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This article draws on the deliberative play framework to examine empirical examples of storytelling in an online deliberative forum: The Oregon Citizen Assembly (ORCA) Pilot on COVID-19 Recovery. ORCA engaged 36 citizens in deliberation about state policy through an online deliberative process spanning seven weeks. Drawing on literature on small stories in deliberation, we trace stories related to a policy proposal about paying parents to educate children at home. Our analysis demonstrates that storytelling activities accomplish aspects of deliberative play through introducing uncertainty, resisting premature closure, and promoting an "as if" frame that allows groups to explore the scope and implications of proposals. Forum design influences interaction and our analysis suggests that technology use and timing are key design features that can facilitate or inhibit deliberative play.
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This qualitative study evaluated barriers and facilitators to mobility in the homes of children with medical complexity (CMC) and the subsequent impact on CMC and their families. Eighteen caregivers of CMC were interviewed. Parents described that accessibility barriers impaired delivery of care at home and impacted the child's participation in family life. The most inaccessible areas were stairs and bathrooms. Mobility and transfers became more difficult as children grew larger. Parents and children sustained injuries from performance of activities of daily living (ADLs). When available, durable medical equipment (DME) and home modifications improved home access and typically were funded using insurance and state Title V funds. However, parents reported that larger home modifications, such as bathroom modifications, were cost prohibitive. A pediatrician's inquiry about mobility barriers may reveal crucial information about delivery of home care to CMC. CMC may be referred to rehabilitation specialists to address mobility needs.
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Crianças com Deficiência , Serviços de Assistência Domiciliar , Atividades Cotidianas , Cuidadores , Criança , Equipamentos Médicos Duráveis , Humanos , Pesquisa QualitativaRESUMO
INTRODUCTION: We sought to characterize the current supports used by parents to care for children with medical complexity (CMC) at home and parental preferences for additional supports to meet identified gaps. METHOD: Semistructured interviews were conducted with parents of 18 CMC. Interviews were transcribed then analyzed using a constant comparative approach. RESULTS: Extended family and community offloaded nonmedical tasks, assisted financially, gave emotional reinforcement, and cared for CMC. Home health providers also directly cared for CMC, but access and quality varied. Government programs paid for in-home care, but eligibility varied. Parents wanted more paid home care but also more support completing nonmedical tasks, mitigating financial strains, and accessing mental health services. DISCUSSION: Parents of CMC relied on family and community members to help fill existing gaps in-home care, but gaps remained, suggesting the need for more medical and social supports for the in-home care of CMC and their families.
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Serviços de Assistência Domiciliar , Pais , Criança , Família , Humanos , Pais/psicologia , Apoio SocialRESUMO
In this article, we demonstrate the method of participatory causal modeling to map the interdependencies of critical performance variables in a complex nonprofit health care provider with considerable financial and operational control challenges. Critical performance variables are output performance dimensions that are fundamental indicators of organizational success. Causal modeling provides an approach for nonprofit leaders to examine how critical performance variables dynamically and recursively affect each other and thereby offers a path to identify key points of leverage for organizational action. Using a case study, we show that participatory system dynamics modeling revealed assumptions, choices, and complexities and so helped a nonprofit health care organization recognize possible strategic opportunities. This study demonstrates an approach that other nonprofits may deploy in situations where they are experiencing competing objectives and constraints in managing critical performance variables.
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There are many nonsurgical treatment options for patients with upper limb spasticity. This article presents an algorithmic approach to management, encompassing evidence-based rehabilitation therapies, medications, and promising new orthotic and robotic innovations.
