RESUMO
Prescription opioids are the gold standard for treating moderate to severe pain despite their well-documented adverse effects. Of all prescription medications, opioids are abused most widely, and fatal overdoses have reached epidemic levels. One strategy for improving the margin of safety of opioids is combining them with non-opioid drugs to decrease the opioid dose needed for pain relief, thereby reducing adverse effects that occur with larger doses. The N-methyl-D-aspartate receptor antagonist ketamine has been used safely as an analgesic but only under a very limited range of conditions. The current studies characterized the antinociceptive, behavioral suppressant, and gastrointestinal effects of morphine and ketamine alone and in mixtures to determine their interaction in 24 adult male Sprague-Dawley rats (nâ =â 8 per assay). Given alone, both morphine and ketamine produced antinociception, decreased responding for food, and reduced gastrointestinal transit (i.e. produced constipation). The effects of morphine:ketamine mixtures generally were additive, except for the antinociceptive effects of 1:1 mixtures for which the difference in slope (i.e. non-parallel shift) between the observed and predicted effects suggested synergy at smaller doses and additivity at larger doses. The potency of morphine to produce constipation was not enhanced by administration of morphine:ketamine mixtures with antinociceptive effects. The nature of the interaction between morphine and ketamine for adverse effects such as dependence, withdrawal, abuse, or respiratory depression remains unknown but also might be related to the ratio of each drug in mixtures. It will be important to identify conditions that produce the largest potential therapeutic window in humans.
Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Ketamina , Adulto , Humanos , Masculino , Ratos , Animais , Morfina/efeitos adversos , Ketamina/efeitos adversos , Ratos Sprague-Dawley , Analgésicos Opioides/efeitos adversos , Dor/tratamento farmacológicoRESUMO
BACKGROUND: Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations. RESULTS: Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty. CONCLUSIONS: Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Beleza , Face , Povo Asiático , Atitude , Consenso , Estética , HumanosRESUMO
BACKGROUND: The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience. RESULTS: The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to[55 years are presented. CONCLUSIONS: In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages. LEVEL OF EVIDENCE V: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Assuntos
Técnicas Cosméticas , Preenchedores Dérmicos , Idoso , Povo Asiático , Consenso , Estética , Humanos , Pessoa de Meia-Idade , RejuvenescimentoRESUMO
BACKGROUND: Historically, the majority of insertable cardiac monitor (ICM) procedures were performed in the cardiac catheterization (cath) lab, electrophysiology (EP) lab, or operating room (OR). The miniaturization of ICMs allows the procedure to be relocated within the hospital without compromising patient safety. We sought to estimate the rate of untoward events associated with procedures performed within the hospital but outside the traditional settings and to characterize resource utilization, procedure time intervals, and physician experience. METHODS: The Reveal LINQ in-Office 2 (RIO 2) International study was a single arm, multicenter, prospective study. Patients indicated for an ICM and willing to undergo device insertion outside the cath/EP lab or OR were eligible and followed for 90 days after insertion. RESULTS: A total of 191 patients (45.5% female aged 63.8 ± 26.9 years) underwent successful Reveal LINQ ICM insertion at 17 centers in Europe, Canada and Australia. The median total visit duration was 106 min (interquartile range [IQR]: 55-61). Patient preparation and patient education accounted for 10 min (IQR: 5-20) and 10 min (IQR: 8-15) of total visit duration, respectively. Preparation and education occurred in the procedure room for 90.6 and 60.2% of patients, respectively. There were no untoward events (0.0, 95% CI: 0.0-2.1%) though four patients presented with procedure-related adverse events that did not require invasive intervention. Physicians rated procedure location as convenient or very convenient. CONCLUSIONS: The Reveal LINQ™ ICM insertion can be safely and efficiently performed in the hospital outside the cath/EP lab or OR. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02412488 ; registered on April 9, 2015.
