Incorporating remote visits into an outpatient clinic

Copyright @ 2009 Operational Research Society Ltd. This is a post-peer-review, pre-copyedit version of an article published in Journal of Simulation. The definitive publisher-authenticated version Eatock and Eldabi (2009), "Incorporating remote visits into an outpatient clinic", Journal of Simulation, 3, 179–188 is available online at the link below.Most telemedicine studies are concerned with either the technological or diagnostic comparisons, rather than assessing the impact on clinic management. This has attributed to the retrospective nature of the studies, with lack of data being the main cause for not using simulation for prospective analysis. This article demonstrates the use of simulation to assess the impact of prospective systems by utilising data generated from clinical trials. The example used here is the introduction of remote consultations into an outpatient's clinic. The article addresses the issues of using secondary data, in terms of the differences between the trial, the model and future reality. The result of running the simulation model show that exchanging the mode of service delivery does not improve patient wait times as expected, and that a protocol change in association with the introduction of remote visits is necessary to provide a substantial reduction in patient wait times

Oral Levosimendan Increases Cerebral Blood Flow Velocities in Patients with a History of Stroke or Transient Ischemic Attack : A Pilot Safety Study

Peer reviewe

Milloin kaulavaltimoahtauman hoito on aiheellista?

Kaulavaltimoahtauman hoidon tavoitteena on estää aivoinfarkti.Kaikille potilaille suositellaan lääkehoitoa ja elintapaohjausta. Lääkkeistä keskeisiä ovat verihiutaleiden estäjät ja statiinit.Oireisille potilaille, joilla on yli 70 %:n ahtauma, suositellaan endarterektomiaa. Sitä tulee harkita, jos ahtauma on 50–69 %.Oireettomille potilaille tulee harkita leikkausta, jos ahtauma on yli 60 %, elinajanennuste on yli 5 vuotta ja kuvantamislöydös viittaa suurentuneeseen infarktiriskiin.Valikoiduissa tapauksissa voidaan tehdä suonensisäinen stenttaus.</p

Machine learning-based prediction of motor status in glioma patients using diffusion MRI metrics along the corticospinal tract

Shams et al. report that glioma patients' motor status is predicted accurately by diffusion MRI metrics along the corticospinal tract based on support vector machine method, reaching an overall accuracy of 77%. They show that these metrics are more effective than demographic and clinical variables. Along tract statistics enables white matter characterization using various diffusion MRI metrics. These diffusion models reveal detailed insights into white matter microstructural changes with development, pathology and function. Here, we aim at assessing the clinical utility of diffusion MRI metrics along the corticospinal tract, investigating whether motor glioma patients can be classified with respect to their motor status. We retrospectively included 116 brain tumour patients suffering from either left or right supratentorial, unilateral World Health Organization Grades II, III and IV gliomas with a mean age of 53.51 +/- 16.32 years. Around 37% of patients presented with preoperative motor function deficits according to the Medical Research Council scale. At group level comparison, the highest non-overlapping diffusion MRI differences were detected in the superior portion of the tracts' profiles. Fractional anisotropy and fibre density decrease, apparent diffusion coefficient axial diffusivity and radial diffusivity increase. To predict motor deficits, we developed a method based on a support vector machine using histogram-based features of diffusion MRI tract profiles (e.g. mean, standard deviation, kurtosis and skewness), following a recursive feature elimination method. Our model achieved high performance (74% sensitivity, 75% specificity, 74% overall accuracy and 77% area under the curve). We found that apparent diffusion coefficient, fractional anisotropy and radial diffusivity contributed more than other features to the model. Incorporating the patient demographics and clinical features such as age, tumour World Health Organization grade, tumour location, gender and resting motor threshold did not affect the model's performance, revealing that these features were not as effective as microstructural measures. These results shed light on the potential patterns of tumour-related microstructural white matter changes in the prediction of functional deficits.Peer reviewe

Network analysis shows decreased ipsilesional structural connectivity in glioma patients