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Espasticidade Muscular/fisiopatologia , Espasticidade Muscular/terapia , Extremidade Superior/fisiopatologia , Algoritmos , Interfaces Cérebro-Computador , Humanos , Relaxantes Musculares Centrais/uso terapêutico , Bloqueio Nervoso , Fármacos Neuromusculares/uso terapêutico , Aparelhos Ortopédicos , Modalidades de Fisioterapia , Robótica , Estimulação Magnética Transcraniana , Realidade VirtualAssuntos
Adenoma/veterinária , Carcinoma/veterinária , Doenças do Cão/diagnóstico , Neoplasias Palpebrais/veterinária , Glândulas Tarsais , Adenoma/diagnóstico , Adenoma/patologia , Animais , Carcinoma/diagnóstico , Carcinoma/patologia , Doenças do Cão/patologia , Cães , Neoplasias Palpebrais/diagnóstico , Neoplasias Palpebrais/patologia , Feminino , Granuloma/diagnóstico , Granuloma/patologia , Granuloma/veterináriaRESUMO
A neutered male Mexican Hairless dog was presented for generalized weight loss and weakness. Initial laboratory testing and diagnostic imaging revealed thrombocytopenia and an interstitial to miliary lung pattern affecting all lung fields. Mild joint effusion was found on physical examination affecting the stifle, tarsal, carpal, and elbow joints. Examination of synovial fluid demonstrated an inflammatory polyarthropathy in 3 joints. Cytocentrifuged and direct preparations of the bronchoalveolar lavage (BAL) fluid sample were made and cells consistent with lupus erythematosus (LE) cells and ragocytes were found. Based on these findings, the anti-nuclear antibody (ANA) titer was determined as 1:640. A clinical diagnosis of systemic LE was made based on the satisfaction of 2 major criteria (thrombocytopenia and inflammatory polyarthritis), 4 minor criteria (central nervous system signs, lymphadenopathy, fever of unknown origin, and pleuritis), positive ANA titer, and the identification of presumed LE cells in BAL fluid. This case report highlights a novel finding of LE cells in respiratory secretions and provides a review of diagnostic criteria of systemic LE.
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Líquido da Lavagem Broncoalveolar/citologia , Doenças do Cão/diagnóstico , Lúpus Eritematoso Sistêmico/veterinária , Animais , Doenças do Cão/patologia , Cães , Lúpus Eritematoso Sistêmico/diagnóstico , Lúpus Eritematoso Sistêmico/patologia , MasculinoRESUMO
A 15-year-old female blue and gold macaw ( Ara ararauna) was presented for evaluation after being found laterally recumbent, reluctant to move, and lethargic. Results of a complete blood count showed an increased number of immature heterophils with increased cytoplasmic basophilia and degranulation and the presence of a left shift. Radiographs and a computed tomography scan were performed and revealed a markedly enlarged spleen. An ultrasound-guided fine-needle aspirate of the spleen was submitted for cytologic examination and aerobic bacterial culture. While the culture revealed no growth, cytologic examination identified mononuclear phagocytes with cytoplasmic vacuoles containing structures consistent with bacteria. Pan-bacterial 16S rRNA polymerase chain reaction of the splenic sample followed by direct sequencing identified a Coxiella-like agent identical to one previously isolated in the liver of a golden-mantled rosella ( Platycercus eximius). Phylogenetic analysis shows that avian coxiellosis agents and Coxiella burnetii, the agent of Q fever, represent 2 independent events of development of vertebrate pathogenicity in this group of tick endosymbionts. This report suggests diagnostic and treatment directions for coxiellosis in avian patients and indicates where further study is needed.
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Doenças das Aves/microbiologia , Coxiella/isolamento & purificação , Infecções por Bactérias Gram-Negativas/veterinária , Papagaios , Animais , Doenças das Aves/diagnóstico , Coxiella/classificação , Evolução Fatal , Feminino , Infecções por Bactérias Gram-Negativas/diagnóstico , Infecções por Bactérias Gram-Negativas/microbiologiaRESUMO
Investigators from Necker Enfants Malades Hospital, Sorbonne Paris Cite University, Raymond Poincare University, and Paris Descartes University studied motor neuron function in children with Dravet syndrome (DS).
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Inhalant abuse is the intentional inhalation of a volatile substance for the purpose of achieving an altered mental state. As an important, yet underrecognized form of substance abuse, inhalant abuse crosses all demographic, ethnic, and socioeconomic boundaries, causing significant morbidity and mortality in school-aged and older children. This review presents current perspectives on epidemiology, detection, and clinical challenges of inhalant abuse and offers advice regarding the medical and mental health providers' roles in the prevention and management of this substance abuse problem. Also discussed is the misuse of a specific "over-the-counter" dissociative, dextromethorphan.
