Showing papers by "Jewish Hospital published in 2007"

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders in Primary Care.

Abstract: These practical guidelines for the biological treatment of unipolar depressive disorders in primary care settings were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). They embody the results of a systematic review of all available clinical and scientific evidence pertaining to the treatment of unipolar depressive disorders and offer practical recommendations for general practitioners encountering patients with these conditions. The guidelines cover disease definition, classification, epidemiology and course of unipolar depressive disorders, and the principles of management in the acute, continuation and maintenance phase. They deal primarily with biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy).

Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice.

Abstract: OBJECTIVES: To integrate the principles of geriatric assessment into the care of older patients with cancer in order to identify vulnerable older adults and develop interventions to optimize cancer treatment. DESIGN: A brief, comprehensive, self-administered questionnaire and intervention algorithm were developed consisting of measures of geriatric assessment that are brief, reliable, validated, and predictive of mortality and morbidity in older patients. SETTING: Academic tertiary care cancer center and community-based satellite practice. PARTICIPANTS: Patients aged 65 and older with cancer. MEASUREMENTS: The questionnaire solicits information about the patient's functional status, comorbidity, psychological status, nutritional status, and social support. A scoring algorithm for referral to a multidisciplinary team was developed. RESULTS: Two hundred forty-five of 250 patients completed the questionnaire (mean age 76, range 65–95). The majority of patients were women (71%), white (95%), married (52%), and retired (90%), with a variety of tumor types and stages. Most patients (78%) completed the questionnaire on their own and reported acceptance of questionnaire length (91%), no difficult questions (94%), no upsetting questions (96%), and no missing questions (89%). The mean time to completion was 15 minutes, with a median of 12.5 (standard deviation 10, range 2–60). Information from this questionnaire helped identify physical and psychological impairments, poor nutrition, lack of social support, and untreated comorbidities. Appropriate referrals to a multidisciplinary team were made. CONCLUSION: This brief, comprehensive, self-administered questionnaire is feasible for use in the outpatient oncology setting and helped identify the needs of geriatric oncology patients. Prospective trials are needed to determine the effectiveness of the interventions offered.

The radial nerve in the brachium: an anatomic study in human cadavers.

Abstract: Purpose To explore the course of the radial nerve in the brachium and to identify practical anatomic landmarks that can be used to avoid iatrogenic injury during humerus fracture fixation. Methods Data were collected from 27 adult cadaveric specimens, including 18 embalmed cadavers and 9 fresh-frozen limbs. Measurements were taken using osseous landmarks to define the relationship of the radial nerve and the posterior and lateral humerus. The extremities were studied further to determine the association of the radial nerve and anatomic landmarks on both longitudinal and cross-sectioned specimens. Results A 6.3 cm ± 1.7 segment of radial nerve was found to be in direct contact with the posterior humerus from 17.1 cm ± 1.6 to 10.9 cm ± 1.5 proximal to the central aspect of the lateral epicondyle, centered within 0.1 cm ± 0.2 of the level of the most distal aspect of the deltoid tuberosity. The radial nerve lay in direct contact with the periosteum in all specimens, without evidence of a structural groove in the humerus in any specimen. On entering the anterior compartment, the radial nerve had very little mobility as it was interposed between the obliquely oriented lateral intermuscular septum and the lateral aspect of the humerus. As it extended distally, the nerve coursed anterior to the humerus and became protected by brachialis muscle at the level of the proximal aspect of the lateral metaphyseal flare. Conclusions The radial nerve is at risk of injury with fractures of the humerus and with subsequent operative fixation in 2 areas. The first is along the posterior midshaft region for a distance of 6.3 cm ± 1.7 centered at the distal aspect of the deltoid tuberosity. The second is along the lateral aspect of the humerus in its distal third from 10.9 cm ± 1.5 proximal to the lateral epicondyle to the level of the proximal aspect of the metaphyseal flare. The deltoid tuberosity is a consistent and practical anatomic landmark that can be used to determine the level of the radial nerve along the posterior aspect of the humerus during operative fixation from an anterior approach.

Insulin-like growth factor-related signaling and cancer development

Abstract: In this review, selected examples of recent research developments concerning insulin-like growth factors (IGFs) and insulin in the context of cancer risk assessment and prevention will be discussed. We reviewed background information related to IGF physiology at the cellular and whole-organism levels, together with prior work concerning IGF-I levels and risk of a variety of cancers, including breast, prostate, colon, and lung in 2004 (Pollak et al. 2004). A comprehensive update to that general review (Pollak et al. 2004) is scheduled for Nature Reviews Cancer in early 2007.

