Showing papers by "Beaumont Health published in 2012"

The SNMMI Practice Guideline for Therapy of Thyroid Disease with 131I 3.0

Abstract: Preamble……1 I. Introduction: patient management, licensure.……2 II. Goals.……2 III. Definitions: risk levels……2 IV. Common clinical indications……3 V. Qualifications and responsibilities of personnel (in the United States).……3 VI. Procedure/specifications of the

Improving symptoms and quality of life of female cancer survivors: a randomized controlled study.

Abstract: Surgeons, along with the Centers for Disease Control and Prevention, emphasize the importance of managing symptoms and improving the quality of life of cancer survivors. A 2008 meta-analysis of mindfulness-based stress reduction (MBSR) concluded that this technique might improve patients’ adjustment to their disease. However, randomized controlled trials using standardized measures for evaluating MBSR are limited. The primary objective of this study was to evaluate, using valid and reliable measures, the effects of a unique, interactive, 8-week cancer recovery and wellness program on symptoms and quality of life of female cancer survivors. Sixty-eight female cancer patients were randomized into either an intervention or waitlisted control group. Patients were evaluated using the Symptoms Checklist (SCL-90-R), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-30), and the Symptoms of Stress Inventory (SOSI). Of the participants, 70.6% were breast cancer survivors. Mean age was 57.5 years (treatment group) and 56.4 years (control group). Between-group demographic differences were not significant (P > 0.6). The treatment group improved significantly on the EORTC QLQ-30 (P = 0.005), on six of the eight SOSI subscales (P ≤ 0.049), and on both SCL-90-R subscales (P ≤ 0.023), while the control group did not improve on any of these measures (P > 0.2). The MBSR-based cancer recovery and wellness intervention improved the symptoms and quality of life of this largely breast cancer survivor population across a variety of cancer symptoms and quality-of-life measures.

α-Synuclein and anti-α-synuclein antibodies in Parkinson's disease, atypical Parkinson syndromes, REM sleep behavior disorder, and healthy controls.

Abstract: α-synuclein is thought to play a key role in Parkinson's disease (PD) because it is the major protein in Lewy bodies, and because its gene mutations, duplication, and triplication are associated with early-onset PD. There are conflicting reports as to whether serum and plasma concentrations of α-synuclein and anti-α-synuclein antibodies differ between PD and control subjects. The objectives of this study were to compare the levels of α-synuclein and its antibodies between individuals with typical PD (n=14), atypical Parkinson syndromes (n=11), idiopathic rapid eye movement sleep behavior disorder (n=10), and healthy controls (n=9), to assess the strength of association between these serum proteins, and to determine group sizes needed for a high probability (80% power) of detecting statistical significance for 25% or 50% differences between typical PD and control subjects for these measurements. Analysis of log-transformed data found no statistically significant differences between groups for either α-synuclein or its antibodies. The concentrations of these proteins were weakly correlated (Spearman rho=0.16). In subjects with typical PD and atypical Parkinson syndromes, anti-α-synuclein antibody levels above 1.5 µg/ml were detected only in subjects with no more than four years of clinical disease. Power analysis indicated that 236 and 73 samples per group would be required for an 80% probability that 25% and 50% differences, respectively, in mean α-synuclein levels between typical PD and control subjects would be statistically significant; for anti-α-synuclein antibodies, 283 and 87 samples per group would be required. Our findings are consistent with those previous studies which suggested that serum concentrations of α-synuclein and its antibodies are not significantly altered in PD.

Breast-cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment AIDS, treatment paradigms, and risk reduction.

Abstract: With improved outcomes following treatment of breast cancer, chronic toxicities including breast cancer related lymphedema (BCRL), gain increased significance with limited evidence-based guidelines present. This review attempts to summarize data addressing these concerns and provides recommendations based on currently published data. Substantial differences exist in rates of BCRL reported in the literature ranging from less than 5% to 65% based on locoregional therapy. Based on recent data, early diagnosis of BCRL appears critical and requires careful attention to patient risk factors and the use of newer diagnostic tools. Initial treatment with decongestive lymphatic therapy/compressive stockings can provide significant improvement in patient symptoms and volume reduction of edematous extremities. At this time, consensus recommendations for disease classification, diagnostic testing and treatment are still lacking. Awareness of the frequency of this toxicity is now important as more accurate clinical aids have become accessible to diagnose the condition at an earlier stage allowing timely intervention providing the opportunity for treatment strategies to be more effective.

