Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Mars Exploration Rovers Propulsive Maneuver Design

The Mars Exploration Rovers Spirit and Opportunity successfully landed respectively at Gusev Crater and Meridiani Planum in January 2004. The rovers are essentially robotic geologists, sent on a mission to search for evidence in the rocks and soil pertaining to the historical presence of water and the ability to possibly sustain life. In order to conduct NASA's 'follow the water' strategy on opposite sides of the planet Mars, an interplanetary journey of over 300 million miles culminated with historic navigation precision. Rigorous trajectory targeting and control was necessary to achieve the atmospheric entry requirements for the selected landing sites. The propulsive maneuver design challenge was to meet or exceed these requirements while preserving the necessary design margin to accommodate additional project concerns. Landing site flexibility was maintained for both missions after launch, and even after the first trajectory correction maneuver for Spirit. The final targeting strategy was modified to improve delivery performance and reduce risk after revealing constraining trajectory control characteristics. Flight results are examined and summarized for the six trajectory correction maneuvers that were planned for each mission

Mars Exploration Rovers Launch Performance and TCM-1 Maneuver Design

The Mars Exploration Rover (MER) project successfully landed two identical rovers on Mars in order to remotely conduct geologic investigations, including characterization of rocks and soils that may hold clues to past water activity. Two landing sites, Gusev crater and Meridiani Planum, were selected out of nearly 200 candidate sites after balancing science returns and flight system engineering and safety. Precise trajectory targeting and control was necessary to achieve the atmospheric entry requirements for the selected landing sites within the flight system constraints. This paper discusses the expected and achieved launch vehicle performance and the impacts of that performance on the first Trajectory Correction Maneuver (TCM-1) while maintaining targeting flexibility in accommodating additional project concerns about landing site safety and possible in-flight retargeting to alternate landing sites

Regulatory effects of estradiol on peripheral blood mononuclear cells activation in patients with Asthma

Asthma prevalence and severity are greater in women than in men, and mounting evidence suggests this is in part related to female steroid sex hormones. Conflicting data are reported regarding pro-and anti-inflammatory properties of estradiol. This study was designed to clarify whether estradiol may contribute to enhanced T helper (Th) 17-Associated cytokines production by peripheral blood mononuclear cells (PBMC) in asthmatic patients and healthy individuals. PBMCs from patients with asthma and healthy donors were cultured with 17-β estradiol (E2) and phytohemagglutinin (PHA). The quantitative real-Time polymerase chain reaction (qRT-PCR) was used to measure IL-6, IL-17, IL-23 and TGF-β. We observed a significant increased IL-17, IL-23 and TGF-β expression in PBMCs of patients compared to the healthy individuals. In addition, our findings indicated that IL-6 and IL-17 expressions in PBMCs were induced, following E2 treatment. Our results identified an impact of E2 in stimulation of Th17 phenotype, and upon hormonal oscillations and hormone replacement therapy (HRT), asthma inflammation may be mediated by Th17-Associated cytokines. © February 2018, Iran J Allergy Asthma Immunol. All rights reserved

Regulatory effects of estradiol on peripheral blood mononuclear cells activation in patients with Asthma

Asthma prevalence and severity are greater in women than in men, and mounting evidence suggests this is in part related to female steroid sex hormones. Conflicting data are reported regarding pro-and anti-inflammatory properties of estradiol. This study was designed to clarify whether estradiol may contribute to enhanced T helper (Th) 17-Associated cytokines production by peripheral blood mononuclear cells (PBMC) in asthmatic patients and healthy individuals. PBMCs from patients with asthma and healthy donors were cultured with 17-β estradiol (E2) and phytohemagglutinin (PHA). The quantitative real-Time polymerase chain reaction (qRT-PCR) was used to measure IL-6, IL-17, IL-23 and TGF-β. We observed a significant increased IL-17, IL-23 and TGF-β expression in PBMCs of patients compared to the healthy individuals. In addition, our findings indicated that IL-6 and IL-17 expressions in PBMCs were induced, following E2 treatment. Our results identified an impact of E2 in stimulation of Th17 phenotype, and upon hormonal oscillations and hormone replacement therapy (HRT), asthma inflammation may be mediated by Th17-Associated cytokines. © February 2018, Iran J Allergy Asthma Immunol. All rights reserved

Effect of Self - Care Education on Quality of Life in Patients With Primary Hypertension: Comparing Lecture and Educational Package