Assuntos
Eletrocardiografia Ambulatorial/instrumentação , Procedimentos Cirúrgicos Operatórios , Transdutores , Tecnologia sem Fio/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Austrália , Canadá , Desenho de Equipamento , Europa (Continente) , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Miniaturização , Duração da Cirurgia , Educação de Pacientes como Assunto , Segurança do Paciente , Estudos Prospectivos , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de Tempo , Fluxo de TrabalhoRESUMO
INTRODUCTION: This study evaluated safety and efficacy of onabotulinumtoxinA for moderate to severe glabellar lines (GL) following laser therapy in Chinese subjects. MATERIALS AND METHODS: Subjects (n = 173) were followed for 120 days following a single onabotulinumtoxinA (20 U) treatment for GL after recent laser therapy. Subjects completed validated patient-reported outcomes, including Facial Lines Outcome 11-item (FLO-11) Questionnaire and Facial Lines Satisfaction Questionnaire (FLSQ). Physicians and subjects assessed GL severity at maximum frown and at rest using the Facial Wrinkle Scale with Asian Photonumeric Guide (FWS-A). RESULTS: Mean total FLO-11 scores increased from 47.7 (baseline) to 75.9 (day 120) (p < 0.0001), with mean improvement of at least two grades for most items maintained to day 120. Most subjects were mostly or very satisfied, per the FLSQ. Percentages of subjects with at least one-grade improvement in FWS-A (responders) at maximum frown per subjects and physicians were 93.1% and 97.1%, respectively, at day 30, and 72.3% and 81.5% at day 120 (all, p < 0.0001). More than 70% were FWS-A responders at day 120. All adverse events were mild or moderate; none were related to onabotulinumtoxinA. CONCLUSIONS: A single onabotulinumtoxinA (20 U) treatment following laser therapy was safe and effective in correcting GL for up to 120 days.
Assuntos
Toxinas Botulínicas Tipo A/uso terapêutico , Fármacos Neuromusculares/uso terapêutico , Envelhecimento da Pele/efeitos dos fármacos , Adulto , Povo Asiático , Toxinas Botulínicas Tipo A/efeitos adversos , China , Feminino , Testa , Humanos , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Fármacos Neuromusculares/efeitos adversos , Medidas de Resultados Relatados pelo Paciente , Satisfação do Paciente , Estudos Prospectivos , Ritidoplastia/métodos , Envelhecimento da Pele/efeitos da radiação , Resultado do TratamentoRESUMO
BACKGROUND: Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations. RESULTS: Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty. CONCLUSIONS: Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.
Assuntos
Atitude , Beleza , Face/anatomia & histologia , Adolescente , Adulto , Envelhecimento , Povo Asiático , Formação de Conceito , Feminino , Humanos , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce. METHOD: The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience. RESULTS: The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to >55 years are presented. CONCLUSIONS: In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages. LEVEL OF EVIDENCE V: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Assuntos
Técnicas Cosméticas , Preenchedores Dérmicos , Face , Adolescente , Adulto , Povo Asiático , Preenchedores Dérmicos/administração & dosagem , Feminino , Humanos , Injeções Subcutâneas , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND: There is increasing interest among patients and plastic surgeons for alternatives to rhinoplasty, a common surgical procedure performed in Asia. OBJECTIVES: To evaluate the safety, efficacy, and longevity of a hyaluronic acid filler in the correction of aesthetically detracting or deficient features of the Asian nose. METHODS: Twenty-nine carefully screened Asian patients had their noses corrected with the study filler (Juvéderm VOLUMA [Allergan plc, Dublin, Ireland] with lidocaine injectable gel), reflecting individualized treatment goals and utilizing a standardized injection procedure, and were followed for over 12 months. RESULTS: A clinically meaningful correction (≥1 grade improvement on the Assessment of Aesthetic Improvement Scale) was achieved in 27 (93.1%) patients at the first follow-up visit. This was maintained in 28 (96.6%) patients at the final visit, based on the independent assessments of a central non-injecting physician and the patients. At this final visit, 23 (79.3%) patients were satisfied or very satisfied with the study filler and 25 (86.2%) would recommend it to others. In this small series of patients, there were no serious adverse events (AEs), with all treatment-related AEs being mild to moderate, transient injection site reactions, unrelated to the study filler. CONCLUSIONS: Using specific eligibility criteria, individualized treatment goals, and a standardized injection procedure, the study filler corrected aesthetically detracting or deficient features of the Asian nose, with the therapeutic effects lasting for over 12 months, consistent with a high degree of patient satisfaction. This study supports the safety and efficacy of this HA filler for specific nose augmentation procedures in selected Asian patients. LEVEL OF EVIDENCE 3: Therapeutic.