The Quality and Impact of Risk Factor Control in Patients With Stable Claudication Presenting for Peripheral Vascular Interventions

Abstract: Background—Peripheral arterial disease is a manifestation of systemic atherosclerosis and is predictive of future cardiovascular events. Clinical trial data have demonstrated that medical therapy can attenuate cardiovascular morbidity and mortality in patients with peripheral arterial disease. The utilization and impact of recommended medical therapy in a contemporary population of patients who undergo percutaneous interventions for lifestyle-limiting peripheral arterial disease is unknown. Methods and Results—Using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Peripheral Vascular Intervention (BMC2 PVI) database, we identified 1357 peripheral vascular intervention encounters between January 2007 and December 2009 for the purpose of treating claudication. Before the intervention, 85% of these patients used aspirin, 76% used statin, 65% abstained from smoking, and 47% did all 3. There was no difference in cardiovascular events among those taking an aspirin and a statin on admission and t...

Infections Associated with Use of Ultrasound Transmission Gel: Proposed Guidelines to Minimize Risk

Abstract: Affiliations: 1. Department of Epidemiology, Beaumont Health System, Royal Oak, Michigan; 2. Oakland University William Beaumont School of Medicine, Royal Oak, Michigan. Received April 26, 2012; accepted July 21, 2012; electronically published October 23, 2012. 2012 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2012/3312-0008$15.00. DOI: 10.1086/668430 Ultrasound transmission gel (USTG) is used in a variety of healthcare settings for both diagnostic and interventional procedures. Its potential role as a vehicle for spread of infections to patients is frequently overlooked. It has been shown on multiple occasions that USTG can become contaminated with bacteria, leading to significant outbreaks of infection among patients. It is incumbent upon all medical professionals to be aware of the potential risks these products pose to patients. Manufacturers of USTG should label products clearly as to their intended use. Producers of medical devices where USTG is likely to be used should provide explicit instructions on the type of USTG recommended and methods of use. Finally, standardized professional society guidelines would enhance patient safety and improve outcomes. On the basis of our recently described outbreak of infections associated with intrinsically contaminated ultrasound gel and a review of all other clusters, we would like to describe the differences between gels and propose guidelines for use of both nonsterile and sterile ultrasound gel. USTG is available from multiple manufacturers and comes in a variety of formulations and dispenser sizes, often without clearly defined differences between products or suggested uses. A review of one manufacturer’s website found 6 separate USTGs available for purchase, although it was not made clear what significant differences existed between products or if there were specific intended uses for them. Although these gels are often considered bacteriostatic because of components such as parabens or methyl benzoate, one study demonstrated that an ultrasound gel had no intrinsic antimicrobial properties and could function as a medium for bacterial growth. Pseudomonas aeruginosa, Escherichia coli, and Staphylococcus aureus were all demonstrated to survive in USTG in another in vitro study. The term “bacteriostatic” should not be used unless the product meets defined requirements to prove this. Contaminated USTG has been associated with outbreaks of infection due to a variety of procedures and microorganisms (Table 1). In all circumstances, the outbreaks were aborted after a switch to single-dose sterile gel. Our more recent report of cases of respiratory infections and colonizations with P. aeruginosa strongly suggested that gel contaminated at or around the time of manufacture was associated with infections. In this series, 16 patients were found to have P. aeruginosa in their respiratory tract after undergoing cardiovascular surgery. Laboratory isolates for 10 patients were saved, and all 10 proved to be more than 99% similar by molecular typing via repetitive extragenic palindromic polymerase chain reaction (rep-PCR). This surgery included the use of an intraoperative transesophageal echocardiogram (TEE) that utilized USTG as a conducting agent. The TEE probes were culture negative, but cultures of in-use multidose bottles of gel as well as sealed, unopened bottles of gel grew P. aeruginosa, which were also more than 99% similar to the outbreak strain by rep-PCR. Procedures utilizing USTG can range from noninvasive studies (such as transthoracic echocardiography, bladder scans, and vascular scans), to those with mucous membrane contact (such as TEE and transvaginal ultrasonography), to frankly invasive procedures (such as transrectal prostate biopsy [TRPB], thyroid biopsy, epiaortic ultrasonography [EAU], and stereotactic breast biopsies). As such, the Spaulding classification scheme can be applied to guide clinicians in making decisions regarding proper disinfection and sterilization of devices on the basis of the risk of infection involved with use of the item. By this scheme, scanning devices used for noninvasive procedures could be considered “noncritical devices” because of their contact with intact skin. Likewise, diagnostic studies using TEE or TRPB would require “semicritical” disinfection because of contact with mucous membranes. EAU transducers are required to be sterile, as they are introduced directly into the surgical field. On the basis of the Spaulding classification scheme, how does one define the appropriate use of USTG for procedures? Any procedure involving sterile skin preparation would likely also require sterile USTG. Sterility is not a necessary require-

