scholarly journals P-P49 Predicting Future Pathological and Operative Complexity in Pancreatoduodenectomy: 30 Years of Experience

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
James Halle-Smith ◽  
James Hodson ◽  
Christopher Coldham ◽  
Bobby Dasari ◽  
Nikolaos Chatzizacharias ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Patient Selection ◽  
Linear Trend ◽  
Technical Difficulty ◽  
Rate Of Change ◽  
Ductal Adenocarcinoma ◽  
Venous Resection ◽  
Local Experience ◽  
Log Linear ◽  
Over Time

Abstract Background Patient selection for pancreatoduodenectomy (PD) is largely based upon local experience and established practice. This study sought to observe changes in complexity and patient cohort over time with the aim of predicting future cohort characteristic of patients undergoing PD. Methods All PDs at our institution between 1988 and 2020 were reviewed (n = 1,878) to observe changing trends in patient demographic, pathological diagnosis, operative factors and postoperative outcomes. Coefficients from regression models were reported as gradients per decade, to quantify the rate of change over time. The resulting models were then plotted to illustrate the trend across the study period, as well as forecasts for subsequent years. Results The annual volume (7 to 128) and proportion of pancreatic ductal adenocarcinoma (PDAC) (28 to 53%) increased at a linear rate. The proportion of associated vein resection (3 to 25%) and technical difficulty (type 2-4; 5 to 28%) increased in a nonlinear way, increasing more rapidly in later times. The average age (48 to 67) increased in a log linear trend. Length of stay reduced by 9.3%, whilst mortality reduced with an odds ratio of 0.69, per decade. Furthermore, When performance at our institution was compared to recently established benchmarks, it was shown that our institution regularly performed within these standards with few exceptions. By 2030 our predictions indicate that the average age will increase to 69, PDAC will comprise 62% of pathology, 40% will have an associated venous resection and 43% will be graded 2-4 in technical difficulty. Length of stay will have reduced to 9.6 days and mortality to 2%.  Conclusions Despite increasing complexity of surgery and patient age, length of stay and mortality after PD are reducing. Understanding changes over time permits an estimation of a future surgical cohort where complexity will increase. It is important that surgeons continue to push boundaries. Patient selection, based upon prior experience may inhibit progression and development of services.

scholarly journals Factors associated with professional identity formation within psychiatry residency training: A longitudinal study

2021 ◽  
Author(s):  
Qian Hui Chew ◽  
Yvonne Steinert ◽  
Kang Sim
Keyword(s):  
Professional Identity ◽  
Identity Formation ◽  
Psychiatry Residency ◽  
Mixed Model ◽  
Linear Mixed Model ◽  
Developmental Stages ◽  
Rate Of Change ◽  
Psychiatry Residents ◽  
Factors Associated ◽  
Over Time

Abstract Introduction Conceptual frameworks for professional identity (PI) formation highlight the importance of developmental stages and socialization as the learner progresses from legitimate peripheral to full participation. Based on extant literature and clinical impressions, the authors aimed to explore factors associated with PI formation in psychiatry residents over time, and hypothesized that time in training, seniority status, and duration of exposure to psychiatry prior to residency would be associated with PI formation. Methods Eighty out of 96 psychiatry residents (response rate, 83.3%) from the National Psychiatry Residency Program in Singapore participated and rated their PI development using the Professional Self Identity Questionnaire (PSIQ) across four timepoints from January 2016–December 2019. The residents were classified as junior (first 3 years) or senior residents (years 4–5). Linear mixed model analyses were conducted, with time in training, seniority status (junior versus senior residents), duration of psychiatry postings prior to residency, and their interaction as associated factors with PI over time. Results Time in training, seniority, and duration of psychiatry postings before residency (all p < 0.01) were significantly associated with higher PSIQ scores at baseline. Over time, although all residents had increases in PSIQ scores, this rate of change did not differ significantly between junior and senior residents. Discussion Exposure to psychiatry postings before residency, time in learning, and seniority are factors which influence PI development in residents. This has implications for psychiatry residency selection and training, adequate clinical exposure during training rotations, and continual support for new and senior residents to foster PI formation over time.

scholarly journals Partnership among hospitals to reduce healthcare associated infections: a quasi-experimental study in Brazilian ICUs

