSEM3D and CT. This finding was accounted for by a significantly greater dz on the OSEM2D-SPECT images. In the patient data, dz was by approximately 15.5% greater for OSEM2D than for the other two modalities (P < .05)., Conclusions: The use of OSEM3D avoids deformation of hot SPECT lesions in z-direction. This may be of particular importance in SPECT/CT hybrid imaging capitalizing on the exact match of both modalities.

Objective: To investigate the frequency of mutations of the cystic fibrosis transmembrane regulator (CFTR) gene in males with reduced sperm quality before intracytoplasmic sperm injection (ICSI)., Design: The nine most frequent cystic-fibrosis-causing mutations in the German population and IVS8T alleles were analyzed., Setting: University-based centers for reproductive medicine and clinical genetics., Patient(s): An unselected group of 597 males with oligo-, astheno-, terato-, crypto-, oligoasthenoteratozoospermia, or azoospermia, which underwent pre-ICSI genetic counseling over a 5-year period., Intervention(s): Blood samples were collected from the patients during genetic counseling., Main Outcome Measure(s): Frequency of mutations of CFTR gene in infertile males., Result(s): A heterozygous CFTR mutation was observed in 34 of 597 patients (5.70%). None of the patients had two CFTR mutations. Given that our mutation panel recognizes about 82% of heterozygotes, it can be assumed that the frequency of CFTR heterozygotes in our cohort is about 6.94%. The frequency of CFTR mutations in our cohort did not correlate with a reduced sperm count., Conclusion(s): The frequency of cystic fibrosis in the German population is 1:3300. Thus, a CFTR heterozygosity of 3.42% can be estimated. This indicates that in our cohort of infertile males, the frequency of CFTR heterozygosity is twofold higher than in the general population (P<.0001).

The long acquisition times (up to hours) in PET brain imaging bear a high risk of head motion, which results in artefacts like blurred images and may even lead to misinterpretation and useless data. With the increased resolution of high performance PET scanners, the influence of head movements becomes more and more relevant. Especially in the analysis of small brain structures, e.g. during ROI-analysis, head motion results in inaccuracies of quantified data. This may also influence the kinetic analysis and generate artifacts in parametric images calculated from a motion-affected image sequence. This work presents the feasibility of head motion registration using an external motion tracking system. The implementation of the multi acquisition frame method and an event-by-event method to correct PET data for motion are described. The effects of motion correction are demonstrated on the basis of phantom measurements and patient data. The influence of motion correction on parametric imaging is described in a receptor study.

Unlabelled: Involuntary patient motion from insufficient patient preparation may lead to local misregistration of PET/CT images and, thus, can invalidate the attempt to fuse the resulting images. We estimate the efficacy of selected patient support structures in reducing the likelihood of patient motion in the area of the head and neck during whole-body PET/CT studies., Methods: Motion of the head and neck was estimated in 51 healthy volunteers during simulated whole-body PET/CT studies using an infrared camera-based tracking system. Four patient positioning schemes (arms down) were studied, with the neck placed on a standard PET head holder with no support at the sides (setup A), on a special head holder fitted with a subject-specific mold from construction foam (setup B), on a vacuum-lock bag (setup C), and on a special head holder fitted with a vacuum-lock bag (setup D). We report the average motion of the head and neck as the difference in the position of a set of target points between the simulated CT image and PET image of the head and neck. To estimate the efficacy of additional patient support measures in clinical practice, we reviewed the misregistration of the head and neck in whole-body PET/CT studies of 10 patients each who were imaged using setups A and C by comparing the mean translational and rotational alignment parameters from a semiautomatic linear registration approach needed to realign the CT and PET images., Results: Average translational and rotational misalignment of the head and neck was highest for setup A, at 7 mm and 1 degrees , respectively. Misalignment was reduced to a minimum of 1.4 mm and 0.3 degrees for setup D. Setup B resulted in a similar reduction in patient motion of the head and neck: 2.4 mm and 0.4 degrees , whereas setup C provided only somewhat improved support, with a resulting average misalignment of 4.5 mm and 0.7 degrees. In clinical PET/CT, we found setup C to reduce translational misalignment of the CT and PET images of the head and neck to 2 mm, compared with 6 mm for setup A, whereas no significant reduction of rotational misalignment was observed., Conclusion: Average motion of the head and neck in unrestrained subjects during whole-body PET/CT examinations can be reduced by use of rigid positioning aids, such as foam molds, or vacuum-lock bags. Vacuum-lock bags are reusable, quickly adaptable, and olfactory neutral and can be used routinely, either alone or in combination with a head holder, in whole-body PET/CT for high-quality examinations.

