IMPORTANCE: Urinary stone disease is a common presentation in the emergency department, and α-adrenergic receptor blockers, such as tamsulosin, are commonly used to facilitate stone passage. ...OBJECTIVE: To determine if tamsulosin promotes the passage of urinary stones within 28 days among emergency department patients. DESIGN, SETTING, AND PARTICIPANTS: We conducted a double-blind, placebo-controlled clinical trial from 2008 to 2009 (first phase) and then from 2012 to 2016 (second phase). Participants were followed for 90 days. The first phase was conducted at a single US emergency department; the second phase was conducted at 6 US emergency departments. Adult patients were eligible to participate if they presented with a symptomatic urinary stone in the ureter less than 9 mm in diameter, as demonstrated on computed tomography. INTERVENTIONS: Participants were randomized to treatment with either tamsulosin, 0.4 mg, or matching placebo daily for 28 days. MAIN OUTCOMES AND MEASURES: The primary outcome was stone passage based on visualization or capture by the study participant by day 28. Secondary outcomes included crossover to open-label tamsulosin, time to stone passage, return to work, use of analgesic medication, hospitalization, surgical intervention, and repeated emergency department visit for urinary stones. RESULTS: The mean age of 512 participants randomized to tamsulosin or placebo was 40.6 years (range, 18-74 years), 139 (27.1%) were female, and 110 (22.8%) were nonwhite. The mean (SD) diameter of the urinary stones was 3.8 (1.4) mm. Four hundred ninety-seven patients were evaluated for the primary outcome. Stone passage rates were 50% in the tamsulosin group and 47% in the placebo group (relative risk, 1.05; 95.8% CI, 0.87-1.27; P = .60), a nonsignificant difference. None of the secondary outcomes were significantly different. All analyses were performed according to the intention-to-treat principle, although patients lost to follow-up before stone passage were excluded from the analysis of final outcome. CONCLUSIONS AND RELEVANCE: Tamsulosin did not significantly increase the stone passage rate compared with placebo. Our findings do not support the use of tamsulosin for symptomatic urinary stones smaller than 9 mm. Guidelines for medical expulsive therapy for urinary stones may need to be revised. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00382265
This study examines B-type natriuretic peptide (BNP) levels in patients with systolic versus non-systolic dysfunction presenting with shortness of breath.
Preserved systolic function is increasingly ...common in patients presenting with symptoms of congestive heart failure (CHF) but is still difficult to diagnose.
The Breathing Not Properly Multinational Study was a seven-center, prospective study of 1,586 patients who presented with acute dyspnea and had BNP measured upon arrival. A subset of 452 patients with a final adjudicated diagnosis of CHF who underwent echocardiography within 30 days of their visit to the emergency department (ED) were evaluated. An ejection fraction of greater than 45% was defined as non-systolic CHF.
Of the 452 patients with a final diagnosis of CHF, 165 (36.5%) had preserved left ventricular function on echocardiography, whereas 287 (63.5%) had systolic dysfunction. Patients with non-systolic heart failure (NS-CHF) had significantly lower BNP levels than those with systolic heart failure (S-CHF) (413 pg/ml vs. 821 pg/ml, p < 0.001). As the severity of heart failure worsened by New York Heart Association class, the percentage of S-CHF increased, whereas the percentage of NS-CHF decreased. When patients with NS-CHF were compared with patients without CHF (n = 770), a BNP value of 100 pg/ml had a sensitivity of 86%, a negative predictive value of 96%, and an accuracy of 75% for detecting abnormal diastolic dysfunction. Using Logistic regression to differentiate S-CHF from NS-CHF, BNP entered first as the strongest predictor followed by oxygen saturation, history of myocardial infarction, and heart rate.
We conclude that NS-CHF is common in the setting of the ED and that differentiating NS-CHF from S-CHF is difficult in this setting using traditional parameters. Whereas BNP add modest discriminatory value in differentiating NS-CHF from S-CHF, its major role is still the separation of patients with CHF from those without CHF.
Preadmission testing (PAT) before surgical procedures ensures patient safety and decreases last minute case cancellations.
PAT before surgery improves efficiency for the health system; however, the ...process is often inconvenient for the patient. We sought to determine the impact of telemedicine on the presurgical assessment.
We performed a retrospective review comparing patients who participated in telemedicine-based PAT to patients who had a routine, on-site PAT. Our outcomes aligned with National Quality Forum recommended domains for telehealth measures: access (time spent in evaluation), experience (patient satisfaction), and effectiveness (case cancellation rate).
There were 7,803 people evaluated; 361 with telemedicine and 7,442 without telemedicine. Compared with those not using telemedicine, the telemedicine group spent less time in the PAT by 24 min (95% confidence interval, 21.4-26.5), and had no case cancellations (0% vs. 1.1%; 95% confidence interval for the difference, 0.028-1.25%). Patient experience showed high rates of satisfaction with telemedicine.
