A pilot study on quantification of training load: The use of HRV in training practice.

Recent laboratory studies have suggested that heart rate variability (HRV) may be an appropriate criterion for training load (TL) quantification. The aim of this study was to validate a novel HRV index that may be used to assess TL in field conditions. Eleven well-trained long-distance male runners performed four exercises of different duration and intensity. TL was evaluated using Foster and Banister methods. In addition, HRV measurements were performed 5 minutes before exercise and 5 and 30 minutes after exercise. We calculated HRV index (TLHRV) based on the ratio between HRV decrease during exercise and HRV increase during recovery. HRV decrease during exercise was strongly correlated with exercise intensity (R = -0.70; p < 0.01) but not with exercise duration or training volume. TLHRV index was correlated with Foster (R = 0.61; p = 0.01) and Banister (R = 0.57; p = 0.01) methods. This study confirms that HRV changes during exercise and recovery phase are affected by both intensity and physiological impact of the exercise. Since the TLHRV formula takes into account the disturbance and the return to homeostatic balance induced by exercise, this new method provides an objective and rational TL index. However, some simplification of the protocol measurement could be envisaged for field use.

Catheterisation. Indwelling catheters in adults. Urethral and suprapubic. Evidence-based guidelines for best practice in urological health care

The EAUN Guidelines Working Group for indwelling catheters have prepared this guideline document to help nurses assess the evidence-based management of catheter care and to incorporate the guidelines’ recommendations into their clinical practice. These guidelines are not meant to be proscriptive, nor will adherence to these guidelines guarantee a successful outcome in all cases. Ultimately, decisions regarding care must be made on a case-by-case basis by healthcare professionals after consultation with their patients using their clinical judgement, knowledge and expertise.

Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey.

BACKGROUND: Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI. METHODS: A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014. RESULTS: A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI. CONCLUSION: The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

Available evidence and outcome of off-label use of rituximab in clinical practice

Purpose: To analyze the therapeutic indications for off-label use of rituximab, the available evidence for its use, the outcomes, and the cost. Methods: This was a retrospective analysis of patients treated with rituximab for off-label indications from January 2007 to December 2009 in two tertiary hospitals. Information on patient characteristics, medical conditions, and therapeutic responses was collected from medical records. Available evidence for the efficacy of rituximab in each condition was reviewed, and the cost of treatment was calculated. Results: A total of 101 cases of off-label rituximab use were analyzed. The median age of the patients involved was 53 [interquartile range (IQR) 37.5-68.0] years; 55.4 % were women. The indications for prescribing rituximab were primarily hematological diseases (46 %), systemic connective tissue disorders (27 %), and kidney diseases (20 %). Available evidence supporting rituximab treatment for these indications mainly came from individual cohort studies (53.5 % of cases) and case series (25.7 %). The short-term outcome (median 3 months, IQR 2-4 months) was a complete response in 38 % of cases and partial response in 32.6 %. The highest short-term responses were observed for systemic lupus erythematosus and membranous glomerulonephritis, and the lowest was for neuromyelitis optica, idiopathic thrombocytopenic purpura, and miscellaneous indications. Some response was maintained in long-term follow-up (median 23 months IQR 12-30months) in 69.2%of patients showing a short-term response. Median cost per patient was 5,187.5 (IQR 5,187.5-7,781.3). Conclusions: In our study, off-label rituximab was mainly used for the treatment of hematological, kidney, and systemic connective tissue disorders, and the response among our patient cohort was variable depending on the specific disease. The level of evidence supporting the use of rituximab for these indications was low and the cost was very high. We conclude that more clinical trials on the off-label use of rituximab are needed, although these may be difficult to conduct in some rare diseases. Data from observational studies may provide useful information to assist prescribing in clinical practice.

Gonalgies: que faire en médecine de premier recours [Knee pain in ambulatory practice].

Knee pain is a frequent complaint in ambulatory practice. Because of its complexity, the knee is prone to trauma, arthritis and the impact of aging. Septic arthritis is an emergency and has to be suspected when important knee pain is associated with fever, an alteration of the general condition, or in a particular social context. In most cases the clinical examination can identify the type of pathology. Conservative treatment is beneficial in most cases and physiotherapy a major component of the prognosis.

Trace element monitoring in the ICU: quality and economic impact of a change in sampling practice.