Assuntos
Técnicas Cosméticas , Ácido Hialurônico/análogos & derivados , Nariz , Satisfação do Paciente/estatística & dados numéricos , Adulto , Ásia , Fármacos Dermatológicos/administração & dosagem , Estética , Feminino , Seguimentos , Humanos , Ácido Hialurônico/administração & dosagem , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The characteristics of atrial fibrillation (AF) episodes in cryptogenic stroke patients have recently been explored in carefully selected patient populations. However, the incidence of AF among a large, real-world population of patients with an insertable cardiac monitor (ICM) placed for the detection of AF following a cryptogenic stroke has not been investigated. METHODS: Patients in the de-identified Medtronic DiscoveryLink™ database who received an ICM (Reveal LINQ™) for the purpose of AF detection following a cryptogenic stroke were included. AF detection rates (episodes ≥2 min) were quantified using Kaplan-Meier survival estimates at 1 and 6 months and compared to the CRYSTAL AF study at 6 months. The time to AF detection and maximum duration of AF episodes were also analyzed. RESULTS: A total of 1,247 patients (age 65.3 ± 13.0 years) were followed for 182 (IQR 182-182) days. A total of 1,521 AF episodes were detected in 147 patients, resulting in AF detection rates of 4.6 and 12.2% at 30 and 182 days, respectively, and representing a 37% relative increase over that reported in the CRYSTAL AF trial at 6 months. The median time to AF detection was 58 (IQR 11-101) days and the median duration of the longest detected AF episode was 3.4 (IQR 0.4-11.8) h. CONCLUSIONS: The real-world incidence of AF among patients being monitored with an ICM after a cryptogenic stroke validates the findings of the CRYSTAL AF trial and suggests that continuous cardiac rhythm monitoring for periods longer than the current guideline recommendation of 30 days may be warranted in the evaluation of patients with cryptogenic stroke.
Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Doenças Cardiovasculares/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Eletrocardiografia Ambulatorial/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Fatores de TempoRESUMO
BACKGROUND: Eyelashes of Asians differ from those of Caucasians in morphology and growth characteristics. Ethnic differences also exist for the tolerability profile of prostaglandin analogues. OBJECTIVE: To evaluate the long-term utility and durability of bimatoprost 0.03% in eyelash augmentation in Asian females. METHODS: One cohort received bimatoprost 0.03% for 36 weeks and another for 20 weeks, with the latter cohort followed for 16 weeks after treatment cessation. The primary endpoint was the percent change in eyelash length at week 20. Secondary measures included percent change in eyelash thickness and darkness, physician's Global Eyelash Assessment and patient satisfaction. RESULTS: At week 20, eyelash length was enhanced in a time-dependent manner, with maximum improvement achieved (19.3%; p < 0.0001). Significant improvements in thickness and darkness were also achieved (22.9%, 6.0%; p < 0.0001). 77.8% of subjects improved by ≥1 grade on Global Eyelash Assessment, with 83.1% satisfied/very satisfied. Improvements were maintained with ongoing treatment to 36 weeks, while these effects were progressively lost with discontinuation. CONCLUSION: Bimatoprost 0.03% safely enhanced eyelashes in Asian females, maintained with ongoing treatment. Cessation of treatment was associated with progressive loss of effects.
Assuntos
Amidas/administração & dosagem , Povo Asiático/estatística & dados numéricos , Cloprostenol/análogos & derivados , Pestanas/efeitos dos fármacos , Pestanas/crescimento & desenvolvimento , Administração Tópica , Adulto , Análise de Variância , Bimatoprost , Cloprostenol/administração & dosagem , Estudos de Coortes , Técnicas Cosméticas , Relação Dose-Resposta a Droga , Esquema de Medicação , Estética , Feminino , Humanos , Assistência de Longa Duração , Segurança do Paciente , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , SingapuraRESUMO
This study assesses characteristics of the normalized compression distance (NCD) technique for building phylogenetic trees from molecular data. We examined results from a mammalian biological data set as well as a collection of simulated data with varying levels of incomplete lineage sorting. The implementation of NCD we analyze is a concatenation-based, distance-based, alignment-free, and model-free phylogeny estimation method, which takes concatenated unaligned sequence data as input and outputs a matrix of distances. We compare the NCD phylogeny estimation method with various other methods, including coalescent- and concatenation-based methods.
