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Emergency Medicine Clinics of North... Feb 2001The defining characteristic of emergency medicine is "time," or the acuity of disease presentation. Observation, like resuscitation, involves the management of... (Review)
Review
The defining characteristic of emergency medicine is "time," or the acuity of disease presentation. Observation, like resuscitation, involves the management of time-sensitive conditions. In the ED there is a continuum of time-sensitive conditions. This continuum extends from resuscitation on one end to observation on the other. When performed well, observation services have been shown to improve diagnostic accuracy, improve treatment outcomes, decrease costs, and improve patient satisfaction. For the subset of ED patients who would have been inappropriately discharged or unnecessarily admitted, the OU has become a safety net of the ED itself. Like EDs, OUs have progressed from being poorly managed areas of the hospital to the cutting edge of acute health care. The principles developed through past experience and research provide a framework for future developments in emergency medicine.
Topics: Emergency Medicine; Emergency Service, Hospital; Female; Guidelines as Topic; Humans; Male; Observation; Sensitivity and Specificity; United States
PubMed: 11214392
DOI: 10.1016/s0733-8627(05)70165-6 -
Social Neuroscience 2008Performing an action and observing it activate the same internal representations of action. The representations are therefore shared between self and other (shared... (Review)
Review
Performing an action and observing it activate the same internal representations of action. The representations are therefore shared between self and other (shared representations of action, SRA). But what exactly is shared? At what level within the hierarchical structure of the motor system do SRA occur? Understanding the content of SRA is important in order to decide what theoretical work SRA can perform. In this paper, we provide some conceptual clarification by raising three main questions: (i) are SRA semantic or pragmatic representations of action?; (ii) are SRA sensory or motor representations?; (iii) are SRA representations of the action as a global unit or as a set of elementary motor components? After outlining a model of the motor hierarchy, we conclude that the best candidate for SRA is intentions in action, defined as the motor plans of the dynamic sequence of movements. We shed new light on SRA by highlighting the causal efficacy of intentions in action. This in turn explains phenomena such as inhibition of imitation.
Topics: Humans; Imitative Behavior; Intention; Models, Psychological; Movement; Observation; Social Perception
PubMed: 18633828
DOI: 10.1080/17470910802045109 -
Current Opinion in Pediatrics Jun 2015To reflect the recent advances in the field of pediatric sleep medicine. The pediatrician will be able to define which children to refer for a sleep study and what to... (Review)
Review
PURPOSE OF REVIEW
To reflect the recent advances in the field of pediatric sleep medicine. The pediatrician will be able to define which children to refer for a sleep study and what to expect from the sleep specialist in 2015.
RECENT FINDINGS
In the first study that compared adeno tonsillectomy (TA) to watchful waiting, TA reduced symptoms and improved children's behavior, quality of life, and polysomnographic results. Anti-inflammatory therapy for mild obstructive sleep apnea was effective and well tolerated according to a double-blind study. A retrospective study showed that it is beneficial for 80% of the patients. TA is associated with a decrease in asthma symptoms and medication utilization.
SUMMARY
Pediatricians need to be aware of the clear benefits of tonsillectomy (including better asthma control), although anti-inflammatory therapy may improve symptoms and polysomnographic findings in children with nonsevere obstructive sleep apnea.
Topics: Adenoidectomy; Child; Child Behavior; Child, Preschool; Double-Blind Method; Humans; Polysomnography; Quality of Life; Retrospective Studies; Sleep Apnea, Obstructive; Tonsillectomy; Treatment Outcome; Watchful Waiting
PubMed: 25944313
DOI: 10.1097/MOP.0000000000000218 -
JAMA Surgery Jan 2017The reporting of individual urologist rates of observation for localized prostate cancer may be a valuable performance measure with important downstream implications for...
IMPORTANCE
The reporting of individual urologist rates of observation for localized prostate cancer may be a valuable performance measure with important downstream implications for patient and payer stakeholder groups. However, few studies have examined the urologist-level variation in the use of observation across all risk strata of prostate cancer.
OBJECTIVES
To measure variation in the use of observation at the urologist level by disease risk strata and to evaluate the association between the urologist-level rates of observation for men with low-risk and high-risk prostate cancer.
DESIGN, SETTING, AND PARTICIPANTS
With the use of linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data, a population-based study of men diagnosed with prostate cancer from January 1, 2004, to December 31, 2009, was performed in SEER catchment areas of the United States. A total of 57 639 men with prostate cancer with 1884 diagnosing urologists were identified. Data were analyzed from October 1 to December 31, 2015.
