Provision of primary care to patients with chronic cough in the community pharmacy setting

BACKGROUND: Community pharmacies are at the forefront of primary care providers and have an important role in the referral of patients to a medical practitioner for review when necessary. Chronic cough is a common disorder in the community and requires medical assessment. The proficiency of community pharmacy staff to refer patients with chronic cough is currently unknown. OBJECTIVE: To assess the ability of community pharmacy staff to recognize and medically refer patients with a chronic nonproductive cough. METHODS: Following ethics approval, a simulated patient study of 156 community pharmacies in Perth, Western Australia, was conducted over a 3-month period. Simulated patients presented to the pharmacy requesting treatment for a cough. The simulated patient required a referral based on a designated scenario. Demographic details, assessment questions, and advice provided were recorded by the simulated patient immediately postvisit. A logistic regression analysis was performed, with referral for medical assessment as the dependent variable. RESULTS: Of the 155 community pharmacies included in the analysis, 38% provided appropriate medical referral. Cough suppressants were provided as therapy in 72% of all visits. Predictors of medical referral were assessment of symptom duration, medical history, current medications being taken, frequency of reliever use, and the position of the pharmacy staff member conducting the consultation. A third of community pharmacies provided appropriate primary care by recommending medical referral advice to patients with chronic cough. The majority of pharmacy staff members acquired information from the patient that suggested a need for medical referral, yet did not provide referral advice. CONCLUSIONS: Appropriate medical referral is more likely when adequate assessment is undertaken and when a pharmacist is directly involved in the consultation. This highlights the need for pharmacies to ensure that processes are in place for patients to access the pharmacist.

Manometry-Based Cough Identification Algorithm

Gastroesophageal reflux disease (GERD) is a common cause of chronic cough. For the diagnosis and treatment of GERD, it is desirable to quantify the temporal correlation between cough and reflux events. Cough episodes can be identified on esophageal manometric recordings as short-duration, rapid pressure rises. The present study aims at facilitating the detection of coughs by proposing an algorithm for the classification of cough events using manometric recordings. The algorithm detects cough episodes based on digital filtering, slope and amplitude analysis, and duration of the event. The algorithm has been tested on in vivo data acquired using a single-channel intra-esophageal manometric probe that comprises a miniature white-light interferometric fiber optic pressure sensor. Experimental results demonstrate the feasibility of using the proposed algorithm for identifying cough episodes based on real-time recordings using a single channel pressure catheter. The presented work can be integrated with commercial reflux pH/impedance probes to facilitate simultaneous 24-hour ambulatory monitoring of cough and reflux events, with the ultimate goal of quantifying the temporal correlation between the two types of events.

A New Approach for Eliminating the Spurious States in Recurrent Neural Networks

As is well known, the Convergence Theorem for the Recurrent Neural Networks, is based in Lyapunov ́s second method, which states that associated to any one given net state, there always exist a real number, in other words an element of the one dimensional Euclidean Space R, in such a way that when the state of the net changes then its associated real number decreases. In this paper we will introduce the two dimensional Euclidean space R2, as the space associated to the net, and we will define a pair of real numbers ( x, y ) , associated to any one given state of the net. We will prove that when the net change its state, then the product x ⋅ y will decrease. All the states whose projection over the energy field are placed on the same hyperbolic surface, will be considered as points with the same energy level. On the other hand we will prove that if the states are classified attended to their distances to the zero vector, only one pattern in each one of the different classes may be at the same energy level. The retrieving procedure is analyzed trough the projection of the states on that plane. The geometrical properties of the synaptic matrix W may be used for classifying the n-dimensional state- vector space in n classes. A pattern to be recognized is seen as a point belonging to one of these classes, and depending on the class the pattern to be retrieved belongs, different weight parameters are used. The capacity of the net is improved and the spurious states are reduced. In order to clarify and corroborate the theoretical results, together with the formal theory, an application is presented.

Recurrent Tibial Tunnel Cyst Formation Following Anterior Cruciate Ligament Reconstruction and Interference Screw Removal

A unique case of a collegiate athlete who suffered an anterior cruciate ligament injury leading to the formation of a synovial cyst is described. The cyst, localized over the tibial tunnel, resulted from irritation caused by the removal of interference screws.

Variable Speed Limit Strategies to Reduce the Impacts of Traffic Flow Breakdown at Recurrent Freeway Bottlenecks