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Compressão de Dados , Doenças não Transmissíveis , Animais , Filogenia , Simulação por Computador , MamíferosRESUMO
Background Diagnosis of shockable rhythms leading to defibrillation remains integral to improving out-of-hospital cardiac arrest outcomes. New machine learning techniques have emerged to diagnose arrhythmias on ECGs. In out-of-hospital cardiac arrest, an algorithm within an automated external defibrillator is the major determinant to deliver defibrillation. This study developed and validated the performance of a convolution neural network (CNN) to diagnose shockable arrhythmias within a novel, miniaturized automated external defibrillator. Methods and Results There were 26 464 single-lead ECGs that comprised the study data set. ECGs of 7-s duration were retrospectively adjudicated by 3 physician readers (N=18 total readers). After exclusions (N=1582), ECGs were divided into training (N=23 156), validation (N=721), and test data sets (N=1005). CNN performance to diagnose shockable and nonshockable rhythms was reported with area under the receiver operating characteristic curve analysis, F1, and sensitivity and specificity calculations. The duration for the CNN to output was reported with the algorithm running within the automated external defibrillator. Internal and external validation analyses included CNN performance among arrhythmias, often mistaken for shockable rhythms, and performance among ECGs modified with noise to mimic artifacts. The CNN algorithm achieved an area under the receiver operating characteristic curve of 0.995 (95% CI, 0.990-1.0), sensitivity of 98%, and specificity of 100% to diagnose shockable rhythms. The F1 scores were 0.990 and 0.995 for shockable and nonshockable rhythms, respectively. After input of a 7-s ECG, the CNN generated an output in 383±29 ms (total time of 7.383 s). The CNN outperformed adjudicators in classifying atrial arrhythmias as nonshockable (specificity of 99.3%-98.1%) and was robust against noise artifacts (area under the receiver operating characteristic curve range, 0.871-0.999). Conclusions We demonstrate high diagnostic performance of a CNN algorithm for shockable and nonshockable rhythm arrhythmia classifications within a digitally connected automated external defibrillator. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03662802; Unique identifier: NCT03662802.
Assuntos
Reanimação Cardiopulmonar , Parada Cardíaca Extra-Hospitalar , Humanos , Parada Cardíaca Extra-Hospitalar/diagnóstico , Parada Cardíaca Extra-Hospitalar/terapia , Estudos Retrospectivos , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/terapia , Desfibriladores , Algoritmos , Eletrocardiografia , Redes Neurais de Computação , Reanimação Cardiopulmonar/métodosRESUMO
Diagnosing cardiac pauses that could produce syncopal episodes is important to guide appropriate therapy. However, the infrequent nature of these episodes can make detection challenging with conventional monitoring (CM) strategies with short-term ECG monitors. Insertable cardiac monitors (ICMs) continuously monitor for arrhythmias but present a higher up-front cost. It is not well understood whether these higher costs are offset by the costs of repeat evaluation in CM strategies. We simulated the likelihood of diagnostic success and cost-per-diagnosis of pause arrhythmias with CM strategies compared to ICM monitoring. ICM device data from syncope patients diagnosed with pause arrhythmias was utilized to simulate patient pathways and diagnostic success with CM. We assumed that detected true pause episodes (≥5 seconds) were symptomatic and prompted a hospital encounter and further evaluation with CM. Subsequent true pause episodes in yet-undiagnosed patients triggered additional rounds of CM. Costs of monitoring were accrued at each encounter and represent the U.S. payer perspective. Cost per diagnosed patient was calculated as the total costs accrued for all patients divided by the number of patients diagnosed, across 1,000 simulations. During a mean 505±333 days of monitoring ICM detected 2.4±2.7 pause events per patient, with an average of 109±94 days until the first event. CM was projected to diagnose between 13.8% (24-hour Holter) and 30.2% (two 30-day monitors) of the ICM-diagnosed patients. Total diagnostic costs per ICM-diagnosed patient averaged $7,847, whereas in the CM strategies average cost-per-diagnosis ranged from $12,950±2,589 with 24-hour Holter to $32,977±14,749 for two 30-day monitors. Relative to patients diagnosed with pause arrhythmias via ICM, CM strategies diagnose fewer patients and incur higher costs per diagnosed patient.