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Antitussígenos/efeitos adversos , Antitussígenos/intoxicação , Dextrometorfano/intoxicação , Abuso de Inalantes/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Humanos , Abuso de Inalantes/prevenção & controle , Transtornos Relacionados ao Uso de Substâncias/mortalidadeRESUMO
In this paper we describe the validation of two scales constructed to measure pre-university students' changing disposition (i) to enter Higher Education (HE) and (ii) to further study mathematically-demanding subjects. Items were selected drawing on interview data, and on a model of disposition as socially- as well as self- attributed. Rasch analyses showed that the two scales each produce robust one-dimensional measures on what we call a 'strength of commitment to enter HE' and 'disposition to study mathematically-demanding subjects further' respectively. However, the former scale was initially found to suffer psychometrically from a ceiling effect, which we 'corrected' by adding some harder items at a later data point, and revised the scale according to our interpretation of subsequent results. We finally discuss the potential significance of the constructed measures of learning outcomes, as variables in monitoring or even explaining students' progress into different subjects in HE.
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Algoritmos , Interpretação Estatística de Dados , Avaliação Educacional/métodos , Modelos Estatísticos , Psicometria/métodos , Inquéritos e Questionários , Simulação por Computador , Tamanho da AmostraRESUMO
This ex vivo human percutaneous absorption study evaluated a set of six model drugs (ketamine hydrochloride, bupivacaine hydrochloride, diclofenac sodium, gabapentin, orphenadrine citrate, pentoxifylline) from two popular formulations for topically applied compounding preparations. The compounded preparations used in this study were Versatile cream and a reference cream. Each formulation was applied to human trunk skin mounted on Franz Diffusion Cells, 50 mg/chamber (or 28.2 mg/cm2). Serial dermal receiver solutions were collected for 48 hours. Analysis of the resultant data supports the concept that the Versatile base formulation provides improved characteristics relative to the reference base. This is of key importance where the patient does not show clinical improvement when a conventional topical delivery vehicle is used in the formulation. From the results, it is reasonable to anticipate that, relative to the reference formulation, the Versatile formulation provides enhanced transdermal delivery of some analgesic medications.
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Analgésicos/farmacocinética , Absorção Cutânea , Administração Cutânea , Aminas/farmacocinética , Analgésicos/administração & dosagem , Bupivacaína/farmacocinética , Química Farmacêutica , Ácidos Cicloexanocarboxílicos/farmacocinética , Diclofenaco/farmacocinética , Gabapentina , Humanos , Ketamina/farmacocinética , Pomadas , Orfenadrina/farmacocinética , Pentoxifilina/farmacocinética , Ácido gama-Aminobutírico/farmacocinéticaRESUMO
PURPOSE: Vorapaxar is an orally active protease-activated receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet aggregation. This open-label study assessed the pharmacokinetics and pharmacodynamics of single-dose warfarin in the presence/absence of multiple-dose vorapaxar in 12 healthy men. METHODS: Subjects received two treatments separated by ≥ 7-day washout: Treatment A warfarin 25 mg (Day 1); Treatment B vorapaxar 2.5 mg/day on Days 1-6 and vorapaxar 40 mg coadministered with warfarin 25 mg (Day 7). R-warfarin, S-warfarin, and prothrombin time (PT) were assayed predose and up to 120 h postdose. RESULTS: The geometric mean ratio (GMR) as a percentage (warfarin + vorapaxar/warfarin) was calculated. The GMR (90 % CIs) estimates of C(max) were 105 (99, 111) and 105 (99, 112) for R- and S-warfarin, respectively. The GMR (90 % CIs) estimates of AUC(0-∞) were 108 (101, 116) and 105 (96, 115) for R- and S-warfarin, respectively. The GMR (95 % CIs) estimates of AUC(0-120 h) for PT and INR were 97 (95, 98) and 96 (94, 98), respectively. CONCLUSION: Results of this study indicate that vorapaxar has no meaningful effect on the pharmacokinetics or pharmacodynamics of warfarin, suggesting that the coadministration of these two drugs or vorapaxar coadministered with other CYP2C9/CYP2C19 substrates is unlikely to cause a clinically significant pharmacokinetic drug interaction.