Variable Speed Limit (VSL) strategies identify and disseminate dynamic speed limits that are determined to be appropriate based on prevailing traffic conditions, road surface conditions, and weather conditions. This dissertation develops and evaluates a shockwave-based VSL system that uses a heuristic switching logic-based controller with specified thresholds of prevailing traffic flow conditions. The system aims to improve operations and mobility at critical bottlenecks. Before traffic breakdown occurrence, the proposed VSL’s goal is to prevent or postpone breakdown by decreasing the inflow and achieving uniform distribution in speed and flow. After breakdown occurrence, the VSL system aims to dampen traffic congestion by reducing the inflow traffic to the congested area and increasing the bottleneck capacity by deactivating the VSL at the head of the congested area. The shockwave-based VSL system pushes the VSL location upstream as the congested area propagates upstream. In addition to testing the system using infrastructure detector-based data, this dissertation investigates the use of Connected Vehicle trajectory data as input to the shockwave-based VSL system performance. Since the field Connected Vehicle data are not available, as part of this research, Vehicle-to-Infrastructure communication is modeled in the microscopic simulation to obtain individual vehicle trajectories. In this system, wavelet transform is used to analyze aggregated individual vehicles’ speed data to determine the locations of congestion. The currently recommended calibration procedures of simulation models are generally based on the capacity, volume and system-performance values and do not specifically examine traffic breakdown characteristics. However, since the proposed VSL strategies are countermeasures to the impacts of breakdown conditions, considering breakdown characteristics in the calibration procedure is important to have a reliable assessment. Several enhancements were proposed in this study to account for the breakdown characteristics at bottleneck locations in the calibration process. In this dissertation, performance of shockwave-based VSL is compared to VSL systems with different fixed VSL message sign locations utilizing the calibrated microscopic model. The results show that shockwave-based VSL outperforms fixed-location VSL systems, and it can considerably decrease the maximum back of queue and duration of breakdown while increasing the average speed during breakdown.

Locally recurrent functions, density topologies and algebraic genericity

We study the algebraic and topological genericity of certain subsets of locally recurrent functions, obtaining (among other results) algebrability and spaceability within these classes.

Risk of Recurrent Stillbirth : Systematic Review and Meta-Analysis

Peer reviewed

Locally recurrent functions, density topologies and algebraic genericity

We study the algebraic and topological genericity of certain subsets of locally recurrent functions, obtaining (among other results) algebrability and spaceability within these classes.

Risk of Recurrent Stillbirth : Systematic Review and Meta-Analysis

Peer reviewed

Recurrent CDKN1B (p27) mutations in hairy cell leukemia

Hairy cell leukemia (HCL) is marked by near 100% mutational frequency of BRAFV600E mutations. Recurrent cooperating genetic events that may contribute to HCL pathogenesis or affect the clinical course of HCL are currently not described. Therefore, we performed whole exome sequencing to explore the mutational landscape of purine analog refractory HCL. In addition to the disease-defining BRAFV600E mutations, we identified mutations in EZH2, ARID1A, and recurrent inactivating mutations of the cell cycle inhibitor CDKN1B (p27). Targeted deep sequencing of CDKN1B in a larger cohort of HCL patients identify deleterious CDKN1B mutations in 16% of patients with HCL (n = 13 of 81). In 11 of 13 patients the CDKN1B mutation was clonal, implying an early role of CDKN1B mutations in the pathogenesis of HCL. CDKN1B mutations were not found to impact clinical characteristics or outcome in this cohort. These data identify HCL as having the highest frequency of CDKN1B mutations among cancers and identify CDNK1B as the second most common mutated gene in HCL. Moreover, given the known function of CDNK1B, these data suggest a novel role for alterations in regulation of cell cycle and senescence in HCL with CDKN1B mutations.

Recurrent varicose veins of the lower limbs after surgery. Role of surgical technique (stripping vs. CHIVA) and surgeon’s experience

Background. Surgical treatment of varicose veins of the lower limbs resolves symptoms and improves quality of life. However, the high recurrence (20-80%) is a costly and complex issue. Patients and methods. This is a retrospective review of 1489 patients with varicose vein of the lower limbs seen at our hospital between January 1980 and December 2005. The aim is to evaluate the effect of surgical technique (stripping vs. CHIVA) and surgeon’s experience in reducing recurrences. Results. With experienced surgeons, CHIVA appears to be more effective than stripping in reducing the recurrence rate (p <0.05). However, when performed by an inexperienced surgeon the results are far worse than those achieved with stripping. Conclusion. There was a clear reduction in recurrences at 5-10 years with CHIVA than with conventional stripping. However, if performed incorrectly, results are far worse with CHIVA. In fact, good results are far more difficult to achieve with CHIVA than with stripping, which is repeatable and easy to perform.

Prosthetic carotid bypass graft for in-stent restenosis performed for post-endarterectomy recurrent stenosis: technical details

Aim. Carotid artery stenting (CAS) is the treatment of choice for recurrent stenosis after carotid endarterectomy (CEA). However a significative incidence of in-stent restenosis could be occurred. Despite classical CEA leads to good results, in selective cases bypass graft may be the best treatment of in-stent restenosis. Case reports. We describe two cases of carotid bypass graft performed to treat a recurrent in-stent stenosis after CAS for post-CEA restenosis. No death and cardiac complication occurred and no cranial nerves impairment was detected. Conclusion. Prosthetic bypass graft is safe and effective in treatment of in-stent recurrent restenosis after CEA restenosis.

Risk factors in reoperative thyroid surgery for recurrent goitre. Our experience

Aim. Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed.Method. 106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively. Results. Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%). Conclusions. Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery azardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative hyroidectomy may be performed safely with little morbidity in experienced hands.