Assuntos
Fibrilação Atrial , Eletrocardiografia Ambulatorial , Fibrilação Atrial/diagnóstico , Eletrocardiografia , Humanos , Síncope/diagnósticoRESUMO
INTRODUCTION: This exploratory study was designed to assess the availability, price, and point-of-purchase marketing strategies for new smokeless tobacco products in 4 test market areas. METHODS: A random sample of 50 gas stations, convenience and food stores, and tobacco shops was selected in each of 4 test market areas. Pairs of observers visited each store, recorded product information, and engaged vendors in conversation about product demand. RESULTS: Snus was available in 64% of the stores, but availability and price differed by brand. Point-of-purchase marketing also varied by brand on a variety of dimensions and all brands appeared to be marketed primarily to smokers. Camel Snus was described by store attendants as having the highest demand and was also the most expensive of the observed products. In light of the number of test market cities and intensity of promotion at retail locations, Camel Snus was the most intensively marketed product. DISCUSSION: The results appear to reflect differences in marketing strategy by American snus manufacturers. These strategies may help to predict future marketing of snus and other tobacco products and may provide a baseline for later assessments of product acceptance.
Assuntos
Marketing , Tabaco sem Fumaça , Cidades , Humanos , Estados UnidosRESUMO
Background: Previous studies support operational benefits when moving insertable cardiac monitor (ICM) insertions outside the cardiac catheterization/electrophysiology laboratories, but this has not been directly assessed in a randomized trial or when the procedure is specifically moved to the office setting. To gain insight, the RIO 2 US study collected resource utilization and procedure time intervals for ICM insertion in-office and in-hospital and these data were used to calculate costs associated with staff time and supply use in each setting.Methods and results: The Reveal LINQ In-Office 2 US study (randomized [1:1], multicenter, unblinded) included 482 patients to undergo insertion of the ICM in-hospital (in an operating room or CATH/EP laboratory) (n = 251) or in-office (n = 231). Detailed information on resource utilization was collected prospectively by the study and used to compare resource utilization and procedure time intervals during ICM insertion procedures performed in-office vs. in-hospital. In addition, costs associated with staff time and supply use in each setting were calculated retrospectively. Total visit duration (check-in to discharge) was 107 min shorter in-office vs. in-hospital (95% CI = 97-116 min; p < 0.001). Patient preparation and education in-office were more likely to occur in the same room as the procedure, compared with in-hospital (91.6% vs. 34.2%, p < 0.001 and 87.3% vs. 22.1%, p < 0.001, respectively). There was a reduction in registered nurse and cardiovascular/operating room technologist involvement in-office, accompanied by higher physician and medical assistant participation. Overall staff time spent per case was 75% higher in-hospital, leading to 50% higher staffing costs compared to in-office.Conclusions: ICM insertion in a physician's office vs. a hospital setting resulted in reduced patient visit time and reduced overall staff time, with a consequent reduction in staffing costs. Clinical trial registration: ClinicalTrials.gov NCT02395536.
