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Correlation of binding affinities with non-bonded interaction energies of thrombin-inhibitor complexes.

Several empirical modeling protocols are evaluated allowing a quantification of the interaction between an enzyme and a series of inhibitors. The evaluation and optimization of the modeling protocols used a database of 35 non-covalently bound inhibitors of human thrombin. Intermolecular interaction energies were calculated with CHARMm after energy minimization of the modeled complexes using various dielectric functions and constraining strategies. These calculated binding energies were correlated with the experimentally obtained binding constants of the inhibitors. The best protocols resulted in linear correlations with correlation coefficients > 0.80. In the best protocols the enzyme was fully constrained, the ligand was allowed to move freely and electrostatics were scaled down drastically or fully neglected during the energy minimization. For the interaction energy evaluation step, a distance-dependent dielectric function epsilon = R proved to be optimal. This simple empirical protocol, that neglects solvation or entropy effects, can be implemented readily in other force field packages and may be applied on various enzyme-inhibitor complexes, providing a tool for the evaluation and rank-ordering of newly designed inhibitors.

Journal Article↗

A two-parameter model of cell membrane permeability for multisolute systems.

A two-parameter model of cell osmotic response (F. W. Kleinhans, 1998, Cryobiology 37, 271-289) is expanded for multisolute systems. The cell water volume W and intracellular osmolalities of N solutes are related as W[1 + L(p)RTSigma(N)(i=1)(M(i)/P(i))] = W(0)[1 + L(p)RTSigma(N)(i=1)(M(0)i)/P(i))], where M(i) is the intracellular osmolality of the ith solute (i = 1 ellipsis N), P(i) is the membrane permeability of the ith solute, L(p) is the membrane hydraulic conductivity, R is the gas constant, T is the absolute temperature, and the subscript "0" denotes the initial values at time zero. The above formula allows calculating the final (equilibrium) volume when all entities are permeable. Simple algebraic expressions for calculation of the number and magnitude of transient maximum volume excursions are presented. These simple expressions can all be calculated by hand on a pocket calculator. Practical examples of one-, two-, and three-solute systems are discussed. Special attention has been given to situations when systems contain an impermeable component. All formulas are simple to use for optimization of variety of cryobiological protocols. Application of the theory for optimization of addition and dilution of a permeable cryoprotectant is also discussed.

Animals↗

A logistic regression model when some events precede treatment: the effect of thrombolytic therapy for acute myocardial infarction on the risk of cardiac arrest.

When outcomes occur in clinical trials before treatment can be given, neither intent-to-treat nor according-to-protocol analyses give optimal estimates of the treatment effect. A better approach employs a time-dependent variable for treatment. Intent-to-treat analyses are conservative, biasing against treatment; according-to-protocol analyses bias in favor of treatment. We show how to measure the effect of a time-dependent variable in a logistic regression using person-time intervals as units of measurement and describe appropriate methods for reporting model performance. The method is applied to develop a model to predict the probability that a patient with a myocardial infarction will have a sudden cardiac arrest within 48 hours of presentation to emergency medical services both when treated with thrombolysis and when not treated. We use a time-dependent treatment variable because many patients went into cardiac arrest while awaiting treatment. This technique has been programmed into an electrocardiograph for real-time use in an emergency department.

Aged↗

A new virtual reality approach for planning of cardiac interventions.

A novel approach to three-dimensional (3D) visualization of high quality, respiratory compensated cardiac magnetic resonance (MR) data is presented with the purpose of assisting the cardiovascular surgeon and the invasive cardiologist in the pre-operative planning. Developments included: (1) optimization of 3D, MR scan protocols; (2) dedicated segmentation software; (3) optimization of model generation algorithms; (4) interactive, virtual reality visualization. The approach is based on a tool for interactive, real-time visualization of 3D cardiac MR datasets in the form of 3D heart models displayed on virtual reality equipment. This allows the cardiac surgeon and the cardiologist to examine the model as if they were actually holding it in their hands. To secure relevant examination of all details related to cardiac morphology, the model can be re-scaled and the viewpoint can be set to any point inside the heart. Finally, the original, raw MR images can be examined on line as textures in cut-planes through the heart models.