A New CAD System for Early Diagnosis of Detected Lung Nodules

Abstract: A pulmonary nodule is the most common manifestation of lung cancer. Lung nodules are approximately-spherical regions of relatively high density that are visible in X-ray images of the lung. Large (generally defined as greater than 1 cm in diameter) malignant nodules can be easily detected with traditional imaging equipment and can be diagnosed by needle biopsy or bronchoscopy techniques. However, the diagnostic options for small malignant nodules are limited due to problems associated with accessing small tumors, especially if they are located deep in the tissue or away from the large airways; therefore, additional diagnostic and imaging techniques are needed. One of the most promising techniques for detecting small cancerous nodules relies on characterizing the nodule based on its growth rate. The growth rate is estimated by measuring the volumetric change of the detected lung nodules over time, so it is important to accurately measure the volume of the nodules to quantify their growth rate over time. In this paper, we introduce a novel Computer Assisted Diagnosis (CAD) system for early diagnosis of lung cancer. The proposed CAD system consists of five main steps. These steps are: (i) segmentation of lung tissues from low dose computed tomography (LDCT) images, (ii) detection of lung nodules from segmented lung tissues, (iii) a non-rigid registration approach to align two successive LDCT scans and to correct the motion artifacts caused by breathing and patient motion, (iv) segmentation of the detected lung nodules, and (v) quantification of the volumetric changes. Our preliminary classification results based on the analysis of the growth rate of both benign and malignant nodules for 10 patients (6 patients diagnosed as malignant and 4 diagnosed as benign) were 100% for 95% confidence interval. The preliminary results of the proposed image analysis have yielded promising results that would supplement the use of current technologies for diagnosing lung cancer.

A modified model of hindlimb osteomyocutaneous flap for the study of tolerance to composite tissue allografts.

Abstract: Composite tissue allotransplantation (CTA) is the new frontier in transplantation. More than 25 hand allograft transplants have been performed worldwide, and the feasibility has been well established. The classical experimental model of CTA involves rat orthotopic hindlimb transplantation, a time-consuming procedure associated with high mortality and morbidity. We describe a rat heterotopic osteomyocutaneous flap that serves as a nonfunctional CTA, allowing the study of tolerance induction to a highly antigenic vascularized allograft of bone, muscle, and skin while minimizing the morbidity and mortality of full hind limb transplantation. In the present studies, we explored whether establishing chimerism by nonmyeloablative conditioning would induce tolerance to CTA. When compared with the classic hind limb transplantation model, these results demonstrate that our heterotopic hind limb flap is less morbid and as an effective experimental model for the study of CTA tolerance.

Metformin before and during pregnancy and lactation in polycystic ovary syndrome

Abstract: Metformin improves the endocrinopathy of polycystic ovary syndrome (PCOS), facilitates conception, appears to reduce first trimester miscarriage and gestational diabetes and does not appear to be teratogenic. The concentrations of metformin in breast milk are generally low and the mean infant exposure to metformin has been reported in the range 0.28-1.08% of the weight-normalized maternal dose, well below the level of concern for breastfeeding. No adverse effects on blood glucose of nursing infants have been reported. Metformin during lactation versus formula feeding appears to have no adverse effects on infants' growth, motor-social development and intercurrent illness during the first 6 months of life. Systematic studies have not yet been done assessing how hyperinsulinemia, polycystic ovary syndrome and metformin may affect lactation.

A Novel Approach for Automatic Follow-Up of Detected Lung Nodules

Abstract: Our long term research goal is to develop an image-based approach for early diagnosis of lung nodules that may lead to lung cancer. This paper focuses on monitoring the progress of detected lung nodules in successive chest low dose CT (LDCT) scans of a patient using non-rigid registration. In this paper, we propose a new methodology for 3D LDCT data registration. The registration methodology is non-rigid and involves two steps: global alignment of one scan (target data) to another scan (reference data) using the learned prior appearance model followed by local alignments in order to correct for intricate deformations. From two subsequent chest scans, visual appearance of the chest images, after equalizing their signals, are modeled with a Markov-Gibbs random field with pairwise interaction. Our approach is based on finding the affine transformation to register one data set (target data) to another data set (reference data) by maximizing a special Gibbs energy function using a gradient descent algorithm. To get accurate appearance model, we developed a new approach to an automatically select the most important cliques that describe the visual appearance of LDCT data. To handle local deformations, we propose a new approach based on deforming each voxel over evolving closed and equi-spaced surfaces (iso-surfaces) to closely match the prototype. The evolution of the iso-surfaces is guided by an exponential speed function in the directions minimizing distances between corresponding pixel pairs on the iso-surfaces on both data sets. Our preliminary results on 10 patients show that the proper registration could lead to precise identification of the progress of the detected lung nodules.