Comparison of insulin pump therapy (continuous subcutaneous insulin infusion) to alternative methods for perioperative glycemic management in patients with planned postoperative admissions

Abstract: Background Patients with diabetes who use insulin pumps [continuous subcutaneous insulin infusion (CSII)] undergo surgeries that require postoperative hospital admission. There are no defined guidelines for CSII perioperative use.

Putting the benefits and risks of aerobic exercise in perspective.

Abstract: Although considerable epidemiologic and clinical evidence suggests that structured exercise, increased lifestyle activity, or both are cardioprotective, the absolute and relative risk of cardiovascular and musculoskeletal complications appear to increase transiently during vigorous physical activity. The estimated relative risk of exercise-related cardiac events ranges from 2.1 to 56 and is highest among habitually sedentary individuals with underlying cardiovascular disease who were performing unaccustomed vigorous physical exertion. Moreover, an estimated 7 million Americans receive medical attention for sports and recreation-related injuries each year. These risks, and their modulators, should be considered when endorsing strenuous leisure time or exercise interventions. If the current mantra "exercise is medicine" is embraced, underdosing and overdosing are possible. Thus, exercise may have a typical dose-response curve with a plateau in benefit or even adverse effects, in some individuals, at more extreme levels.

Characterization of daptomycin-loaded antibiotic cement.

Abstract: Antibiotics are commonly mixed with polymethylmethacrylate (PMMA) cement to suppress severe periprosthetic infections associated with total joint arthroplasty. The relationship between antibiotic concentration and the resulting elution kinetics remains unclear. The purpose of this study was to characterize the release of daptomycin from PMMA cement and the subsequent effects on mechanical properties.Varying concentrations of daptomycin and tobramycin were vacuum mixed in commercially available PMMA and subjected to an in vitro elution period. High-performance liquid chromatography was used to quantify the concentration of the amount of daptomycin eluted at predetermined time points. Samples were subjected to compressive loading to analyze the effect of antibiotic concentration on cement mechanical properties. Daptomycin elution increased when initial tobramycin concentration was increased. Furthermore, the addition of antibiotics increased the compressive strength of the cement in the postelution period. The binary addition of tobramycin with daptomycin antibiotics modifies the elution and mechanical properties of PMMA bone cement. Based on the findings of our study, 2 g of daptomycin and 3.6 g of tobramycin per 40-g packet of cement should be used to promote daptomycin elution without sacrificing PMMA mechanical properties.

Psychological distress with direct-to-consumer genetic testing: a case report of an unexpected BRCA positive test result.

Abstract: We report a case of a client who discovered she had a BRCA mutation following direct-to-consumer (DTC) genetic testing in the absence of genetic counseling. After testing she presented for genetic counseling with anxiety, distress, and a deficit of knowledge about what the DTC genetic testing revealed. Genetic counseling helped alleviate distress while empowering the client to apply the results of testing to improve medical management. Despite recent studies demonstrating no negative psychological impact of DTC genetic testing on the consumer, this case illustrates that significant psychological distress and confusion can occur as a result of DTC genetic testing for highly penetrant single gene disorders. Pre- and post-test genetic counseling in conjunction with DTC genetic testing may alleviate consumers' distress and empower clients to proactively utilize their result information.

Identification and management of pain medication abuse and misuse: current state and future directions.