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Anticoagulantes/farmacocinética , Lactonas/farmacologia , Inibidores da Agregação Plaquetária/farmacologia , Piridinas/farmacologia , Receptor PAR-1/antagonistas & inibidores , Varfarina/farmacocinética , Adolescente , Adulto , Anticoagulantes/efeitos adversos , Anticoagulantes/sangue , Anticoagulantes/farmacologia , Disponibilidade Biológica , Interações Medicamentosas , Monitoramento de Medicamentos , Meia-Vida , Humanos , Coeficiente Internacional Normatizado , Lactonas/efeitos adversos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Tempo de Protrombina , Piridinas/efeitos adversos , Estatística como Assunto , Estereoisomerismo , Varfarina/efeitos adversos , Varfarina/sangue , Varfarina/farmacologia , Adulto JovemRESUMO
Many public and private genome-wide association studies that we have analyzed include flaws in design, with avoidable confounding appearing as a norm rather than the exception. Rather than recognizing flawed research design and addressing that, a category of quality-control statistical methods has arisen to treat only the symptoms. Reflecting more deeply, we examine elements of current genomic research in light of the traditional scientific method and find that hypotheses are often detached from data collection, experimental design, and causal theories. Association studies independent of causal theories, along with multiple testing errors, too often drive health care and public policy decisions. In an era of large-scale biological research, we ask questions about the role of statistical analyses in advancing coherent theories of diseases and their mechanisms. We advocate for reinterpretation of the scientific method in the context of large-scale data analysis opportunities and for renewed appreciation of falsifiable hypotheses, so that we can learn more from our best mistakes.
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Estudo de Associação Genômica Ampla/métodos , Bioestatística , Coleta de Dados , Interpretação Estatística de Dados , Estudo de Associação Genômica Ampla/estatística & dados numéricos , Humanos , Modelos GenéticosRESUMO
Alitretinoin (9-cis-retinoic acid) is an FDA-approved topical therapy for the treatment of Kaposi sarcoma. Alitretinoin is a naturally occurring endogenous retinoid that binds to and activates all known intracellular retinoic acid receptor (RAR) subtypes alpha, beta, and gamma and retinoic X receptor (RXR) subtypes alpha, beta, and gamma. Photoaging of the skin is the result of accumulated exposure to solar UV radiation. Several topically applied retinoids have been proven clinically effective for treating the appearance of photoaging. Tretinoin and tazarotene, which have been shown to improve photodamaged skin, bind RAR subtypes only. The theoretic benefit of alitretinoin gel 0.1% (Panretin) in the treatment of photoaged skin stems from the binding and activation of both RARs and RXRs, which promote the repair mechanisms in damaged skin. The objective of this study was to evaluate the safety and efficacy of topical alitretinoin gel 0.1% in the treatment of photodamaged skin. The treatment was well tolerated by participants (N=20) and subjectively showed improvement of benign skin lesions (eg, seborrheic keratoses) and precancerous lesions (eg, actinic keratoses). Larger, blinded, controlled trials are needed to investigate the role of this novel retinoid in the treatment of photoaging.