Splenic rupture: an unusual complication of colonoscopy.

Abstract: Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.

Geometric Features Based Framework for Colonic Polyp Detection using a New Color Coding Scheme

Abstract: Curvature-based geometric features have been proven to be important for colonic polyp detection. In this paper, we present an automatic detection framework and color coding scheme to highlight the detected polyps. The key idea is to place the detected polyps at the same locations in a newly created polygonal dataset with the same topology and geometry properties as the triangulated mesh surface of real colon dataset, and assign different colors to the two separated datasets to highlight the polyps. Finally, we validate the proposed framework by computer simulated and real colon datasets. For fifteen synthetic polyps with different shapes and different sizes, the sensitivity is 100%, and false positive is 0. For four real colon datasets, the proposed algorithm has achieved the sensitivity of 75%.

Evaluation of various image reconstruction parameters in lower extremity stents using multidetector-row CT angiography: initial findings

Abstract: Image quality, visible lumen and patency of lower limb stents was assessed by multidetector-row computed tomography (MDCT) angiography using various reconstruction parameters and the results compared with conventional angiography. Fourteen patients (25 stents) were evaluated. From MDCT datasets, axial and coronal oblique reformations were reconstructed using differing reconstruction parameters (slice thickness, kernel, views). Artifacts and image quality were assessed using a five-degree scale (1=excellent, 5=poor). Visible stent diameter was measured. Stenosis severity was compared with calibrated catheter angiography. The image quality of medium and sharp image kernels were good/fair (1.9–2.4), while smooth kernel provided only acceptable/poor image quality (3.9–4.4). Coronal oblique images were rated superior to assess in-stent lumen rather than axial. Using medium and sharp kernels, the visible stent lumen was significantly greater than using smooth kernel (P<0.001). thirteen out of fourteen patients (24/25 stents) were correctly classified as patent. In one patient, in-stent stenosis (≥50%) was falsely diagnosed using CT angiography (CTA) with smooth kernel and was, therefore, rated as false positive. Coronal oblique views, as well as medium and sharp kernels, have shown the best results regarding image quality to assess stent patency in the lower limb. Therefore, MDCT could be a valuable non-invasive modality for stent imaging in the peripheral vasculature.

Legg-Calve-Perthes disease, venous and arterial thrombi, and the factor V Leiden mutation in a four-generation kindred.

Abstract: UNLABELLED In a 4-generation kindred identified through a 12-year-old female proband with Legg-Calve-Perthes Disease (LCPD) who was found to be heterozygous for the G1691A factor V Leiden mutation (FV), our specific aim was to assess associations of FV with LCPD and with venous and arterial thrombotic events. Despite lethal thromboembolism in 3 family members at ages 21, 35, and 38, retinal artery thrombosis, and deep venous thrombosis, no family members had previously been studied for the FV mutation until kindred screening-genetic counseling was prompted by the discovery of the FV mutation in a child proband with LCPD. METHODS In a 4-generation kindred identified through a 12-year-old female proband with LCPD and found to be heterozygous for the FV mutation, we assessed the FV genotype and its association with thromboembolism in 14 of 16 living first- and second-degree relatives. RESULTS There was 3-generation vertical and horizontal transmission of heterozygosity for the FV mutation. Of 14 living first- and second-degree relatives, 10 were heterozygous for the FV mutation, including the proband's sister, mother, and maternal grandmother. Of the 14 living relatives, 2 had thrombotic events (retinal artery thrombosis and deep venous thrombosis of the leg). The proband's maternal great-grandfather had a lethal pulmonary embolus at age 35, as did her maternal great aunt at age 38, and a female third cousin at age 21. CONCLUSIONS In a large kindred identified by a child with LCPD who was found to have the FV mutation, FV heterozygosity was found in 3 generations of previously undiagnosed family members and was associated with venous and arterial thrombosis throughout the kindred. We suggest that FV mutation be studied in children with LCPD facilitate diagnosis and genetic counseling for thrombophilia in their parents, siblings, and other kindred members, and because the proband LCPD child with the FV mutation is at increased risk for other thromboembolic abnormalities as an adult. LEVEL OF EVIDENCE 1.

Analysis of Model for End-Stage Liver Disease (MELD) score in a liver transplantation waiting list.