Abstract: Long-term opioid therapy poses a risk for abuse and misuse in some patients. Identifying which patients may potentially be at risk prior to initiation of therapy, and identifying patients in whom these problems develop during therapy, are significant challenges. Outcome prediction is impeded by the complexity of the problem, where considerable heterogeneity results from psychological and socioeconomic factors, as well as interindividual variation in biological pathways due to genetic and epigenetic factors. Screening tools designed to detect opioid misuse and urine drug testing are both used clinically; scant evidence currently exists to allow the formulation of an algorithm for judicious use of these tools. Moreover, these tools may not be addressing the underlying alterations in biological pathways that occur owing to the development of chronic pain or in response to chronic opioid administration. An evidence-based algorithmic approach to risk mitigation that can be applied in a cost-effective manner to...

Gene expression changes associated with the progression of intraductal papillary mucinous neoplasms.

Abstract: ObjectivesThe diagnosis of high-grade intraductal papillary mucinous neoplasm (IPMN) is difficult to distinguish from low-grade IPMN. The aim of this study was to identify potential markers for the discrimination of high-grade and invasive (HgInv) IPMN from low- and moderate-grade dysplasia IPMN.Met

Organ sample generator for expected treatment dose construction and adaptive inverse planning optimization.

Abstract: Purpose: To create an organ sample generator (OSG) for expected treatment dose construction and adaptive inverse planning optimization. The OSG generates random samples of organs of interest from a distribution obeying the patient specific organ variation probability density function (PDF) during the course of adaptive radiotherapy. Methods: Principle component analysis (PCA) and a time-varying least-squares regression (LSR) method were used on patient specific geometric variations of organs of interest manifested on multiple daily volumetric images obtained during the treatment course. The construction of the OSG includes the determination of eigenvectors of the organ variation using PCA, and the determination of the corresponding coefficients using time-varying LSR. The coefficients can be either random variables or random functions of the elapsed treatment days depending on the characteristics of organ variation as a stationary or a nonstationary random process. The LSR method with time-varying weighting parameters was applied to the precollected daily volumetric images to determine the function form of the coefficients. Eleven h and n cancer patients with 30 daily cone beam CT images each were included in the evaluation of the OSG. The evaluation was performed using a total of 18 organs of interest, including 15 organs at risk and 3more » targets. Results: Geometric variations of organs of interest during h and n cancer radiotherapy can be represented using the first 3 {approx} 4 eigenvectors. These eigenvectors were variable during treatment, and need to be updated using new daily images obtained during the treatment course. The OSG generates random samples of organs of interest from the estimated organ variation PDF of the individual. The accuracy of the estimated PDF can be improved recursively using extra daily image feedback during the treatment course. The average deviations in the estimation of the mean and standard deviation of the organ variation PDF for h and n cancer radiotherapy were less than 2 and 1 mm, respectively, for most organs after the second week of treatment. After the first three weeks of treatment, the mean discrepancy of the dose estimation accuracy was within 1% for most of organs, the corresponding standard deviation was within 2.5% for parotids, the brain stem and the cochleae, and within 1% for other organs. Conclusions: A patient specific OSG is feasible and can be used to generate random samples of organs of interest for the expected treatment dose construction and adaptive inverse planning. The accuracy of the OSG can be improved continuously and recursively during the adaptive treatment course using daily volumetric image feedback.« less

Platelet function after cessation of chronic clopidogrel therapy.

Abstract: Surgeons increasingly encounter patients on clopidogrel therapy who are preparing to undergo surgery. The goal of this study was to examine the change in platelet function after the common clinical scenario of discontinuing chronic clopidogrel therapy in those patients preparing to undergo an elective surgery, and the time course of platelet function recovery after clopidogrel discontinuation. Patients on clopidogrel therapy scheduled for an elective surgical procedure had their platelet function tested using a VerifyNow P2Y12 device (Accumetrics, San Diego, CA). Platelet inhibition was evaluated at baseline before clopidogrel discontinuation, and subsequently studied every other day in the week before their scheduled procedure. Mean platelet inhibition was 32.1 per cent on Day 0 (before clopidogrel discontinuation), decreasing to 3.7 per cent on Day 4. Platelet inhibition decreased significantly after discontinuation of clopidogrel in a time-dependent manner (P = 0.011), although a considerable interindividual variability of P2Y12 reaction units values was observed over the study period. Patients on concomitant proton pump inhibitors and clopidogrel demonstrated a decreased effect of clopidogrel. In conclusion, individual platelet function monitoring may assist the surgeon in perioperative decision-making in patients receiving clopidogrel therapy preparing to undergo elective surgery.