Cardiovascular Diseases↗

Protocure: supporting the development of medical protocols through formal methods.

Medical guidelines and protocols describe the optimal care for a specific group of patients and therefore, when properly applied, improve the quality of patient care. During the last decade, a large number of medical guidelines and protocols have been published. However, the work done on developing and disseminating them far outweighs the efforts on guaranteeing their quality. Indeed, anomalies like ambiguity and incompleteness are frequent in medical guidelines and protocols. An approach grounded on a formal representation, can answer these needs, as we have demonstrated in the Protocure project'. The Protocure II project will aim at integrating formal methods in the life cycle of guidelines.

Clinical Protocols↗

Validity of the ipsilateral acoustic reflex as a screening parameter.

Historically, the ipsilateral acoustic reflex (IAR) has played a prominent role in middle ear screening protocols. However, in 1990, the American Speech-Language-Hearing Association's revised guidelines, "Screening for Hearing Impairment and Middle Ear Disorders," deleted the IAR as a screening parameter. This decision was based on studies that demonstrated that the inclusion of the IAR resulted in a high false-positive rate without adding to the hit rate and thus was a major contributor to over-referral. However, other investigations demonstrated the converse, that the IAR is a sensitive and contributory measure in a screening protocol. Our data suggest that the conflicting results are due to different operating systems in the middle ear analyzers that were used to elicit the IAR. Based on our findings, an optimal IAR screening protocol would use a pulsed elicitation immittance system (multiplexing circuit) and a maximum intensity level of 105 dB HL. Further, if the IAR screening were to be carried out using an automated (programmed) immittance system with an equivalent volume change criteria for IAR detection, the equivalent volume change of > or = 0.03 ml is recommended.

Adolescent↗

Recommendations and guidelines regarding the preferred research protocol for investigating the impact of an optimal healing environment on patients with hypertension.

Cardiovascular disease is the leading cause of death in the United States. Hypertension is the most common single reason for visits to primary care physicians accounting for more than 35 million visits annually. Pharmacotherapy can achieve adequate control of blood pressure. Multiple interventions compares to single therapies are more efficacious in treating hypertension, and this fact supports using the holistic approach to hypertension treatment. Implementing an optimal healing environment (OHE) in a hypertension treatment regimen has the potential to impact not only health care costs, but also to optimize blood pressure control, and thus decrease the total cardiovascular disease burden. The research questions for the study of OHE in hypertension may differ between the individual patient perspective and the public health perspective. The use of a 2 x 2 factorial design would allow analysis of both perspectives simultaneously. Using an OHE setting with multiple interventions in formulating an individualized approach to hypertension management merits further exploration and research.

Cardiovascular Diseases↗

Short tau inversion recovery and proton density-weighted fat suppressed sequences for the evaluation of osteoarthritis of the knee with a 1.0 T dedicated extremity MRI: development of a time-efficient sequence protocol.

Aim of this study was to develop a time-efficient sequence protocol for a 1.0 T dedicated MR system to be used for whole-organ scoring of osteoarthritis (OA). Thirty-four knees were examined using a protocol that included fat suppressed fast spin echo proton density weighted sequences (PDFS) in three planes plus a coronal STIR sequence. Two radiologists scored each knee by consensus for five OA features. In separate sessions, all knees were scored using three different combinations of sequences: (1) all four sequences (reference protocol, 16 min 31 s scanning time), (2) three PDFS sequences without STIR ("No STIR", 12 min 25 s scanning time) and (3) sagittal and axial PDFS sequences plus a coronal STIR sequence ("No PDFS", 11 min 49 s scanning time). Agreement of the readings using both subsets of sequences compared to the reference protocol was evaluated using weighted kappa statistics. kappa-coefficients showed good or excellent agreement for both sequence subsets in comparison to the reference protocol for all assessed features. kappa-coefficients for No PDFS/No STIR: bone marrow abnormalities (0.74/0.67), subarticular cysts (0.84/0.63), marginal osteophytes (0.77/0.71), menisci (0.75/0.79), tibial cartilage (0.71/0.78). Optimization of sequence protocols consisting of three sequences results in time savings and cost efficiency in imaging of knee OA without loss of information over a more time consuming protocol.

Female↗

A possible quality control protocol for Doppler ultrasound for organizational time optimization.