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Envelhecimento da Pele/efeitos dos fármacos , Tretinoína/administração & dosagem , Administração Tópica , Idoso , Alitretinoína , Feminino , Géis , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Resultado do Tratamento , Tretinoína/efeitos adversosRESUMO
BACKGROUND: Botulinum toxin type B (BTX-B, Myobloc, San Francisco, CA, USA) was FDA-approved for the treatment of cervical dystonia in December 2000. It has since been used off-label for the treatment of axillary hyperhidrosis. However, there are sparse data in the medical literature evaluating the safety and efficacy of Myobloc (botulinum toxin type B) for this indication. OBJECTIVE: To assess the safety, efficacy and duration of action of Myobloc (botulinum toxin type B) in the treatment of bilateral axillary hyperhidrosis. METHODS: This study was a double-blinded, randomized, pilot study conducted in an outpatient office setting at a private academic medical center beginning in November 2001. Twenty-three male and female volunteers between the ages of 18 and 80 were screened for participation; 20 participants with primary axillary hyperhidrosis were enrolled. Participants were injected subcutaneously with either Myobloc (botulinum toxin type B) (2500 U, or 0.5 ml, per axilla) or 0.5 ml vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/ml human albumin) into bilateral axillae. Participants who received placebo were rolled over and received Myobloc (botulinum toxin type B) at subsequent visits. All participants were followed until sweating returned to baseline levels. This trial was initially conceived as a placebo-controlled study; however, owing to the insufficient size of the placebo group, the placebo arm of this trial was dropped during data analysis. The main outcome measures were safety, efficacy, and duration of effect. RESULTS: According to participant assessment of axillary hyperhidrosis improvement (A-HI) and quality of life (A-HQOL) scores and the physician assessment scores, a significant difference was observed in treatment response at Day 30 in the participants receiving Myobloc (botulinum toxin type B) injections. Duration of action ranged from 2.2 to 8.1 months (mean 5.0 months). The adverse event profile included bruising, flu-like symptoms, and dry eyes. CONCLUSION: Myobloc (botulinum toxin type B) proved to be safe and efficacious for the treatment of bilateral axillary hyperhidrosis. More studies are needed to assess the duration of response using different doses of Myobloc (botulinum toxin type B).
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Toxinas Botulínicas/uso terapêutico , Hiperidrose/tratamento farmacológico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila , Toxinas Botulínicas/administração & dosagem , Toxinas Botulínicas Tipo A , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Injeções Subcutâneas , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Palmar hyperhidrosis is a problem of unknown etiology that affects patients both socially and professionally. Botulinum toxin type B (Myobloc), approved by the Food and Drug Administration for use in the treatment of cervical dystonia in the United States in December 2000, has subsequently been used effectively in an off-label indication to treat hyperhidrosis. There are sparse data, however, in the literature evaluating the safety and efficacy of BTX-B for the treatment of palmar hyperhidrosis. OBJECTIVE: We evaluated the safety and efficacy of Myobloc in the treatment of bilateral palmar hyperhidrosis. This was a double-blind, randomized, placebo-controlled study to report on the safety and efficacy of Myobloc. METHODS: Twenty participants (10 men, 10 women) diagnosed with palmar hyperhidrosis were injected with either Myobloc (5,000 U per palm) or a 1.0 mL vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/mL human albumin) into bilateral palms (15 Myobloc, 5 placebo). The participants were followed until sweating returned to baseline levels. The main outcome measures were safety, efficacy versus placebo, and duration of effect. RESULTS: A significant difference was found in treatment response at day 30, as determined by participant assessments, between 15 participants injected with Myobloc and 3 participants injected with placebo. The duration of action, calculated in the 17 participants who received Myobloc injections and completed the study, ranged from 2.3 to 4.9 months, with a mean duration of 3.8 months. The single most reported adverse event was dry mouth or throat, which was reported by 18 of 20 participants. The adverse event profile also included indigestion or heartburn (60%), excessively dry hands (60%), muscle weakness (60%), and decreased grip strength (50%). CONCLUSION: Myobloc proved to be efficacious for the treatment of palmar hyperhidrosis. Myobloc had a rapid onset, with most participants responding within 1 week. The duration of action ranged from 2.3 to 4.9 months, with a mean of 3.8 months. The adverse event profile included dry mouth, indigestion or heartburn, excessively dry hands, muscle weakness, and decreased grip strength.
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Toxinas Botulínicas , Toxinas Botulínicas/uso terapêutico , Hiperidrose/tratamento farmacológico , Metaloendopeptidases/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Toxinas Botulínicas/efeitos adversos , Toxinas Botulínicas Tipo A , Método Duplo-Cego , Feminino , Humanos , Masculino , Metaloendopeptidases/efeitos adversos , Pessoa de Meia-Idade , Projetos Piloto , Qualidade de VidaRESUMO
Myobloc, known as Neurobloc in Europe, is a member of the botulinum toxin family. It has been used for a myriad of problems since its approval in the United States in December 2000. It is currently not approved for cosmetic use but has been used for this purpose. This article reviews what is currently known about botulinum toxin type B and its efficacy and safety.