Improved Feature Selection by Incorporating Gene Similarity into the LASSO

Abstract: Personalized medicine is customizing treatments to a patient's genetic profile and has the potential to revolutionize medical practice. An important process used in personalized medicine is gene expression profiling. Analyzing gene expression profiles is difficult, because there are usually few patients and thousands of genes, leading to the curse of dimensionality. To combat this problem, researchers suggest using prior knowledge to enhance feature selection for supervised learning algorithms. The authors propose an enhancement to the LASSO, a shrinkage and selection technique that induces parameter sparsity by penalizing a model's objective function. Their enhancement gives preference to the selection of genes that are involved in similar biological processes. The authors' modified LASSO selects similar genes by penalizing interaction terms between genes. They devise a coordinate descent algorithm to minimize the corresponding objective function. To evaluate their method, the authors created simulation data where they compared their model to the standard LASSO model and an interaction LASSO model. The authors' model outperformed both the standard and interaction LASSO models in terms of detecting important genes and gene interactions for a reasonable number of training samples. They also demonstrated the performance of their method on a real gene expression data set from lung cancer cell lines.

Development of antihuman IgG antibodies and hematologic deficits but not clinical abnormalities in C57BL/6 mice after repeated administration of human intravenous immunoglobulin.

Abstract: Intravenous immunoglobulin (IvIg) preparations consist of pooled and purified antibodies (primarily IgG) from thousands of healthy human subjects. These drugs are approved by the US Food and Drug Administration for treatment of 6 conditions27 and frequently are used off-label to treat other disorders.46 Some IvIg antibodies are low-affinity natural antibodies,28 which are present in healthy persons, bind to a variety of exogenous antigens and to self-antigens, and arise independently of known immunization.17 IvIg is being evaluated as a possible treatment for Alzheimer disease because it contains antibodies to amyloid β, the major protein in senile plaques in the Alzheimer disease brain.15,30,43,50 In 2 clinical trials involving patients with Alzheimer disease, IvIg treatment stabilized or improved cognitive scores.14,44 A phase III trial is in progress. The mechanisms by which IvIg produces its therapeutic effects are not fully understood. Its antiinflammatory effects, for example, have been suggested to be due to inhibition of complement, Fc blockade of cellular receptors for immunoglobulins, modulation of cytokine production, neutralization of autoantibodies, or modulation of inhibitory Fc receptor expression.37 The actions of IvIg might be understood better through studying its effects in experimental animal models of human disease such as transgenic mice. Although administered to experimental animals (primarily models of human autoimmune or immunodeficiency disorders) in many previous studies,1,4,6,13,20,23,31,39,47,48 the possibility that IvIg might induce the hypersensitivity reaction known as ‘serum sickness’ or side effects reported in human subjects such as hemolysis, uremia, hypercoagulability, and thrombotic events16 apparently has not been investigated. Serum sickness can develop after exposure to foreign antigens including xenogeneic serum proteins. Early in the last century serum sickness often was seen in connection with administration of antidiptheria and antitetanus toxin serum of equine origin.40 The condition also has occurred after administration of horse antilymphocyte globulin, which is used to treat acute graft rejection,26 and antimelanoma immunotoxin (mouse monoclonal antimelanoma antibody, conjugated to ricin A chain).21,34 Antibodies generated to these foreign antigens may bind to them and form immune complexes. If present in sufficient amounts to overwhelm normal clearance mechanisms, the immune complexes can be deposited in blood vessels and tissues, inducing complement-mediated damage.2,18 Clinical signs of serum sickness in humans include chills, fever, rash, joint pain, and renal failure.26 The rash associated with serum sickness is accompanied by urticaria due to release of histamine from degranulating mast cells. Serum sickness generally resolves when the immune complexes are cleared.26 The development of serum sickness or other clinical abnormalities, or even the production of high levels of antibodies to human IgG in the absence of clinical abnormalities, potentially could interfere with the effects of IvIg in these animal models. The objective of the current study was therefore to determine whether repeated IvIg administration to immunocompetent mice would result in serum sickness or other clinical, hematologic, or immunologic abnormalities.

Dynamic PET-CT studies for characterizing nasopharyngeal carcinoma metabolism: comparison of analytical methods.