Assuntos
Desfibriladores Implantáveis , Recursos em Saúde , Miniaturização , Consultórios Médicos , Centro Cirúrgico Hospitalar , Procedimentos Cirúrgicos Operatórios/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Segurança do PacienteRESUMO
BACKGROUND: Middle Eastern women worldwide increasingly seek aesthetic treatment to enhance their beauty and improve self-esteem, but literature describing standards of beauty across the Middle East are scarce. Knowledge of facial anthropometry and Middle Eastern subregional beauty preferences and aesthetic weaknesses are key to develop an effective facial enhancement strategy that does not jeopardize ethnic identity or facial harmony. METHODS: Dermatologists and plastic surgeons from 8 Middle Eastern countries who had 7.5-25 (mean 13.5) years of experience in aesthetic medicine examined female Middle Eastern beauty in 4 geographic subregions: the Gulf (comprising Bahrain, Kuwait, Saudi Arabia, and the United Arab Emirates), Iran, Lebanon, and Egypt. They developed consensus opinions regarding facial beauty, aesthetic deficiencies, and injectable treatment solutions. RESULTS: Facial anthropometry differs between Middle Eastern and Western women, and also within the region. Although subregional differences are seen, beauty is generally recognized by an oval or round face; temple fullness; pronounced, elevated, arched eyebrows; large almond-shaped eyes; well-defined, laterally full cheeks; a small, straight nose; full lips; a well-defined jawline; and a prominent, pointed chin. The relative prominence of the nose necessitates attention to the lips and the shape and projection of the chin. Aging is often accompanied by midface sagging that leads to increased heaviness in the lower facial third. CONCLUSIONS: Middle Eastern beauty is characterized by striking eyes, defined cheeks, and full lips. These consensus opinions inform aesthetic practitioners who treat Middle Eastern women worldwide about their aesthetic ideals and the implications for treatment.
RESUMO
We studied the effect of injecting botulinum toxin A (BTX-A) into the pars ciliaris--also known as Riolan's muscle--of patients with eyelid apraxia (ELA). Six patients with ELA were treated with injections of BTX-A into the region of Riolan's muscle at the medial and lateral portions of the upper and lower pretarsal orbicularis oculi. Clinical benefit was seen in all 6 patients, 2 of whom had previously been treated with conventional pretarsal injections of BTX-A and had not improved. BTX-A injections into Riolan's muscle are effective as treatment for ELA. The proposed mechanism is not that of muscle relaxation but rather modulation of the somatosensory cortex, similar to that of a 'sensory trick' in patients with dystonia.
Assuntos
Apraxias/tratamento farmacológico , Toxinas Botulínicas Tipo A/uso terapêutico , Pálpebras , Fármacos Neuromusculares/uso terapêutico , Músculos Oculomotores/inervação , Idoso , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Injeções Intramusculares , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
BACKGROUND: Undersensing of premature ventricular beats and low-amplitude R waves are primary causes for inappropriate bradycardia and pause detections in insertable cardiac monitors (ICMs). OBJECTIVE: The purpose of this study was to develop and validate an enhanced algorithm to reduce inappropriately detected bradycardia and pause episodes. METHODS: Independent data sets to develop and validate the enhanced algorithm were derived from a database of ICM-detected bradycardia and pause episodes in de-identified patients monitored for unexplained syncope. The original algorithm uses an auto-adjusting sensitivity threshold for R-wave sensing to detect tachycardia and avoid T-wave oversensing. In the enhanced algorithm, a second sensing threshold is used with a long blanking and fixed lower sensitivity threshold, looking for evidence of undersensed signals. Data reported includes percent change in appropriate and inappropriate bradycardia and pause detections as well as changes in episode detection sensitivity and positive predictive value with the enhanced algorithm. RESULTS: The validation data set, from 663 consecutive patients, consisted of 4904 (161 patients) bradycardia and 2582 (133 patients) pause episodes, of which 2976 (61%) and 996 (39%) were appropriately detected bradycardia and pause episodes. The enhanced algorithm reduced inappropriate bradycardia and pause episodes by 95% and 47%, respectively, with 1.7% and 0.6% reduction in appropriate episodes, respectively. The average episode positive predictive value improved by 62% (P < .001) for bradycardia detection and by 26% (P < .001) for pause detection, with an average relative sensitivity of 95% (P < .001) and 99% (P = .5), respectively. CONCLUSION: The enhanced dual sense algorithm for bradycardia and pause detection in ICMs substantially reduced inappropriate episode detection with a minimal reduction in true episode detection.
