Background: This study explored the perspectives and experiences from patients and families around how patient/family preferences and priorities are considered in medication-related discussions and decisions within the healthcare system. Methods: We conducted a qualitative study using focus groups with residents of Southern Ontario and British Columbia ( N = 16). Three focus groups were conducted using a semi-structured focus group guide. The audiotaped focus group discussions were transcribed verbatim. A thematic analysis, using inductive coding, was completed. Results: A total of three main themes [and several sub-themes (and sub-sub-themes)] emerged from the data: patient and family expertise [ lived experience, information expert , and perceived expert roles (patient/family, healthcare provider)], perceived patient-centredness ( relationship qualities of healthcare provider and assumptions about patients ), and system ( time, coordination and communication , and culture ). Stories told by participants helped to clarify the relationships between the themes and sub-themes, leading to, what we understand as shared decision-making around medications and subsequent health outcomes. Conclusions: Our findings showed that shared decision-making resulted from both recognition and integration of the personal expertise of the patient and family in medications, and perceived patient-centredness. This is broadly consistent with the current conceptualization of evidence-based medicine. The stories told highlight the complex, dynamic, and nonlinear nature of shared decision-making for medications, and that patient priorities are not as integrated into shared decision-making about medications as we would hope. This suggests the need for developing a systematic process to elicit, record, and integrate patient preferences and priorities about medications to create space for a more patient-centred conversation.
Background Polypharmacy in older adults can be associated with negative outcomes including falls, impaired cognition, reduced quality of life, and general and functional decline. It is not clear to what extent these are reversible if the number of medications is reduced. Primary care does not have a systematic approach for reducing inappropriate polypharmacy, and there are few, if any, approaches that account for the patient’s priorities and preferences. The primary objective of this study is to test the effect of TAPER (Team Approach to Polypharmacy Evaluation and Reduction), a structured operationalized clinical pathway focused on reducing inappropriate polypharmacy. TAPER integrates evidence tools for identifying potentially inappropriate medications, tapering, and monitoring guidance and explicit elicitation of patient priorities and preferences. We aim to determine the effect of TAPER on the number of medications (primary outcome) and health-related outcomes associated with polypharmacy in older adults. Methods We designed a multi-center randomized controlled trial, with the lead implementation site in Hamilton, Ontario. Older adults aged 70 years or older who are on five or more medications will be eligible to participate. A total of 360 participants will be recruited. Participants will be assigned to either the control or intervention arm. The intervention involves a comprehensive multidisciplinary medication review by pharmacists and physicians in partnership with patients. This review will be focused on reducing medication burden, with the assumption that this will reduce the risks and harms of polypharmacy. The control group is a wait list, and control patients will be given appointments for the TAPER intervention at a date after the final outcome assessment. All patients will be followed up and outcomes measured in both groups at baseline and 6 months. Discussion Our trial is unique in its design in that it aims to introduce an operationalized structured clinical pathway aimed to reduce polypharmacy in a primary care setting while at the same time recording patient’s goals and priorities for treatment. Trial registration Clinical Trials.gov NCT02942927. First registered on October 24, 2016.
Amyloid beta protein (Abeta) in Alzheimer's disease induces oxidative stress through several mechanisms, including stimulation of nitric oxide synthase (NOS) activity. We examined NOS activity and expression in the senescence-accelerated mouse P8 (SAMP8) line. The SAMP8 strain develops with aging cognitive impairments, increases in Abeta, and oxidative stress, all reversed by amyloid precursor protein antisense or Abeta antibody treatment. We found here that hippocampal NOS activity in 12-month-old SAMP8 mice was nearly double that of 2-month-old SAMP8 or CD-1 mice, but with no change in NOS isoenzyme mRNA and protein levels. Antisense or antibody treatment further increased NOS activity in aged SAMP8 mice. Antisense treatment increased inducible NOS (iNOS) mRNA levels, decreased neuronal NOS mRNA and protein levels, but did not affect endothelial NOS (eNOS) or iNOS protein or eNOS mRNA levels. These results suggest a complex relation between Abeta and NOS in the SAMP8 that is largely mediated through posttranslational mechanisms.