MAIN OUTCOMES AND MEASURES
The main outcome was observation, which is defined as the absence of definitive treatment within 1 year of diagnosis. In each risk stratum, a multivariable mixed-effects model was fit to characterize associations between observation and selected patient characteristics. From these models, the estimated probability of observation was calculated for each urologist within each risk stratum, and the association between the physician-level estimated rates of observation for low-risk and high-risk disease was assessed.
RESULTS
Among the 57 639 men included in the study, the estimated probability of observation for low-risk disease varied impressively (mean, 27.8%; range, 5.1%-71.2%) at the individual urologist level. Considerably less urologist-level variation was seen in the use of observation for intermediate-risk disease (11.1%; range, 4.8%-31.5%) and high-risk disease (5.8%; range, 3.2%-16.5%). Furthermore, the estimated rates of observation for low- and high-risk disease were correlated at the urologist level (Spearman ρ = 0.17; P < .001). A comparable correlation was likewise observed among urologists with high-volume prostate cancer practices (Spearman ρ = 0.24; P < .001).
CONCLUSIONS AND RELEVANCE
Considerable urologist-level variation is seen in the use of observation for men with low-risk prostate cancer. More important, the use of observation for low-risk and high-risk patients with prostate cancer is correlated at the urologist level. This study reveals the strikingly variable use of observation among US urologists and establishes a framework for the use of urologist-level treatment signatures as a quality measure in the emerging value-based health care environment.
Topics: Aged; Aged, 80 and over; Humans; Male; Practice Patterns, Physicians'; Probability; Prostatic Neoplasms; Risk Assessment; Risk Factors; SEER Program; United States; Urology; Watchful Waiting
PubMed: 27653425
DOI: 10.1001/jamasurg.2016.2907 -
Presse Medicale (Paris, France : 1983) Dec 2011Simple goiter is defined as an enlarged thyroid without dysfunction, thyroiditis or cancer. Complications of the goiter appear only at stage of plurinodulaire goiter.... (Review)
Review
Simple goiter is defined as an enlarged thyroid without dysfunction, thyroiditis or cancer. Complications of the goiter appear only at stage of plurinodulaire goiter. Homogeneous simple goiters of young subjects resolve with thyroid hormone administration. Many simple multinodular goiters of adults can benefit from simple monitoring. Total thyroidectomy is recommended for goiters that become symptomatic, unsightly, accompanied by lowering of TSH concentration, or containing suspicious nodules. Radioactive iodine constitutes an alternative to surgery for voluminous, compressive, hyperfunctionnal goiters, especially in older people.
Topics: Adult; Algorithms; Brachytherapy; Endocrine Surgical Procedures; Goiter; Hormone Replacement Therapy; Humans; Iodine; Models, Biological; Practice Guidelines as Topic; Thyroidectomy; Watchful Waiting
PubMed: 22088619
DOI: 10.1016/j.lpm.2011.10.005 -
Seminars in Perinatology Mar 2020Elective induction of labor is defined as labor induction in the absence of a clear medical indication. Whether elective labor induction at 39 weeks is a reasonable... (Review)
Review
Elective induction of labor is defined as labor induction in the absence of a clear medical indication. Whether elective labor induction at 39 weeks is a reasonable option for obstetric practice has been a hotly debated topic for decades. Historically, labor induction in low-risk nulliparous women has been discouraged due to the belief that this intervention increases the risk for cesarean delivery without a clear benefit. This review discusses the observational and randomized data that have informed this debate, focusing on recent studies that have reshaped how we think about elective labor induction at 39 weeks of gestation.
Topics: Cesarean Section; Female; Gestational Age; Humans; Labor, Induced; Parity; Pregnancy; Pregnancy Outcome; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Watchful Waiting
PubMed: 31812315
DOI: 10.1016/j.semperi.2019.151214 -
Current Opinion in Urology Jul 2018With this review, we describe the most recent advances in active surveillance as well as diagnosis and management of small renal masses (SRMs). (Review)
Review
PURPOSE OF REVIEW
With this review, we describe the most recent advances in active surveillance as well as diagnosis and management of small renal masses (SRMs).
RECENT FINDINGS
We discuss diagnosis, differentiation of solid from cystic lesions, risk prediction and treatment of the SRM. A better understanding of the disease facilitates the use of more conservatory treatments, such as active surveillance. Active surveillance has been increasingly accepted not only for SRM, but also for larger tumors and even metastatic patients. Exiting advances in risk prediction will help us define which patients can be safely managed with active surveillance and which require immediate treatment. Meanwhile, the use of renal tumor biopsies is still an important tool for these cases.