BACKGROUND & AIMS: Trace elements (TE) are involved in the immune and antioxidant defences which are of particular importance during critical illness. Determining plasma TE levels is costly. The present quality control study aimed at assessing the economic impact of a computer reminded blood sampling versus a risk guided on-demand monitoring of plasma concentrations of selenium, copper, and zinc. METHODS: Retrospective analysis of 2 cohorts of patients admitted during 6 months periods in 2006 and 2009 to the ICU of a University hospital. INCLUSION CRITERIA: to receive intravenous micronutrient supplements and/or to have a TE sampling during ICU stay. The TE samplings were triggered by computerized reminder in 2006 versus guided by nutritionists in 2009. RESULTS: During the 2 periods 636 patients met the inclusion criteria out of 2406 consecutive admissions, representing 29.7% and 24.9% respectively of the periods' admissions. The 2009 patients had higher SAPS2 scores (p = 0.02) and lower BMI compared to 2006 (p = 0.007). The number of laboratory determinations was drastically reduced in 2009, particularly during the first week, despite the higher severity of the cohort, resulting in à 55% cost reduction. CONCLUSIONS: The monitoring of TE concentrations guided by a nutritionist resulted in a reduction of the sampling frequency, and targeting on the sickest high risk patients, requiring a nutritional prescription adaptation. This control leads to cost reduction compared to an automated sampling prescription.

Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice.

Trabecular bone score (TBS) is a recently-developed analytical tool that performs novel grey-level texture measurements on lumbar spine dual X-ray absorptiometry (DXA) images, and thereby captures information relating to trabecular microarchitecture. In order for TBS to usefully add to bone mineral density (BMD) and clinical risk factors in osteoporosis risk stratification, it must be independently associated with fracture risk, readily obtainable, and ideally, present a risk which is amenable to osteoporosis treatment. This paper summarizes a review of the scientific literature performed by a Working Group of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. Low TBS is consistently associated with an increase in both prevalent and incident fractures that is partly independent of both clinical risk factors and areal BMD (aBMD) at the lumbar spine and proximal femur. More recently, TBS has been shown to have predictive value for fracture independent of fracture probabilities using the FRAX® algorithm. Although TBS changes with osteoporosis treatment, the magnitude is less than that of aBMD of the spine, and it is not clear how change in TBS relates to fracture risk reduction. TBS may also have a role in the assessment of fracture risk in some causes of secondary osteoporosis (e.g., diabetes, hyperparathyroidism and glucocorticoid-induced osteoporosis). In conclusion, there is a role for TBS in fracture risk assessment in combination with both aBMD and FRAX.

Venttiili- ja toimilaitetehtaan tuotannon suunnittelu

Venttiili- ja toimilaitetehtaassa kokoonpannaan erilaisia venttiilityyppejä sekä toimi- laitteita. Koko Metso Automationin Helsingin tehtaiden tuotantotilanteen muuttuessa käynnistettiin kehitysprojekti, jonka tarkoituksena oli uudenaikaistaa venttiilien ja toimilaitteiden valmistus vastaamaan nykypäivän vaatimuksia. Laajamittaisen osa- valmistuksen ulkoistuksen ja tuotteiston muutoksen vuoksi tuotannon uudelleen- järjestäminen oli välttämätöntä. Diplomityön tarkoituksena oli suunnitella venttiili- ja toimilaitetehtaan layout sekä uutta tuotantotilannetta vastaavat toimintatavat. Haasteena oli kolmen hyvin erilailla toimivan tuotetehtaan yhdistäminen yhdeksi kokonaisuudeksi, jossa kunkin tehtaan parhaat toimintatavat yhdistyvät. Nykyinen tuotanto ja valmistusmäärät kartoitettiin ja analysoitiin, minkä jälkeen tuotannon suunnittelu uusiin tiloihin käynnistettiin. Työ jaettiin järjestelmällisesti osiin teorian ja käytännön osuuksien kesken siten, että teoria tukee työn käytännön- osuutta. Apuna käytettiin useita erilaisia materiaalivirtojen kartoitusmenetelmiä, lukuisia mittareita, selvityksiä, ennusteita ja erilaisia malleja tulevasta tuotannosta. Layout suunniteltiin käytössäolevaan tehdashalliin, mikä aiheutti runsaasti haasteita ja rajoitteita. Aikataulu tehtiin tarkasti siten, että muuttojärjestys lyötiin lukkoon, mutta kuormitustilanne ja koneiden siirrot aiheuttivat muutoksia aikataulussa. Tavoite tuotannon häiriöttömyydestä toteutui hyvin aikataulun kustannuksella. Käytännönosuudessa tarkasteltiin erityisesti kapasiteetin joustavuutta kuormituksen vaihdellessa sekä kehitettiin toimintatavat, joilla se hallitaan. Lisäksi tutkimuksen aikana käynnistettiin useita kehitysprojekteja työn tulosten pohjalta. Näitä olivat erilaiset varaston hallintaan sekä solujen itseohjautuvuuteen liittyvät asiat. Diplomityön tuloksena saatiin uusi layout sekä sitä tukeva uusi toimintatapa, solujen itseohjautuvuuden kehittäminen käynnistettiin, varastojen hallinnan osittainen ulkoistaminen aloitettiin. Lisäksi tuotannolle kehitettiin lukuisia seurantamittareita. Layoutprojekti toteutettiin loppuun diplomityön aikana