Acceptance tests quantitatively determine equipment performance characteristics. Before a new probe is accepted, performance tests can be also used to compare performance of other probes. Routine performance tests verify device operational stability over the time. We developed an efficient and effective testing programme aiming to demonstrate changes in imaging performance relevant to clinical quantitative use of pulsed and colour Doppler. For each scanner-transducer tested, we introduced some quantitative and semi-quantitative parameters in relation to the clinical request for which the equipment was chosen. The proposed quantitative tests may also be used as qualitative tests, when it is suspected that scanner performance is deteriorating. The measurements, obtained with different units, differed also in the case of probes operating at the same depth and peak velocity. Without a quality control (QC) program, significant variations are likely to be reported when peak velocity of the same flow is measured with different instruments. Our experience suggests that modern digital equipments used in serial measurements may be stable over the time and that calibrated phantom may enable preventive identification of corrective action to units and probes. Manufacturers and independent laboratories applying a quality control protocol can increase our experience to recognize and deal with the involved problems.

Blood Flow Velocity↗

Prediction of internal electric current distribution from surface application in atrophied muscle tissue.

The use of surface electrical stimulation therapy for clinical rehabilitation has created the need for an improved modeling method to predict internal current density. A method was developed to model quantitatively the current density delivered to an atrophied muscle. Some stimulation protocols do not produce measurable physiological effects, such as muscle contraction. Therefore, traditional response-based current density modeling cannot be used. Additionally, lumped circuit models do not provide the resolution needed to optimize electrode size, shape, and placement. The quantitative approach developed here can be used to optimize electrical stimulation protocols in abnormal muscle tissue. In this study, the finite element method (FEM) is used to model the low intensity electric current stimulation resulting from surface application. FEM provides the ability to model complex tissue properties found in living tissue. A leg of lamb was modeled because its size and level of tissue complexity is similar to that of a human child's thigh. Voltage gradient measurements were made upon a sacrificed leg of lamb during the application of bipolar stimulation. These measurements were made at numerous points in the stimulated leg of lamb and allowed the mapping of the current density. The leg of lamb was then sliced and photographed to be able to create the finite element model. The empirical data compared favorably to the results of the FEM model, thus verifying the method. This FEM model was then modified to study the effects of muscle atrophy on electric current densities. This modeling method will ultimately lead to improved stimulation protocols and better clinical treatment.

Animals↗

Two-stage application of the optimised uncertainty method: a practical assessment.

Uncertainty estimates from routine sampling and analytical procedures can be assessed as being fit for purpose using the optimised uncertainty (OU) method. The OU method recommends an optimal level of uncertainty that should be reached in order to minimise the expected financial loss, given a misclassification of a batch as a result of the uncertainty. Sampling theory can used as a predictive tool when a change in sampling uncertainty is recommended by the OU method. The OU methodology has been applied iteratively for the first time using a case study of wholesale butter and the determination of five quality indicators (moisture, fat, solids-not-fat (SNF), peroxide value (PV) and free fatty acid (FFA)). The sampling uncertainty (s(samp)) was found to be sub-optimal for moisture and PV determination, for 3-fold composite samples. A revised sampling protocol was devised using Gy's sampling theory. It was predicted that an increase in sample mass would reduce the sampling uncertainty to the optimal level, resulting in a saving in expectation of loss of over pounds 2000 per 20 tonne batch, when compared to current methods. Application of the optimal protocol did not however, achieve the desired reduction in s(samp) due to limitations in sampling theory. The OU methodology proved to be a useful tool in identifying broad weaknesses within a routine protocol and assessing fitness for purpose. However, the successful routine application of sampling theory, as part of the optimisation process, requires substantial prior knowledge of the sampling target.

Animals↗

Prophylactic cranial irradiation as a component of intensified initial treatment of locally advanced non-small cell lung cancer.

Patients with locally advanced non-small cell lung cancer are threatened by the concurrent risks of local, regional and distant failure. By improving local and regional control with multimodality protocols, the brain becomes one of the major sites of relapse. PCI has a high potential to reduce the risk of brain metastases. Long-term toxicity is presently poorly defined and represents an important potential risk. The value of PCI as an adduct to present aggressive multimodality protocols and the optimal total dose with conventional fractionation will be investigated within clinical studies by two study groups in the future. As the best dose and fractionation still remains undefined, the integration of PCI into multimodality protocols.