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Ladjane Santos Wolmer de Melo ◽  
Maria Verônica Monteiro de Abreu ◽  
Bernuarda Roberta de Oliveira Santos ◽  
Maria das Graças Washington Casimiro Carr ◽  
Maria Fernanda Aparecida Moura de Souza ◽  
...  
Keyword(s):  
Experimental Study ◽  
Length Of Stay ◽  
Public Hospitals ◽  
Incidence Density ◽  
Healthcare Associated Infections ◽  
Collaborative Project ◽  
Quasi Experimental ◽  
Tract Infections ◽  
Healthcare Associated ◽  
Over Time

Abstract Background Healthcare-associated infections (HAIs) are relevant in developing countries where frequencies can be at least 3 times higher than in developed countries. The purpose of this research was to describe the intervention implemented in intensive care units (ICUs) to reduce HAIs through collaborative project and analyze the variation over 18 months in the incidence density (ID) of the three main HAIs: ventilator associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs) and catheter-related urinary tract infections (CAUTIs) and also the length of stay and mortality in these ICUs. Methods A quasi-experimental study in five public adult clinical-surgical ICUs, to reduce HAIs, through interventions using the BTS-IHI “Improvement Model”, during 18 months. In the project, promoted by the Ministry of Health, Brazilian philanthropic hospitals certified for excellence (HE), those mostly private, certified as excellence and exempt from security contributions, regularly trained and monitored public hospitals in diagnostics, data collection and in developing cycles to improve quality and to prevent HAIs (bundles). In the analysis regarding the length of stay, mortality, the IDs of VAP, CLABSIs and CAUTIs over time, a Generalized Estimating Equation (GEE) model was applied for continuous variables, using the constant correlation (exchangeable) between assessments over time. The model estimated the average difference (β coefficient of the model) of the measures analyzed during two periods: a period in the year 2017 (prior to implementing the project) and in the years 2018 and 2019 (during the project). Result A mean monthly reduction of 0.427 in VAP ID (p = 0.002) with 33.8% decrease at the end of the period and 0.351 in CAUTI ID (p = 0.009) with 45% final decrease. The mean monthly reduction of 0.252 for CLABSIs was not significant (p = 0.068). Length of stay and mortality rates had no significant variation. Conclusions Given the success in reducing VAP and CAUTIs in a few months of interventions, the achievement of the collaborative project is evident. This partnership among public hospitals/HE may be applied to other ICUs including countries with fewer resources.

scholarly journals Wealth-related inequalities in demand for family planning satisfied among married and unmarried adolescent girls and young women in sub-Saharan Africa

2021 ◽  
Vol 18 (S1) ◽  
Author(s):  
Martin K. Mutua ◽  
Yohannes D. Wado ◽  
Monica Malata ◽  
Caroline W. Kabiru ◽  
Elsie Akwara ◽  
...  
Keyword(s):  
Family Planning ◽  
West Africa ◽  
Adolescent Girls ◽  
Young Women ◽  
Rate Of Change ◽  
Sub Saharan Africa ◽  
Demographic And Health Surveys ◽  
Sexually Active ◽  
Sub Saharan ◽  
Over Time

Abstract Background The use of modern contraception has increased in much of sub-Saharan Africa (SSA). However, the extent to which changes have occurred across the wealth spectrum among adolescents is not well known. We examine poor-rich gaps in demand for family planning satisfied by modern methods (DFPSm) among sexually active adolescent girls and young women (AGYW) using data from national household surveys. Methods We used recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys to describe levels of wealth-related inequalities in DFPSm among sexually active AGYW using an asset index as an indicator of wealth. Further, we used data from countries with more than one survey conducted from 2000 to assess DFPSm trends. We fitted linear models to estimate annual average rate of change (AARC) by country. We fitted random effects regression models to estimate regional AARC in DFPSm. All analysis were stratified by marital status. Results Overall, there was significant wealth-related disparities in DFPSm in West Africa only (17.8 percentage points (pp)) among married AGYW. The disparities were significant in 5 out of 10 countries in Eastern, 2 out of 6 in Central, and 7 out of 12 in West among married AGYW and in 2 out of 6 in Central and 2 out of 9 in West Africa among unmarried AGYW. Overall, DFPSm among married AGYW increased over time in both poorest (AARC = 1.6%, p < 0.001) and richest (AARC = 1.4%, p < 0.001) households and among unmarried AGYW from poorest households (AARC = 0.8%, p = 0.045). DPFSm increased over time among married and unmarried AGYW from poorest households in Eastern (AARC = 2.4%, p < 0.001) and Southern sub-regions (AARC = 2.1%, p = 0.030) respectively. Rwanda and Liberia had the largest increases in DPFSm among married AGYW from poorest (AARC = 5.2%, p < 0.001) and richest (AARC = 5.3%, p < 0.001) households respectively. There were decreasing DFPSm trends among both married (AARC = − 1.7%, p < 0.001) and unmarried (AARC = − 4.7%, p < 0.001) AGYW from poorest households in Mozambique. Conclusion Despite rapid improvements in DFPSm among married AGYW from the poorest households in many SSA countries there have been only modest reductions in wealth-related inequalities. Significant inequalities remain, especially among married AGYW. DFPSm stalled in most sub-regions among unmarried AGYW.