Abstract: Objectives To investigate the optimal PET protocol and analytical method to characterize the glucose metabolism in nasopharyngeal carcinoma (NPC). Methods Newly diagnosed NPC patients were recruited and a dynamic PET-CT scan was performed. The optimized threshold to derive the arterial input function (AIF) was studied. Two-tissue compartmental kinetic modeling using three, four, and five parameters, Patlak graphical analysis, and time sensitivity (S-factor) analysis were performed. The best compartmental model was determined in terms of goodness of fit, and correlated with Ki from Patlak graphical analysis and the S-factor. The methods with R>0.9 and P<0.05 were considered acceptable. The protocols using two static scans with its retention index (RI=(SUV2/SUV1–1)100%, where SUV is the standardized uptake value) were also studied and compared with S-factor analysis. Results The best threshold of 0.6 was determined and used to derive AIF. The kinetic model with five parameters yields the best statistical results, but the model with k4=0 was used as the gold standard. All Ki values and some Sfactors from data between various intervals (10–30, 10–45, 15–30, 15–45, 20–30, and 20–45min) fulfilled the criteria. The RIs calculated from the S-factor were highly correlated to RI derived from simple two-point static scans at 10 and 30min (R=0.9, P<0.0001). Conclusion The Patlak graphical analyses and even a 20-min-interval S-factor analysis or simple two-point static scans were shown to be sufficient to characterize NPC metabolism, confirming the clinical feasibility of applying a short dynamic with image-derived AIF or simple two-point static PET scans for studying NPC. Nucl Med Commun 33:191–197 � c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins. Nuclear Medicine Communications 2012, 33:191–197

The Acute Effect of Bipolar Radiofrequency Energy Thermal Chondroplasty on Intrinsic Biomechanical Properties and Thickness of Chondromalacic Human Articular Cartilage

Abstract: Radio frequency energy (RFE) thermal chondroplasty has been a widely-utilized method of cartilage debridement in the past. Little is known regarding its effect on tissue mechanics. This study investigated the acute biomechanical effects of bipolar RFE treatment on human chondromalacic cartilage. Articular cartilage specimens were extracted (n = 50) from femoral condyle samples of patients undergoing total knee arthroplasty. Chondromalacia was graded with the Outerbridge classification system. Tissue thicknesses were measured using a needle punch test. Specimens underwent pretreatment load-relaxation testing using a spherical indenter. Bipolar RFE treatment was applied for 45 s and the indentation protocol was repeated. Structural properties were derived from the force-time data. Mechanical properties were derived using a fibril-reinforced biphasic cartilage model. Statistics were performed using repeated measures ANOVA. Cartilage thickness decreased after RFE treatment from a mean of 2.61 mm to 2.20 mm in Grade II, II-III, and III specimens (P < 0.001 each). Peak force increased after RFE treatment from a mean of 3.91 N to 4.91 N in Grade II and III specimens (P = 0.002 and P = 0.003, respectively). Equilibrium force increased after RFE treatment from a mean of 0.236 N to 0.457 N (P < 0.001 each grade). Time constant decreased after RFE treatment from a mean of 0.392 to 0.234 (P < 0.001 for each grade). Matrix modulus increased in all specimens following RFE treatment from a mean 259.12 kPa to 523.36 kPa (P < 0.001 each grade). Collagen fibril modulus decreased in Grade II and II-III specimens from 60.50 MPa to 42.04 MPa (P < 0.001 and P = 0.005, respectively). Tissue permeability decreased in Grade II and III specimens from 2.04 ∗10(-15) m(4)/Ns to 0.91 ∗10(-15) m(4)/Ns (P < 0.001 and P = 0.009, respectively). RFE treatment decreased thickness, time constant, fibril modulus, permeability, but increased peak force, equilibrium force, and matrix modulus. While resistance to shear and tension could be compromised due to removal of the superficial layer and decreased fibril modulus, RFE treatment increases matrix modulus and decreases tissue permeability which may restore the load- bearing capacity of the cartilage.