Brain Neoplasms↗

Adolescents with cancer: access to clinical trials and age-appropriate care.

Many adolescents with cancer are denied the benefits of protocol inclusion and optimal supportive care. More than 70% of older adolescent patients are not treated at institutions representing pediatric cooperative groups and are not enrolled in clinical trials, despite a demonstrated survival advantage for patients registered in protocols. Failure to refer adolescent cancer patients to specialized pediatric oncology treatment centers also has an impact on their quality of care. The challenge before both the medical and pediatric health care communities is to assure adolescent patients the benefits of inclusion in clinical trials and treatment in age-appropriate settings.

Adolescent↗

[Protocol for preoperative chest X-rays in elective surgery].

BACKGROUND: To evaluate the effects of a protocol designed to optimize the use of preoperative chest X-rays (CXRs) in the evaluation of patients undergoing anesthesia for elective surgery. DESIGN: Observational prospective study. SETTING: General 350 bedded hospital, with main surgical branches. METHODS: a) PROTOCOL: routine CXRs can be avoided in patients aged less than 60 years, nonsmokers, without acute-chronic respiratory, cardiovascular symptoms, free from neoplastic diseases, not candidates to major vascular, abdominal or thoracic surgery, not treated with immunosuppressive therapy, nor immigrants from areas of endemic TB. b) All out patient subjects admitted to anesthesiology service for evaluation prior to elective surgery. RESULTS: Out of 5198 patients, 3795 were enrolled in the protocol; in 152 cases, preoperative CXRs were performed, 3456 patients (57.2% ASA 1; 42% ASA 2; 0.8% ASA 3) underwent surgery without CXRs. Thirty-four percent of patients had general anesthesia, 54.5% regional anesthesia, 20.6% regional-peripheral anesthesia with/without MAC. No critical events nor major complications were observed in the perioperative period in these subjects. Preoperative CXRs (performed in 152 cases) yelded useful informations with effect on the clinical management in 20 instances. CONCLUSIONS: In a context of adequate preoperative anesthesiologic evaluation, this protocol proved to be effective in reducing the number of routine preoperative CXRs in patients undergoing elective surgery. This resulted in a substantial reduction of radiation exposure both to the subject and to the general population, and costs saving, without evident negative side-effects.

Adolescent↗

Recommendations and guidelines regarding the preferred research protocol for investigating the impact of an optimal healing environment on patients with substance abuse.

The addictive disorders affect every aspect of a person's life, and thus the most effective interventions are those that address many or all of these issues. Although the initial evaluation and intake process for addiction assessment is lengthy, this process does give the practitioner an opportunity to provide what can be considered an optimal healing environment (OHE) in treating the addictive disorders. In addition to our traditional medical treatment modalities of pharmacotherapy and psychotherapy, many complementary and alternative treatment modalities address and provide additional support for the holistic approach to treatment and recovery. The important role of spirituality in obtaining and maintaining recovery and sobriety has been recognized for many years. Because one specific treatment is not effective for all people and for all of the addictive disorders, using a holistic approach and individualizing the treatment regimen is the recommended approach to disease intervention and establishing an OHE. There are instruments available for measuring the facility, the staff, and the patient in their contributions to providing an OHE for substance abuse treatment. This paper suggests study design considerations for investigating the impact of an OHE on the results of treatment and specific instruments designed for use in patients with addictive disorders.

Clinical Protocols↗

Modified treadmill protocol for evaluation of physical fitness in pediatric age group--comparison with Bruce and Balke protocols.