SUMMARY
Active surveillance is an option for many patients with renal masses. Noninvasive methods for diagnosis and risk prediction are being developed, but meanwhile, renal tumor biopsy is a useful tool. A better understanding of the disease increases the number of patients who can undergo active surveillance fully certain of the safety of their management.
Topics: Biopsy; Humans; Kidney; Kidney Neoplasms; Practice Guidelines as Topic; Risk Assessment; Societies, Medical; United States; Urology; Watchful Waiting
PubMed: 29697471
DOI: 10.1097/MOU.0000000000000506 -
Progres En Urologie : Journal de... Jan 2015The widespread use of prostate cancer screening has led to a stage migration resulting in an increase in the diagnosis of low-risk disease, which currently accounts for... (Review)
Review
INTRODUCTION
The widespread use of prostate cancer screening has led to a stage migration resulting in an increase in the diagnosis of low-risk disease, which currently accounts for 40-50% of diagnosed forms. New therapeutic strategies have been developed in order to minimize the risk of overtreatment.
METHODS
A systematic review of the literature over the past 20 years was performed using the Medline database. The literature selection was based on evidence and practical considerations.
RESULTS
Low-risk tumors are conventionally defined by the d'Amico classification. The use of multiparametric MRI helps to better characterize these tumors. The contribution of molecular biology remains to be determined in clinical practice. Novel therapeutic options for low-risk disease are currently being evaluated.
CONCLUSION
The new therapeutic strategies are evolving. They seek to reduce overtreatment without compromising oncological success.
Topics: Disease Progression; Humans; Magnetic Resonance Imaging; Male; Patient Selection; Prostate-Specific Antigen; Prostatectomy; Prostatic Neoplasms; Secondary Prevention; Watchful Waiting
PubMed: 25454776
DOI: 10.1016/j.purol.2014.10.007 -
Current Treatment Options in Oncology Apr 2020Despite its rarity, hairy cell leukemia (HCL) remains a fascinating disease and the physiopathology is becoming more and more understood. The accurate diagnosis of HCL... (Review)
Review
Despite its rarity, hairy cell leukemia (HCL) remains a fascinating disease and the physiopathology is becoming more and more understood. The accurate diagnosis of HCL relies on the recognition of hairy cells by morphology and flow cytometry (FCM) in the blood and/or bone marrow (BM). The BRAF V600E mutation, an HCL-defining mutation, represents a novel diagnostic parameter and a potential therapeutic target. The precise cellular origin of HCL is a late-activated postgerminal center memory B cell. BRAF mutations were detected in hematopoietic stem cells (HSCs) of patients with HCL, suggesting that this is an early HCL-defining event. Watch-and-wait strategy is necessary in approximately 10% of asymptomatic HCL patients, sometimes for several years. Purine analogs (PNAs) are the established first-line options for symptomatic HCL patients. In second-line treatment, chemoimmunotherapy combining PNA plus rituximab should be considered in high-risk HCL patients. The three options for relapsed/refractory HCL patients include recombinant immunoconjugates targeting CD22, BRAF inhibitors, and BCR inhibitors. The clinical interest to investigate blood minimal residual disease (MRD) was recently demonstrated, with a high risk of relapse in patients with positive testing for MRD and a low risk in patients with negative testing. However, efforts must be made to standardize MRD analyses in the near future. Patients with HCL are at risk of second malignancies. The increased risk could be related to the disease and/or the treatment, and the respective role of PNAs in the development of secondary malignancies remains a topic of debate.
Topics: Animals; Biomarkers, Tumor; Biopsy; Bone Marrow; Clinical Decision-Making; Combined Modality Therapy; Disease Management; Disease Progression; Disease Susceptibility; Genetic Predisposition to Disease; Histocytochemistry; Humans; Immunophenotyping; Leukemia, Hairy Cell; Mutation; Retreatment; Signal Transduction; Treatment Outcome; Watchful Waiting
PubMed: 32350628
DOI: 10.1007/s11864-020-00732-0 -
Health Technology Assessment... Apr 2017Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC)...
PET-NECK: a multicentre randomised Phase III non-inferiority trial comparing a positron emission tomography-computerised tomography-guided watch-and-wait policy with planned neck dissection in the management of locally advanced (N2/N3) nodal metastases in patients with squamous cell head and neck...