Abstract: Background The Model for End-Stage Liver Disease (MELD) was introduced in 1999 to quantify the 3-month prognosis of cirrhotic patients after a transjugular intrahepatic portosystemic shunt (TIPS). Because of the imbalance between organ donors and patients on the waiting list, the MELD was adopted by the United States in 2002 to allocate liver grafts for transplantation. Preliminary results have indicated a reduction in waiting list deaths and an increase in transplantation rates for candidates. Seeking to find a new model to predict death on the waiting list and after liver transplantation, retrospective studies have examined MELD scores in waiting list patients. The aim of this study was to analyze the MELD scores of patients on the liver waiting list for comparisons between transplanted patients. Patients and Methods A retrospective study was performed analyzing 131 registrations of 127 orthotopic liver transplant (OLT) patients (4 underwent retransplantation) grafted between November 2000 and January 2006, excluding 24 patients: 2 had urgent retransplantations due to hepatic artery thrombosis and 22 had incomplete data. These patients were divided into 3 groups: group I (transplanted patients)—53 patients underwent 55 OLT; group II—29 patients who died on the waiting list; group III—patients on the waiting list including 23 patients still waiting as of the date of the study. Results The main indication for OLT was hepatitis C virus cirrhosis (50.50%), followed by alcoholic liver cirrhosis (23.30%), cryptogenic cirrhosis (12.60%), autoimmune hepatitis (5.80%), hepatitis B virus cirrhosis (4.85%), and primary biliary cirrhosis (2.91%). Group I: MELD score 15.62 (range, 6–39) on admission to the list, and 18.87 (range, 7–39) at transplantation. The mean waiting time for OLT was 478.39 days (range, 2–1270 days). The 38 patients who survived underwent 39 OLT (1 retransplantation). The MELD score at entrance to the list was 14.62 (range, 7–30) and at transplantation, 17.70 (range, 7–39). The mean time between admission to the list and transplantation was 505.37 days (range, 6–1270 days). The 15 patients who died had received 16 OLT (1 retransplantation). Their MELD scores were 17.80 (range, 6–39) and 21.81 (range, 9–39) at admission to the list and at transplantation, respectively, with a mean time on the waiting list of 417.93 days (range, 2–872 days). Group II: 29 patients died before OLT, at a mean age of 52.60 years (range, 22–67 years). Their MELD score was 19.24 (range, 7–45), and the interval between admission to the waiting list and death was 249.55 days (range, 3–1247 days). Group III: 23 patients still active on the OLT waiting list at the time of study displayed a mean MELD score of 13.65 (range, 6–28) and 354.30 days (range, 2–905 days) waiting until the moment. In conclusion, MELD score at the time of admission to the waiting list was higher among those patients who died either awaiting a liver graft (19.24) or after OLT (17.80) compared with those who survived after OLT (14.60) or are still awaiting OLT (13.65).

Amaurosis fugax caused by heritable thrombophilia-hypofibrinolysis in cases without carotid atherosclerosis: thromboprophylaxis prevents subsequent transient monocular partial blindness.

Abstract: Nineteen patients (age 60 ± 14) with amaurosis fugax associated with heritable thrombophilia-hypofibrinolysis without ipsilateral atherosclerotic carotid plaque or other causes of amaurosis fugax were studied. Our hypothesis was that case-specific thromboprophylaxis would prevent subsequent amaurosis fugax episodes. Prospective treatment data were available for 13 cases. Thrombophilic disorders included high Factors VIII and XI, G20210A prothrombin heterozygosity, low proteins C and S, MTHFR mutations, and the PL A1/A2 mutation. Hypofibrinolytic disorders included plasminogen activator inhibitor-1 4G4G, and high lipoprotein (a). Treatments included Coumadin; Lovenox, folic acid-vitamin B6-vitamin B12, discontinuation of estrogens-selective estrogen receptor modulators, Glucophage, and aspirin, as appropriate. Usually within 1 month on therapy, patients became asymptomatic and have remained asymptomatic for ≥ 1 year on therapy, without adverse treatment side effects. When amaurosis fugax occurs without car...

Effective synthesized/preappraised evidence formats in emergency medicine and the use of supplemental knowledge translation techniques.