We found that using telemedicine for PAT had benefits in terms of access, patient experience, and effectiveness, the three domains recommended for use in telehealth quality measures by the National Quality Forum. The improvements in evaluation times are beneficial for both patients and providers.
PAT utilizing telemedicine reduced overall patient time in the PAT and improved patient satisfaction without increasing the operative case cancellation rate.
Impulsivity Hollander, E.; Rosen, J.
Journal of psychopharmacology (Oxford),
01/2000, Letnik:
14, Številka:
2_suppl1
Journal Article
Recenzirano
Disorders characterized by impulsivity include disorders of impulse control (intermittent explosive disorder, pyromania, kleptomania, pathological gambling and trichotillomania), paraphilias, sexual ...impulsions and sexual addictions and impulsive aggression personality disorders (borderline, antisocial, histrionic and narcissistic personality disorders). Impulsivity has a substantial impact on both individuals and society. Impulse control disorders may be conceptualized as a subset of the obsessive-compulsive spectrum. In this article, we examine the genetic and neurobiological aetiology of these disorders and possible treatment options. The link between serotonergic dysfunction and the pathophysiology of impulsivity is discussed, and studies that examine the efficacy of various selective serotonin reuptake inhibitors and other alternatives in the treatment of impulsive disorders such as pathological gambling, sexual addictions and borderline personality disorder are presented.
In Routine Outcome Monitoring (ROM) there is a high demand for short assessments. Computerized Adaptive Testing (CAT) is a promising method for efficient assessment. In this article, the efficiency ...of a CAT version of the Mood and Anxiety Symptom Questionnaire, - Anhedonic Depression scale (MASQ-AD) for use in ROM was scrutinized in a simulation study.
The responses of a large sample of patients (N = 3,597) obtained through ROM were used. The psychometric evaluation showed that the items met the requirements for CAT. In the simulations, CATs with several measurement precision requirements were run on the item responses as if they had been collected adaptively.
CATs employing only a small number of items gave results which, both in terms of depression measurement and criterion validity, were only marginally different from the results of a full MASQ-AD assessment.
It was concluded that CAT improved the efficiency of the MASQ-AD questionnaire very much. The strengths and limitations of the application of CAT in ROM are discussed.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Aims The early diagnosis of acute aortic dissection (AD) remains challenging. We sought to determine the utility of the troponin-like protein of smooth muscle, calponin, as a diagnostic biomarker of ...acute AD. Methods and results Immunoassays against calponin (acidic, basic, and neutral isoforms) were developed and the levels were compared in a convenience sample of 59 patients with radiographically proven AD 34 males, age 59 ± 15 (SD) years vs. 158 patients suspected of having AD at presentation (116 males, age 63 ± 15 years) but whose final diagnosis was not AD. Basic calponin, which is the most specific and abundant in smooth muscle, and acidic calponin, respectively, showed greater than two-fold and three-fold elevations in patients with acute AD. Diagnostic performance as determined by receiver-operating characteristics curve analysis showed that both acidic and basic calponin have the potential to detect AD in the first 24 h respective areas under the curve (AUCs) 0.63 and 0.58, with superior performance of basic calponin (when compared with acidic) in the initial 6 h (respective AUCs 0.63 and 0.67). Conclusion Circulating calponin levels were elevated in acute AD compared with controls. These biomarkers have the potential for use as an early diagnostic biomarker for acute AD.
Stimulating active transport by encouraging replacement of short-distance car trips by active transport modes such as cycling or walking has become a popular policy strategy. It has been suggested ...that neighbourhoods, designed to facilitate healthy behaviour, can influence a person׳s behavioural choices such as transport choice. In the present study, we investigated the association between perceived accessibility of facilities and transport choice for three different trip purposes (shopping, going to public natural spaces, and going to sports facilities) in the Netherlands.
An online questionnaire (N=3663) was used to collect data concerning transport choice for the general Dutch population over a period of one calendar year starting July 2012. Logistic regression analyses were used to model the odds of cycling versus car use and to model the odds of walking versus car use.
When perceived accessibility by car is high, persons were less likely to use active transport modes (OR range: 0.09–0.66) and when perceived accessibility by active transport modes is high, persons were more likely to use the bicycle (OR range: 2.18–10.43) or walk (OR range: 2.97–11.22).
Our results showed a strong association between perceived accessibility and transport choice even after adjusting for personal and environmental characteristics. Our results suggest that perceived accessibility should be taken into account when stimulating a shift from car use to cycling or walking.
•Perceived accessibility was found to be strongly associated with transport choice.•When perceived accessibility by car is high, persons were less likely to use active modes.•Perceived accessibility should be taken into account when stimulating a mode shift.
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