scholarly journals Impact of Medicare’s Bundled Payments Initiative on Patient Selection, Payments, and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

2020 ◽  
Vol 13 (9) ◽  
Author(s):  
Christian McNeely ◽  
E. John Orav ◽  
Jie Zheng ◽  
Karen E. Joynt Maddox
Keyword(s):  
Length Of Stay ◽  
Patient Selection ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Intervention Period ◽  
Difference In Differences ◽  
Emergency Department Use ◽  
Bundled Payments ◽  
Percutaneous Coronary ◽  
And Control

Background: The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown. Methods and Results: We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, P =0.048; control hospitals +$551, P =0.022; difference in differences $122, P =0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change −$2918, P <0.001; control baseline, $36 877, change −$2618, P <0.001; difference in differences, $300; P =0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG. Conclusions: Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.

scholarly journals A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

2021 ◽  
Author(s):  
Y. Kalbas ◽  
M. Lempert ◽  
F. Ziegenhain ◽  
J. Scherer ◽  
V. Neuhaus ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Descriptive Analysis ◽  
Patient Characteristics ◽  
Severe Trauma ◽  
Diagnostic Tools ◽  
Trauma Patients ◽  
Treatment Algorithms ◽  
Injured Patients ◽  
Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

PCAOB Inspections and Large Accounting Firms

2011 ◽  
Vol 26 (1) ◽  
pp. 43-63 ◽  
Author(s):  
Bryan K. Church ◽  
Lori B. Shefchik
Keyword(s):  
Audit Quality ◽  
Linear Trend ◽  
Dominant Role ◽  
Data Availability ◽  
Financial Statement ◽  
Public Companies ◽  
Accounting Firms ◽  
Big 4 ◽  
Second Tier ◽  
Over Time

SYNOPSIS The purpose of this paper is to analyze the PCAOB's inspection reports of large, annually inspected accounting firms. The inspection reports identify audit deficiencies that have implications for audit quality. By examining the inspection reports in detail, we can identify the nature and severity of audit deficiencies; we can track the total number of deficiencies over time; and we can pinpoint common, recurring audit deficiencies. We focus on large accounting firms because they play a dominant role in the marketplace (i.e., they audit public companies that comprise approximately 99 percent of U.S.-based issuer market capitalization). We document a significant, downward linear trend in the number of deficiencies from 2004 to 2009. We also identify common, recurring audit deficiencies, determine the financial statement accounts most often impacted by audit deficiencies, and isolate the primary emphasis of the financial statement impacted. Our findings generally are consistent comparing Big 4 and second-tier accounting firms, though a few differences emerge. In addition, we make comparisons with findings that have been documented for small, triennially inspected firms. Data Availability: The data are available from public sources.

Prognostication of Asymptomatic Penetrating Aortic Ulcers: A Modern Approach

Circulation ◽  
2021 ◽  
Author(s):  
Charles DeCarlo ◽  
Christopher A. Latz ◽  
Laura T. Boitano ◽  
Young Kim ◽  
Adam Tanious ◽  
...  
Keyword(s):  
Cumulative Incidence ◽  
Radiographic Progression ◽  
Intramural Hematoma ◽  
Rate Of Change ◽  
Change Over Time ◽  
Modern Approach ◽  
Ulcer Size ◽  
Risk Of Death ◽  
Over Time