Background: Hypertension is a dangerous risk factor for public health. It profoundly affects the patients’ quality of life. However, there is lack of agreement on the best method for self-care management in patients with hypertension. Objectives: This study was conducted to compare the effect of lecture and educational pamphlets on quality of life (QOL) in patients with primary hypertension. Patients and Methods: A quasi-experimental study was performed on 90 patients with chronic primary hypertension referred to two outpatient clinics in Kashan city. Patients were randomly divided into three groups including lecture group, educational package group, and control group. The participants’ quality of life was measured using the SF-36 questionnaire at the beginning of the study, and two months later. Data was analyzed using ANOVA and Chi-Square tests. Results: No significant differences were observed between the three groups for demographics characteristics and QOL before the intervention except for marital status. Mean scores of QOL dimensions of the intervention groups were increased at the end of the study, except for the dimension of bodily pain. Tukey post-Hoc test showed that except for general health, the two intervention groups were not significantly different in other dimensions, and significant differences were observed between the control group and the two intervention groups (P < 0.05). At start and the end of the study, the mean differences in the general health dimension in three groups were 2.25 ± 0.1, 0.07 ± 0.01, and -1.70 ± 0.01 respectively. There were significant differences among groups (P = 0.04). Conclusions: Lecture and educational package can both improve some dimensions of the QOL in patients with hypertension. However, as pamphlets are cheap and easy to use, this method may be used as an effective method for self-care education in health care settings in Iran, where the system is faced with nursing shortage

Comparative effectiveness of generic and brand-name medication use: A database study of US health insurance claims.

BackgroundTo the extent that outcomes are mediated through negative perceptions of generics (the nocebo effect), observational studies comparing brand-name and generic drugs are susceptible to bias favoring the brand-name drugs. We used authorized generic (AG) products, which are identical in composition and appearance to brand-name products but are marketed as generics, as a control group to address this bias in an evaluation aiming to compare the effectiveness of generic versus brand medications.Methods and findingsFor commercial health insurance enrollees from the US, administrative claims data were derived from 2 databases: (1) Optum Clinformatics Data Mart (years: 2004-2013) and (2) Truven MarketScan (years: 2003-2015). For a total of 8 drug products, the following groups were compared using a cohort study design: (1) patients switching from brand-name products to AGs versus generics, and patients initiating treatment with AGs versus generics, where AG use proxied brand-name use, addressing negative perception bias, and (2) patients initiating generic versus brand-name products (bias-prone direct comparison) and patients initiating AG versus brand-name products (negative control). Using Cox proportional hazards regression after 1:1 propensity-score matching, we compared a composite cardiovascular endpoint (for amlodipine, amlodipine-benazepril, and quinapril), non-vertebral fracture (for alendronate and calcitonin), psychiatric hospitalization rate (for sertraline and escitalopram), and insulin initiation (for glipizide) between the groups. Inverse variance meta-analytic methods were used to pool adjusted hazard ratios (HRs) for each comparison between the 2 databases. Across 8 products, 2,264,774 matched pairs of patients were included in the comparisons of AGs versus generics. A majority (12 out of 16) of the clinical endpoint estimates showed similar outcomes between AGs and generics. Among the other 4 estimates that did have significantly different outcomes, 3 suggested improved outcomes with generics and 1 favored AGs (patients switching from amlodipine brand-name: HR [95% CI] 0.92 [0.88-0.97]). The comparison between generic and brand-name initiators involved 1,313,161 matched pairs, and no differences in outcomes were noted for alendronate, calcitonin, glipizide, or quinapril. We observed a lower risk of the composite cardiovascular endpoint with generics versus brand-name products for amlodipine and amlodipine-benazepril (HR [95% CI]: 0.91 [0.84-0.99] and 0.84 [0.76-0.94], respectively). For escitalopram and sertraline, we observed higher rates of psychiatric hospitalizations with generics (HR [95% CI]: 1.05 [1.01-1.10] and 1.07 [1.01-1.14], respectively). The negative control comparisons also indicated potentially higher rates of similar magnitude with AG compared to brand-name initiation for escitalopram and sertraline (HR [95% CI]: 1.06 [0.98-1.13] and 1.11 [1.05-1.18], respectively), suggesting that the differences observed between brand and generic users in these outcomes are likely explained by either residual confounding or generic perception bias. Limitations of this study include potential residual confounding due to the unavailability of certain clinical parameters in administrative claims data and the inability to evaluate surrogate outcomes, such as immediate changes in blood pressure, upon switching from brand products to generics.ConclusionsIn this study, we observed that use of generics was associated with comparable clinical outcomes to use of brand-name products. These results could help in promoting educational interventions aimed at increasing patient and provider confidence in the ability of generic medicines to manage chronic diseases