Tumors and their location distinctly alter both local and global brain connectivity within the ipsilesional hemisphere of glioma patients. Gliomas that infiltrate networks and systems, such as the motor system, often lead to substantial functional impairment in multiple systems. Network-based statistics (NBS) allow to assess local network differences and graph theoretical analyses enable investigation of global and local network properties. Here, we used network measures to characterize glioma-related decreases in structural connectivity by comparing the ipsi- with the contralesional hemispheres of patients and correlated findings with neurological assessment. We found that lesion location resulted in differential impairment of both short and long connectivity patterns. Network analysis showed reduced global and local efficiency in the ipsilesional hemisphere compared to the contralesional hemispheric networks, which reflect the impairment of information transfer across different regions of a network.Peer reviewe

Effect of Inhaled Xenon on Cerebral White Matter Damage in Comatose Survivors of Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial

IMPORTANCE: Evidence from preclinical models indicates that xenon gas can prevent the development of cerebral damage after acute global hypoxic-ischemic brain injury but, thus far, these putative neuroprotective properties have not been reported in human studies. OBJECTIVE: To determine the effect of inhaled xenon on ischemic white matter damage assessed with magnetic resonance imaging (MRI). DESIGN, SETTING, AND PARTICIPANTS: A randomized single-blind phase 2 clinical drug trial conducted between August 2009 and March 2015 at 2 multipurpose intensive care units in Finland. One hundred ten comatose patients (aged 24-76 years) who had experienced out-of-hospital cardiac arrest were randomized. INTERVENTIONS: Patients were randomly assigned to receive either inhaled xenon combined with hypothermia (33°C) for 24 hours (n = 55 in the xenon group) or hypothermia treatment alone (n = 55 in the control group). MAIN OUTCOMES AND MEASURES: The primary end point was cerebral white matter damage as evaluated by fractional anisotropy from diffusion tensor MRI scheduled to be performed between 36 and 52 hours after cardiac arrest. Secondary end points included neurological outcome assessed using the modified Rankin Scale (score 0 [no symptoms] through 6 [death]) and mortality at 6 months. RESULTS: Among the 110 randomized patients (mean age, 61.5 years; 80 men [72.7%]), all completed the study. There were MRI data from 97 patients (88.2%) a median of 53 hours (interquartile range [IQR], 47-64 hours) after cardiac arrest. The mean global fractional anisotropy values were 0.433 (SD, 0.028) in the xenon group and 0.419 (SD, 0.033) in the control group. The age-, sex-, and site-adjusted mean global fractional anisotropy value was 3.8% higher (95% CI, 1.1%-6.4%) in the xenon group (adjusted mean difference, 0.016 [95% CI, 0.005-0.027], P = .006). At 6 months, 75 patients (68.2%) were alive. Secondary end points at 6 months did not reveal statistically significant differences between the groups. In ordinal analysis of the modified Rankin Scale, the median (IQR) value was 1 (1-6) in the xenon group and 1 (0-6) in the control group (median difference, 0 [95% CI, 0-0]; P = .68). The 6-month mortality rate was 27.3% (15/55) in the xenon group and 34.5% (19/55) in the control group (adjusted hazard ratio, 0.49 [95% CI, 0.23-1.01]; P = .053). CONCLUSIONS AND RELEVANCE: Among comatose survivors of out-of-hospital cardiac arrest, inhaled xenon combined with hypothermia compared with hypothermia alone resulted in less white matter damage as measured by fractional anisotropy of diffusion tensor MRI. However, there was no statistically significant difference in neurological outcomes or mortality at 6 months. These preliminary findings require further evaluation in an adequately powered clinical trial designed to assess clinical outcomes associated with inhaled xenon among survivors of out-of-hospital cardiac arrest. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00879892