Objective: To examine whether ultralong GnRH analog (GnRH-a) therapy after surgical treatment of endometriosis and before ART influences the pregnancy rate., Design: Prospective, randomized, controlled study., Setting: University clinic for reproductive medicine and gynecologic endocrinology., Patient(s): One hundred ten patients with stage II to IV endometriosis according to ASRM criteria., Intervention(s): Fifty-five patients received GnRH-a for 6 months after surgery and subsequently underwent up to 3 cycles of ART, and 55 patients received 3 cycles of ART alone immediately after surgery., Main Outcome Measure(s): Clinical pregnancy rates., Results: The pregnancy rate per patient was higher among patients who received follow-up treatment with GnRH-a. The same results were found in patients with stage III or IV endometriosis who were undergoing IUI or IVF/ICSI., Conclusion(s): Ultralong GnRH-a therapy increases the pregnancy rate of ART in patients with severe endometriosis.

Aim of the presented study was to find out whether there are any differences in the protein patterns of uterine secretions of fertile and sterile women. Analysis was made by polyacrylamide gel electrophoresis (SDS-PAGE). Uterine secretions and sera of 11 sterile and 8 fertile patients were investigated. Utilizing the reducing SDS-electrophoresis, the comparison of all uterine secretions revealed an additional protein band of molecular weight of 33,000 Dalton in the uterine secretions of the fertile women. Secretions of the sterile women showed a protein band which was of significantly lower weight. The significance of this additional protein band as a possible factor of fertility is discussed.

In 41 women the 17 beta-estradiol-receptors were determined in the cytosol fraction. The highest concentrations were found in cases of glandular-cystic hyperplasia, were as in the cyclic endometrium the highest concentrations were recognized before the date of ovulation at a rate of 189,8 +/- 80 fmol/mg protein. --During the treatment with contraceptive drugs only a small content of receptors was observed in midcycle.

In 86 cases of female infertility an endometrial biopsy was performed. The received tissues were examined by histological methods and the binding of estradiol on the specific cytoplasmic receptor was studied. Serum levels of estradiol and progesterone were estimated at the same day.--The estradiol receptor levels from ovulatory cycles are directly dependent on the histological dated phase of the menstrual cycle. The level was highest in late proliferative phase and declines during the secretory phase.--Luteal phase deficiency and other luteal phase defects are connected with a decrease of estrogen receptor concentrations in secretory endometrium.

Within the period from 1959 to 1984 the development of diagnostic and therapeutic possibilities has been demonstrated in 68 cases of women with a Stein-Leventhal syndrome. In the first group consisting of 11 female patients who were under examination until 1975 the clinical aspects took the leading part in the diagnosis. The ovarian wedge resection meant histological security and therapy at the same time. During the second period until 1980 (26 women) the hormone diagnostics was an essential criterion. The conservative therapy with Clostilbegyt aimed at the correction of these hormonal dysfunction as well. During the last years (31 women) diagnosis has been concentrated on etiological aspects. Correspondingly an individualized therapy was practised. The advances in the medical attendance of infertility become evident in the increase of the pregnancy rate from 9.1 to 61.3%.

Modern sterility therapy presupposes a precise ovulation timing in stimulated cycles. The different contribution and importance clinical hormono-analytical and ultrasonographic methods to and for the determination of the ovulation date were tested in 137 cycles of 84 women with a Clostilbegyt therapy as well as in a control group of 27 spontaneous cycles. It was stated that the results ascertained by ultrasonography are of special importance. Nevertheless the determination of 17 beta-estradiol and the LH estimation must not be neglected as functional criteria. In order to supervise the corpus luteum phase determinations of progesterone, 17 beta-estradiol and prolactin during the second part of the cycle are to be included into a control program.

In 20 women with marked androgynism or testosterone concentrations being suspected for a tumor blood samples were taken by selective retrograde catheterization of the ovarian and suprarenal veins via vena femoralis. Testosterone, 17 beta-estradiol, and progesterone were determined and the concentration gradients to peripheral blood levels were calculated. In 20% of patients an pure adrenal and in 5% an ovarian hypersecretion of testosterone was established. A combined adrenal-ovarian hypersecretion was found in 50%. In 25% of the cases no final estimation was made because anatomic variations in venous size and drainage made catheterization and bilateral blood sampling impossible. There were no references to an androgen-secreting tumor.

It is reported about a first successful program of gamete intra fallopian transfer (GIFT) as a supplement to intrauterine insemination and to in vitro fertilization (IVF). In 29 patients after HMG stimulation of the ovaries and laparoscopic aspiration of follicles recovered oocytes have been introduced together with prepared sperm via a special catheter directly into the ampulla of the oviduct. In 21 patients with different causes of infertility optimal stimulation conditions could be achieved. A pregnancy rate of 41.4% is the result of 29 GIFT events and 3 of them resulted in spontaneous term deliveries (10.3%).