Prevalence of Ischemic Heart Disease and Management of Coronary Risk in Daily Clinical Practice: Results from a Mediterranean Cohort of HIV-Infected Patients

There are conflicting data on the prevalence of coronary events and the quality of the management of modifiable cardiovascular risk factors (CVRF) inHIV-infected patients. Methods.We performed a retrospective descriptive study to determine the prevalence of coronary events and to evaluate the management of CVRF in a Mediterranean cohort of 3760 HIV-1-infected patients from April 1983 through June 2011. Results.We identified 81 patients with a history of a coronary event (prevalence 2.15%); 83% of them suffered an acute myocardial infarction. At the time of the coronary event, CVRF were highly prevalent (60.5% hypertension, 48% dyslipidemia, and 16% diabetes mellitus).OtherCVRF, such as smoking, hypertension, lack of exercise, and body mass index, were not routinely assessed. After the coronary event, a significant decrease in total cholesterol ( � = 0.025) and LDLcholesterol ( � = 0.004) was observed. However, the percentage of patients whomaintained LDL-cholesterol > 100mg/dL remained stable (from 46% to 41%, � = 0.103). Patients using protease inhibitors associated with a favorable lipid profile increased over time ( � = 0.028). Conclusions.The prevalence of coronary events in our cohort is low. CVRF prevalence is high and theirmanagement is far from optimal. More aggressive interventions should be implemented to diminish cardiovascular risk in HIV-infected patients.

Establishment of a Representative Practice-based Research Network (PBRN) for the Monitoring of Primary Care in Switzerland.

Data are urgently needed to better understand processes of care in Swiss primary care (PC). A total of 2027 PC physicians, stratified by canton, were invited to participate in the Swiss Primary care Active Monitoring network, of whom 200 accepted to join. There were no significant differences between participants and a random sample drawn from the same physician databases based on sex, year of obtaining medical school diploma, or location. The Swiss Primary care Active Monitoring network represents the first large-scale, nationally representative practice-based research network in Switzerland and will provide a unique opportunity to better understand the functioning of Swiss PC.

Practical guidance and considerations for transitioning patients from oxcarbazepine or carbamazepine to eslicarbazepine acetate--Expert opinion.

There is currently a lack of guidance on methodology and special considerations for transitioning patients from oxcarbazepine (OXC) or carbamazepine (CBZ) to eslicarbazepine acetate (ESL), if deemed clinically necessary. An advisory panel of epilepsy experts was convened to share their experience on the use of adjunctive ESL in clinical practice and to provide practical recommendations to help address this gap. When changing over from OXC to ESL, an OXC:ESL dose ratio of 1:1 should be employed to calculate the ESL target dose, and the changeover can take place overnight. No changes to comedication are required. Since CBZ has a different mechanism of action to ESL and is a stronger inducer of cytochrome P450 (CYP) enzymes, the transitioning of patients from CBZ to ESL requires careful consideration on a patient-by-patient basis. In general, a CBZ:ESL dose ratio of 1:1.3 should be employed to calculate the ESL target dose, and patients should be transitioned over a minimum period of 1-2weeks. Special considerations include adjustment of titration schedule and target dose in elderly patients and those with hepatic or renal impairment and potential adjustment of comedications metabolized by CYP enzymes. In summary, due to structural distinctions between ESL, OXC, and CBZ, which affect mechanism of action and tolerability, there are clinical situations in which it may be appropriate to consider transitioning patients from OXC or CBZ to ESL. Changing patients over from OXC to ESL is generally more straightforward than transitioning patients from CBZ to ESL, which requires careful consideration.