Assuntos
Bradicardia/diagnóstico , Eletrocardiografia Ambulatorial , Eletrodos Implantados , Síncope , Idoso , Algoritmos , Bradicardia/complicações , Erros de Diagnóstico/prevenção & controle , Precisão da Medição Dimensional , Eletrocardiografia Ambulatorial/efeitos adversos , Eletrocardiografia Ambulatorial/instrumentação , Eletrocardiografia Ambulatorial/métodos , Eletrodos Implantados/efeitos adversos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Síncope/diagnóstico , Síncope/etiologia , Estados UnidosRESUMO
BACKGROUND: Recent miniaturization of an insertable cardiac monitor (ICM) may make it possible to move device insertion from a hospital to office setting. However, the safety of this strategy is unknown. OBJECTIVES: The primary objective was to compare the safety of inserting the Reveal LINQ ICM in an office vs a hospital environment. Ancillary objectives included summarizing device- and procedure-related adverse events and responses to a physician questionnaire. METHODS: Five hundred twenty-one patients indicated for an ICM were randomized (1:1 ratio) to undergo ICM insertion in a hospital or office environment at 26 centers in the United States in the Reveal LINQ In-Office 2 study (ClinicalTrials.gov identifier NCT02395536). Patients were followed for 90 days. RESULTS: ICM insertion was successful in all 482 attempted patients (office: 251; hospital: 231). The untoward event rate (composite of unsuccessful insertion and ICM- or insertion-related complications) was 0.8% (2 of 244) in the office and 0.9% (2 of 227) in the hospital (95% confidence interval, -3.0% to 2.9%; 5% noninferiority: P < .001). In addition, adverse events occurred during 2.5% (6 of 244) of office and 4.4% (10 of 227) of hospital insertions (95% confidence interval [office minus inhospital rates], -5.8% to 1.9%; 5% noninferiority: P < .001). Physicians indicated that for procedures performed in an office vs a hospital, there were fewer delays >15 minutes (16% vs 35%; P < .001) and patient response was more often "very positive." Physicians considered the office location "very convenient" more frequently than the hospital location (85% vs 27%; P < .001). CONCLUSION: The safety profile for the insertion of the Reveal LINQ ICM is excellent irrespective of insertion environment. These results may expand site of service options for LINQ insertion.
Assuntos
Arritmias Cardíacas/diagnóstico , Eletrocardiografia Ambulatorial , Miniaturização/métodos , Complicações Pós-Operatórias/epidemiologia , Implantação de Prótese , Idoso , Procedimentos Cirúrgicos Ambulatórios/instrumentação , Procedimentos Cirúrgicos Ambulatórios/métodos , Eletrocardiografia Ambulatorial/instrumentação , Eletrocardiografia Ambulatorial/métodos , Meio Ambiente , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Preferência do Paciente/estatística & dados numéricos , Implantação de Prótese/efeitos adversos , Implantação de Prótese/métodos , Estados UnidosRESUMO
BACKGROUND: The long-term incidence of atrial fibrillation (AF) in cryptogenic stroke (CS) patients has been explored in carefully controlled clinical trials but real-world data are limited. We investigated the two-year incidence of AF in real-world clinical practice among a large cohort of patients with an insertable cardiac monitor (ICM) placed for AF detection following CS. METHODS: Patients in the de-identified Medtronic Discovery™ Link database who received an ICM (Reveal LINQ™) for the purpose of AF detection following CS were included and monitored for up to 2years. All detected AF episodes (≥2min) were adjudicated. We quantified the AF detection rate using Kaplan-Meier survival estimates, analyzed the median time to initial detection of AF, and simulated the ability of various intermittent monitoring strategies to detect AF. RESULTS: A total of 1247 patients (65.3±13.0years, 53% male) were included and followed for 579±222days. AF episodes (n=4183) were detected in 238 patients, resulting in an AF detection rate of 21.5% at 2years. The median time to AF detection was 112 [IQR 35-293] days. Intermittent monitoring for AF detection was inferior to continuous ICM monitoring with sensitivities ranging from 2.9% (annual 24-hour Holter) to 29.9% (quarterly 7-day Holters), p<0.001. CONCLUSIONS: AF episodes were detected via continuous monitoring with ICMs in approximately 1 of every 5 CS patients within 2years of follow-up. The vast majority of patients with AF would not have been detected with conventional external ambulatory monitors. ICMs should therefore be considered in the evaluation of CS patients.