Abstract: Most clinicians, and especially emergency physicians, are increasingly faced with the need for valid and reliable evidence upon which to base practice decisions in a timely fashion. Despite the accumulation of synthesized evidence in emergency medicine over the past decade, knowledge gaps still exist between what is known and what is practiced. In many cases, this failure in knowledge uptake relates to barriers in uptake as well as the difficulty of translating evidence from research to the bedside. Preappraised evidence syntheses represent a potential partial solution to these problems by providing condensed summaries of the large volume of scientific literature in our field. The participants in this workshop examined the availability, utility, and impact of preappraised evidence and examined innovative ways to translate this knowledge into practice. In addition, the workshop participants also explored more globally all knowledge translation methods that are distinct from clinical pathways (e.g., audit and feedback, academic detailing, reminders, and local opinion leaders). These are initiatives that are instituted at the level of a particular hospital or with respect to a certain condition, and emergency physicians need to understand their definition and application. Overall, the recommendations arising from this workshop have the potential to alter future emergency care in important ways.

Tolerance to organ transplants: Is chimerism bringing it closer than we think?

Abstract: Purpose of reviewThe recent development of novel immunosuppressive agents that target effector cell function has allowed steroid-sparing protocols to promote allograft survival. Although this development is a major step forward, chronic rejection and end-organ toxicity due, to the side-effects of the same agents that are critical to promote graft survival, remain major limitations that result in significant morbidity and mortality in transplant recipients. This review focuses on the translation of research on chimerism and tolerance from mice to large animal models, and focuses on what we can learn from our bone marrow transplantation colleagues. RecentThe observation that the major role for conditioning is to control host-versus-graft alloimmune responses rather than to prepare vacant niches resulted in a paradigm shift in bone marrow transplantation that allowed reduced-intensity approaches for conditioning for bone marrow transplantation. Immune-base conditioning to control host-versus-graft responses allowed the development of nonmyeloablative hematopoietic stem cell transplant therapies, substantially reducing the toxicity of ablative conditioning. Nonmyeloablative hematopoietic stem cell transplantation is now widely used in humans too old or ill to tolerate ablative bone marrow transplantation for malignancy. Chimerism, and therefore tolerance, is readily established in the clinic. Graft-versus-host disease, however, remains the final challenge to be conquered. SummaryApproaches to establish low levels of mixed donor–host chimerism are currently being translated to pilot studies in humans. Novel tolerogenic cell-based approaches, including graft-facilitating cells, in combination with nonmyeloablative conditioning, may provide the final critical component for safe induction of tolerance to transplanted organs and tissue.

The p150 subunit of dynactin (DCTN1) gene in multiple sclerosis

Abstract: Objectives – Mutations in the p150 subunit of the axonal transport protein dynactin (DCTN1) have been reported in patients with amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD). Given the common features of neurodegeneration in multiple sclerosis (MS), FTD and ALS, sequence variants of the DCTN1 gene may be a contributory factor to neurodegeneration in MS. Methods – We investigated a total of 200 MS patients and 200 controls. A total of 100 patients had a relapsing–remitting form of MS, 100 cases were primary progressive. Sequence alterations were screened for in the coding region of DCTN1 using heteroduplex and sequence analyses. Results – Two heterozygous missense mutations (T1249I, I196V) were found in two healthy control subjects. No mutations were identified in 200 MS patients. The frequency of a known single nucleotide polymorphism (R495Q) was not significantly different between patients and controls. Conclusion – The results indicate that the DCTN1 gene is probably not influencing susceptibility to neurodegeneration in MS.

A tool for guiding clinical decisions.

Abstract: “THOSE WHO ARE ENAMORED of practice without science are like a pilot who goes into a ship without rudder or compass and never has any certainty where he is going. Practice should always be based upon a sound knowledge of theory.”1

AN AMINO ACID DELETION ASSOCIATED WITH THE IgG4b ALLOTYPE OF HUMAN IgG4 MYELOMA PROTEINS

Abstract: SUMMARY Comparative aminoacid sequence studies were done on chymotryptic peptides from the Fc fragments of IgG1, IgG2, IgG4a and IgG4b human myeloma proteins. Eleven peptides were positioned within the Fc fragments of IgG4 proteins. While leucine was present at position 309 of the Fc fragment of the IgG4a protein, it was absent from the Fc fragment of the IgG4b protein.

Anterior cruciate ligament reconstruction using allograft: single tunnel technique.

Abstract: The author presents his current technique for reconstructing an isolated anterior cruciate ligament rupture using an allograft. The specific positioning and surgical steps are presented. Dangers to be avoided are included, which have led to this current technique. The step-by-step technique should enable the surgeon to reconstruct the ligament with little difficulty. The postoperative course including rehabilitation is discussed from postoperative day 1 to full restoration of activity.