Assembly of complex viruses exemplified by a halophilic euryarchaeal virus

Many of the largest known viruses belong to the PRD1-adeno structural lineage characterised by conserved pseudo-hexameric capsomers composed of three copies of a single major capsid protein (MCP). Here, by high-resolution cryo-EM analysis, we show that a class of archaeal viruses possess hetero-hexameric MCPs which mimic the PRD1-adeno lineage trimer. These hetero-hexamers are built from heterodimers and utilise a jigsaw-puzzle system of pegs and holes, and underlying minor capsid proteins, to assemble the capsid laterally from the 5-fold vertices. At these vertices proteins engage inwards with the internal membrane vesicle whilst 2-fold symmetric horn-like structures protrude outwards. The horns are assembled from repeated globular domains attached to a central spine, presumably facilitating multimeric attachment to the cell receptor. Such viruses may represent precursors of the main PRD1-adeno lineage, similarly engaging cell-receptors via 5-fold spikes and using minor proteins to define particle size.Peer reviewe

Matrix metalloproteinase-9 activity and a downregulated Hedgehog pathway impair blood-brain barrier function in an <i>in vitro</i> model of CNS tuberculosis

Central nervous system tuberculosis (CNS TB) has a high mortality and morbidity associated with severe inflammation. The blood-brain barrier (BBB) protects the brain from inflammation but the mechanisms causing BBB damage in CNS TB are uncharacterized. We demonstrate that Mycobacterium tuberculosis (Mtb) causes breakdown of type IV collagen and decreases tight junction protein (TJP) expression in a co-culture model of the BBB. This increases permeability, surface expression of endothelial adhesion molecules and leukocyte transmigration. TJP breakdown was driven by Mtb-dependent secretion of matrix metalloproteinase (MMP)-9. TJP expression is regulated by Sonic hedgehog (Shh) through transcription factor Gli-1. In our model, the hedgehog pathway was downregulated by Mtb-stimulation, but Shh levels in astrocytes were unchanged. However, Scube2, a glycoprotein regulating astrocyte Shh release was decreased, inhibiting Shh delivery to brain endothelial cells. Activation of the hedgehog pathway by addition of a Smoothened agonist or by addition of exogenous Shh, or neutralizing MMP-9 activity, decreased permeability and increased TJP expression in the Mtb-stimulated BBB co-cultures. In summary, the BBB is disrupted by downregulation of the Shh pathway and breakdown of TJPs, secondary to increased MMP-9 activity which suggests that these pathways are potential novel targets for host directed therapy in CNS TB

The effect of the regular solution model in the condensation of protoplanetary dust

We utilize a chemical equilibrium code in order to study the condensation process which occurs in protoplanetary discs during the formation of the first solids. The model specifically focuses on the thermodynamic behaviour on the solid species assuming the regular solution model. For each solution, we establish the relationship between the activity of the species, the composition and the temperature using experimental data from the literature. We then apply the Gibbs free energy minimization method and study the resulting condensation sequence for a range of temperatures and pressures within a protoplanetary disc. Our results using the regular solution model show that grains condense over a large temperature range and therefore throughout a large portion of the disc. In the high temperature region (T > 1400 K) Ca-Al compounds dominate and the formation of corundum is sensitive to the pressure. The mid-temperature region is dominated by Fe(s) and silicates such as Mg2SiO4 and MgSiO3 . The chemistry of forsterite and enstatite are strictly related, and our simulations show a sequence of forsterite-enstatite-forsterite with decreasing temperature. In the low temperature regions (T < 600 K) a range of iron compounds and sulfides form. We also run simulations using the ideal solution model and see clear differences in the resulting condensation sequences with changing solution model In particular, we find that the turning point in which forsterite replaces enstatite in the low temperature region is sensitive to the solution model. Our results show that the ideal solution model is often a poor approximation to experimental data at most temperatures important in protoplanetary discs. We find some important differences in the resulting condensation sequences when using the regular solution model, and suggest that this model should provide a more realistic condensation sequence.Comment: MNRAS: Accepted 2011 February 16. Received 2011 February 14; in original form 2010 July 2