Gene expression classification using binary rule majority voting genetic programming classifier

Abstract: The results of a gene expression study are difficult to interpret. To increase interpretability, researchers have developed classification techniques that produce rules to classify gene expression profiles. Genetic programming is one method to produce classification rules. These rules are difficult to interpret because they are based on complicated functions of gene expression values. We propose the binary rule majority voting genetic programming classifier BRMVGPC that classifies samples using binary rules based on the detection calls for genes instead of the gene expression values. BRMVGPC increases rule interpretability. We evaluate BRMVGPC on two public datasets, one brain and one prostate cancer, and achieved 88.89% and 86.39% accuracy respectively. These results are comparable to other classifiers in the gene expression profile domain. Specific contributions include a classification technique BRMVGPC and an iterative k-nearest neighbour technique for handling marginal detection call values.

ACP Journal Club. Multifactorial cardiac rehabilitation did not reduce mortality or morbidity after acute myocardial infarction

Abstract: Source Citation West RR, Jones DA, Henderson AH. Rehabilitation after myocardial infarction trial (RAMIT): multi-centre randomised controlled trial of comprehensive cardiac rehabilitation in patien...

Fatal disruption of a left atrial myxoma associated with trauma.

Abstract: Cardiac myxomas are benign tumors composed of sparse stellate cells in an extensive mucoid stroma. The surface of these tumors is often friable and gelatinous. Their intracardiac location makes embolization a constant threat. We report a patient who had diffuse systemic embolization of a left atrial myxoma coincident with a low-velocity frontal motor vehicle crash.

Pain education: getting an early start.

Abstract: Upon graduation from medical school interns arrive at their first posts in hospitals at varying degrees of readiness with respect to pain management. Despite pain being arguably the most common reason for patient presentation to hospital, novice physicians are generally poorly prepared to evaluate and treat acute pain. Even the initiation and management of a technique as basic as patient-controlled analgesia seems beyond the reach of many new interns. When patients with chronic pain present with superimposed acute pain, the complexity of the scenario is frequently overwhelming. These educational deficits are global and as such will be among the key topics of discussion at the 2013 inaugural congress of the World Institute of Pain Foundation to be held in Kolkata, India. In this issue of Pain Practice, Vadivelu et al. present an update on the state of pain medicine education in medical schools worldwide. In this article, the authors make a plea for pain management specialists to work with health educators to incorporate education on acute pain into medical school curricula. This appeal is indeed timely. The Liaison Committee on Medical Education (LCME), recognizing the widespread deficit in medical education, has included pain management more generally amongst the topics that are to be included in educational programs leading to accreditation of M.D. degree granting programs in the U.S. Likewise, the National Board of Medical Examiners (NBME) Neuroscience section has historically included anatomy, physiology, and pharmacology of acute and chronic pain in their question bank. This too recognizes the importance of a solid foundation in the mechanisms of pain, both for the benefits of patient diagnosis and care and for responding with excellence to the increasingly multifaceted and multidisciplinary United States Medical Licensing Examination (USMLE) questions. As pointed out by Vadivelu et al., a minority of medical schools currently offer formal education in pain management. Those that do provide specific pain education typically present it in or close to the latter clinical years of medical school. However, there are notable exceptions. At Johns Hopkins School of Medicine, an integrated 4-day pain course has been developed and successfully incorporated into the first-year medical school curriculum. This is laudable and may serve as an exemplar for medical schools worldwide. Yet, despite the knowledge that this type of effort is desperately needed, the reality is that the medical school curriculum has many such demands and the competition for time in the schedule can be significant. Oakland University William Beaumont School of Medicine is one among several new medical schools to open recently in the United States. Being involved with the development of a new integrated medical school curriculum afforded the opportunity to include pain medicine (acute and chronic) topics from the outset rather than campaigning to wrest time away from other established disciplines. Even so, developing a distinct pain course, such as the course initiated at Johns Hopkins, was not an option because of scheduling constraints. Instead, a pain course was embedded into the pharmacology curriculum throughout the first two semesters of the first year. Since basic pharmacology principles can be effectively taught using clinical scenarios, why not choose pain-related topics for these sessions? Our approach was to layer increasing levels of complexity over time, building toward specific pain-related embedded sessions. In that manner, first-year students were able to comprehend and competently discuss clinical cases involving complex topics such as addiction, opioidinduced hyperalgesia, synergistic interactions of multiple analgesics, and the development of chronic pain. By way of example, when discussing drug–receptor DOI. 10.1111/j.1533-2500.2012.00581.x