Aim: To estimate the Gross Tumor Volume (GTV) using different modes (axial, helical, slow, KV-CBCT & 4D-CT) of computed tomography (CT) in pulmonary tumors. Materials & Methods: We have retrospectively included ten previously treated case of carcinoma of primary lung or metastatic lung using Stereotactic Body Radiation Therapy (SBRT) in this study. All the patients underwent 4 modes of CT scan Axial, Helical, Slow & 4D-CT using GE discovery 16 Slice PET-CT scanner and daily KV-CBCT for the daily treatment verification. For standardization, all the patients underwent different modes of scan using 2.5 mm slice thickness, 16 detectors rows and field of view of 400mm. Slow CT was performed using axial mode scan by increasing the CT tube rotation time (typically 3 – 4 sec.) as per the breathing period of the patients. 4D-CT scans were performed and the entire respiratory cycle was divided into ten phases. Maximum Intensity Projections (MIP), Minimum Intensity Projections (MinIP) and Average Intensity Projections (AvIP) were derived from the 10 phases. GTV volumes were delineated for all the patients in all the scanning modes (GTVAX - Axial, GTVHL - Helical, GTVSL – Slow, GTVMIP -4DCT and GTVCB – KV-CBCT) in the Eclipse treatment planning system version 11.0 (M/S Varian Medical System, USA). GTV volumes were measured, documented and compared with the different modes of CT scans. Results: The mean ± standard deviation (range) for MIP, slow, axial, helical & CBCT were 36.5 ± 40.5 (2.29 – 87.0), 35.38 ± 39.52 (2.1 – 82), 31.95 ± 37.29 (1.32 – 66.9), 28.98 ± 33.36 (1.01 – 65.9) & 37.16 ± 42.23 (2.29 – 92). Overall underestimation of helical scan and axial scan compared to MIP is 21% and 12.5%. CBCT and slow CT volume has a good correlation with the MIP volume. Conclusion: For SBRT in lung tumors better to avoid axial and helical scan for target delineation. MIP is a still a golden standard for the ITV delineation, but in the absence of 4DCT scanner, Slow CT and KV-CBCT data may be considered for ITV delineation with caution.
Purpose of Study: The purpose of the study was to evaluate the effect of patient characteristics and equipment-related factors on the computed tomography (CT) dose received by patients from positron emission tomography-CT (PET-CT) using system-generated dose-length product (DLP) values and also to check the effective dose (ED) received from various CT protocols at our institute. Materials and Methods: This retrospective study included 78 adult patients who underwent F-18 fluorodeoxyglucose whole-body PET-CT and were divided into three groups based on the area of primary cancerous lesion. In Group A, we had 44 patients who underwent PET-CT (head-and-neck protocol), in Group B, we had 24 patients who underwent PET-CT (whole body with brain protocol), and in Group C, we had 10 patients who underwent PET-CT (pelvis protocol). All of the patients under the study are of South Asian ethnicity. A majority of patients 53.85% were males and remaining 46.15% were females. The product of conversion factor (k-coefficient), as described in “American Association of Physicists in Medicine Report No. 96” and DL P value generated by the scanner, was used to calculate the ED. Moreover, we also performed regression analysis to check relation between body weight, height, scan range, tube current, Volume computed tomography dose index (CTDIvol), DLP, and ED. Results: The regression analysis shows that scan range, patient height, weight, tube current, and DLP were significantly correlated with ED ( P < 0.05 for all). Moreover, the DLP and conversion factor method estimated the ED from various groups. Patients under Group A (head-and-neck protocol), Group B (whole body with brain protocol), Group C (pelvis protocol) received an average ED of 22.45 mSv, 22.40 mSv, and 21.24 mSv, respectively. Conclusion: ED from CT component of PET-CT can be assessed as the product of scanner-generated DLP and conversion factor for selected range. Moreover, body weight, scan range, and tube current had an independent significant effect on ED received from CT.
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