The aim of this study was to compare classical Balke and Bruce protocols with our modification of Balke protocol in pediatric cardiorespiratory diagnostics. The modification of Balke consists of nine stages per 1 min at a constant velocity of 5.6 km x h(-1) and increasing elevation from 6% to 22% in 2% increments. Sixty healthy children (mean age = 13.3+/-0.2 years; BMI = 18.8+/-0.6 kg x m(-2); mean +/- 95% CI), divided into three groups of 20 children each, matched by age, height and BMI performed integrative cardiopulmonary exercise testing using one of the treadmill protocols mentioned. At the end of each exercise increment and throughout the recovery period the children were asked to rate the perceived exertion (RPE) using the Borg Category Ratio scale--CR-10. Exercise results showed that Balke protocol had the longest duration (21.7+/-0.6 min.) and the lowest values for VO2/kg (34.2+/-1.8 ml x min(-1) x kg(-1)) due to the minimal workload increments. Bruce protocol had intermediate duration (14.9+/-1.1 min.) and children achieved the highest VO2/kg (48.6+/-2.7 ml x min(-1) x kg(-1)) but the test is symptom-limited which is ethically unacceptable in childhood. Exercise data revealed that our modification of the classical Balke protocol had an optimal duration (11 min.) and yielded peak VO2/kg values (39.4+/-2.3 ml x min(-1) x kg(-1)) adequate for evaluation of children's exercise capacity. Children's ratings of perceived exertion were highest in Bruce protocol (6.5+/-0.4) and lowest in the original Balke protocol (4.5+/-0.8). In conclusion, the modification of Balke protocol is suitable and reliable for screening and clinical testing in pediatric age group.

Adolescent↗

The generation and characterization of potentially therapeutic Abeta antibodies in mice: differences according to strain and immunization protocol.

Previous studies have shown that in various mouse models of Alzheimer's disease (AD), amyloid beta-protein (Abeta) antibodies generated by Abeta peptide immunization resulted in the prevention of Abeta plaque formation in brains of young mice, decreased Abeta plaque burdens in older mice and improved cognition. The purpose of this study was to optimize Abeta immunization protocols for future trials in transgenic mouse models of AD. The timing and titers of Abeta antibody production, as well as epitope(s) and imunoglobulin isotypes, were compared between two different mouse strains (C57BL/6 and B6D2F1) and five treatment protocols: (1). chronic Abeta nasal administration, (2). repeated Abeta intraperitoneal (i.p.) injection, (3). one i.p. injection followed by chronic Abeta nasal administration, (4). chronic and concurrent Abeta nasal administration + Abeta i.p. injection, and (5). untreated controls. B6D2F1 mice generated Abeta antibodies earlier and in higher quantities than the C57BL/6 mice, indicating that B6D2F1 mice are more responsive to Abeta immunization. For both strains, mice that received the combination of Abeta nasal + Abeta i.p. injection showed the highest antibody titers. Epitope mapping experiments indicated that the mouse anti-Abeta antibodies recognize residues within Abeta1-15. Immunoglobulin isotyping demonstrated that the Abeta antibodies are of the Th-2 anti-inflammatory type, IgG1 and IgG2b, with a few IgM. Currently there is no effective therapy for Alzheimer's disease; thus if Abeta immunization proves effective, it would be a significant step in the prevention and/or treatment of this devastating disease.

Administration, Intranasal↗

Quality improvement efforts in the intensive care unit: development of a new heparin protocol.

CONTEXT: An ongoing process of identifying and implementing breakthrough projects to quickly improve patient outcomes and reduce costs in the intensive care unit. OBJECTIVE: To develop and test a new protocol for heparin administration in the intensive care unit, replacing the 5 existing protocols and ensuring compliance with the recommendations of the Fifth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy. DESIGN: A pilot study comparing results of 58 patients on the 5 existing protocols with those of 10 patients on the new heparin protocol. SETTING: Baylor University Medical Center, a large tertiary hospital in Dallas, Texas, with 115 adult intensive care unit beds. INTERVENTIONS: Heparin dosing was based on a patient's weight, and anticoagulation was monitored through the heparin assay. MAIN OUTCOME MEASURES: In the control group treated according to the existing protocols, 5 patients (8.6%) received optimal bolus doses, and 2 patients (3.4%) received optimal infusion doses. In the pilot group treated according to the new protocols, 9 patients (90%) received optimal bolus doses, and all received optimal infusion doses. RESULTS: The implementation of the new heparin protocol resulted in better patient care, improved nursing efficiency, and reduced costs. CONCLUSIONS: As shown in this example, a rapid breakthrough project following a plan-do-study-act cycle can apply best practices relatively quickly and lead to better patient outcomes.

Journal Article↗