BACKGROUND
Planned neck dissection (ND) after radical chemoradiotherapy (CRT) for locally advanced nodal metastases in patients with head and neck squamous cell carcinoma (HNSCC) remains controversial. Thirty per cent of ND specimens show histological evidence of tumour. Consequently, a significant proportion of clinicians still practise planned ND. Fludeoxyglucose positron emission tomography (PET)-computerised tomography (CT) scanning demonstrated high negative predictive values for persistent nodal disease, providing a possible alternative paradigm to ND. Evidence is sparse and drawn mainly from retrospective single-institution studies, illustrating the need for a prospective randomised controlled trial.
OBJECTIVES
To determine the efficacy and cost-effectiveness of PET-CT-guided surveillance, compared with planned ND, in a multicentre, prospective, randomised setting.
DESIGN
A pragmatic randomised non-inferiority trial comparing PET-CT-guided watch-and-wait policy with the current planned ND policy in HNSCC patients with locally advanced nodal metastases and treated with radical CRT. Patients were randomised in a 1 : 1 ratio. Primary outcomes were overall survival (OS) and cost-effectiveness [incremental cost per incremental quality-adjusted life-year (QALY)]. Cost-effectiveness was assessed over the trial period using individual patient data, and over a lifetime horizon using a decision-analytic model. Secondary outcomes were recurrence in the neck, complication rates and quality of life. The recruitment of 560 patients was planned to detect non-inferior OS in the intervention arm with a 90% power and a type I error of 5%, with non-inferiority defined as having a hazard ratio (HR) of no higher than 1.50. An intention-to-treat analysis was performed by Cox's proportional hazards model.
SETTINGS
Thirty-seven head and neck cancer-treating centres (43 NHS hospitals) throughout the UK.
PARTICIPANTS
Patients with locally advanced nodal metastases of oropharynx, hypopharynx, larynx, oral or occult HNSCC receiving CRT and fit for ND were recruited.
INTERVENTION
Patients randomised to planned ND before or after CRT (control), or CRT followed by fludeoxyglucose PET-CT 10-12 weeks post CRT with ND only if PET-CT showed incomplete or equivocal response of nodal disease (intervention). Balanced by centre, planned ND timing, CRT schedule, disease site and the tumour, node, metastasis stage.
RESULTS
In total, 564 patients were recruited (ND arm, = 282; and surveillance arm, = 282; 17% N2a, 61% N2b, 18% N2c and 3% N3). Eighty-four per cent had oropharyngeal cancer. Seventy-five per cent of tested cases were p16 positive. The median time to follow-up was 36 months. The HR for OS was 0.92 [95% confidence interval (CI) 0.65 to 1.32], indicating non-inferiority. The upper limit of the non-inferiority HR margin of 1.50, which was informed by patient advisors to the project, lies at the 99.6 percentile of this estimate ( = 0.004). There were no differences in this result by p16 status. There were 54 NDs performed in the surveillance arm, with 22 surgical complications, and 221 NDs in the ND arm, with 85 complications. Quality-of-life scores were slightly better in the surveillance arm. Compared with planned ND, PET-CT surveillance produced an incremental net health benefit of 0.16 QALYs (95% CI 0.03 to 0.28 QALYs) over the trial period and 0.21 QALYs (95% CI -0.41 to 0.85 QALYs) over the modelled lifetime horizon.
LIMITATIONS
Pragmatic randomised controlled trial with a 36-month median follow-up.
CONCLUSIONS
PET-CT-guided active surveillance showed similar survival outcomes to ND but resulted in considerably fewer NDs, fewer complications and lower costs, supporting its use in routine practice.
FUTURE WORK
PET-CT surveillance is cost-effective in the short term, and long-term cost-effectiveness could be addressed in future work.
TRIAL REGISTRATION
Current Controlled Trials ISRCTN13735240.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 21, No. 17. See the NIHR Journals Library website for further project information.
Topics: Carcinoma, Squamous Cell; Chemoradiotherapy; Cost-Benefit Analysis; Female; Head and Neck Neoplasms; Humans; Male; Middle Aged; Neck Dissection; Positron Emission Tomography Computed Tomography; Quality-Adjusted Life Years; Squamous Cell Carcinoma of Head and Neck; Survival Rate; Technology Assessment, Biomedical; United Kingdom; Watchful Waiting
PubMed: 28409743
DOI: 10.3310/hta21170