Background: Literature detailing the natural history of asymptomatic penetrating aortic ulcers (PAU) is sparse and lacks long-term follow-up. This study sought to determine the rate of asymptomatic PAU growth over time and adverse events from asymptomatic PAU. Methods: A cohort of patients with asymptomatic PAU from 2005-2020 was followed. One ulcer was followed per patient. Primary endpoints were change in size over time and the composite of symptoms, radiographic progression, rupture, and intervention; cumulative incidence function estimated the incidence of the composite outcome. Ulcer size and rate of change were modeled using a linear mixed effects model. Patient and anatomic factors were evaluated as potential predictors of the outcomes. Results: There were 273 patients identified. Mean age was 75.5±9.6 years; 66.4% were male. The majority of ulcers were in the descending thoracic aorta (53.9%), followed by abdominal aorta (41.4%), and aortic arch (4.8%). Fusiform aneurysmal disease was present in 21.6% of patients at a separate location; 2.6% had an associated intramural hematoma; 23.6% had at least one other PAU. Symptoms developed in one patient who ruptured; 8 patients (2.9%) underwent an intervention for PAU (one for rupture, 2 for radiographic progression, 5 for size/growth) at a median of 3.1 years (IQR:1.0-6.5) after diagnosis. Five and 10-year cumulative incidence of the primary outcome, adjusted for competing risk of death, was 3.6% (95% CI: 1.6-6.9%) and 6.5% (95% CI: 3.1-11.4%), respectively. For 191 patients with multiple CT scans (760 total CT's) with median radiographic follow-up of 3.50 years (IQR:1.20-6.63 years), mean initial ulcer width, ulcer depth, and total diameter in millimeters (mm) was 13.6, 8.5, and 31.4, respectively. Small, but statistically significant change over time was observed for ulcer width (0.23 mm/year) and total diameter (0.24 mm/year); ulcer depth did not significantly change over time. Hypertension, hyperlipidemia, diabetes, initial ulcer width>20 mm, thrombosed PAU, and associated saccular aneurysm were associated with larger changes in ulcer size over time, however the magnitude of difference was small, ranging from 0.4-1.9 mm/year. Conclusions: Asymptomatic PAU displayed minimal growth and infrequent complications including rupture. Asymptomatic PAU may be conservatively managed with serial imaging and risk-factor modification.

Abstract 15416: Longitudinal Assessment of Electrical-Mechanical Interactions in Children and Young Adults With Repaired Tetralogy of Fallot

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Suellen M Yin ◽  
Laura M Mercer-rosa ◽  
Jungwon Min ◽  
Elizabeth Goldmuntz ◽  
Victoria L Vetter
Keyword(s):  
Young Adults ◽  
Sudden Cardiac Death ◽  
Right Ventricular ◽  
Tetralogy Of Fallot ◽  
Cardiac Death ◽  
Volume Ratio ◽  
Rate Of Change ◽  
Ventricular Ectopy ◽  
Repaired Tetralogy Of Fallot ◽  
Over Time

Introduction: Electrical-mechanical interactions contribute to arrhythmias, sudden cardiac death, and right ventricular remodeling in repaired tetralogy of Fallot (TOF). Hypothesis: There are significant changes in electrocardiographic properties and electrical-mechanical interactions that occur over time after complete TOF repair and with pulmonary valve replacement (PVR). Methods: This retrospective cohort study of 177 patients, initially recruited for a cross-sectional research protocol, underwent complete TOF repair at 0.3±0.9 years with 21.5±4.2 years of clinical follow-up. We assessed ECG, Holter, cardiopulmonary exercise testing (CPET), and MRI data. We used linear mixed effects models to examine QRS duration (QRSd) and its rate of change over time, associations between comparable ECG and MRI, Holter and MRI, ECG and Holter, ECG and CPET, and pre-PVR and post-PVR results. Results: QRSd increased after TOF repair, but the rate of change decreased from 5.2 ms/year 1 year post-operatively to 1.7 ms/year 20 years post-operatively. Twenty years from TOF repair, post-operative arrhythmias included ventricular ectopy: ventricular tachycardia (4 of 20 patients) on Holter and premature ventricular contractions (14 of 19 patients) on CPET. QRSd was positively associated with right ventricular (RV) volumes, RV:left ventricular (LV) end-diastolic volume ratio, and complex ventricular ectopy on Holter; and negatively associated with RV ejection fraction (EF). The association between QRSd and RV volumes was weaker post-PVR. QRSd and its rate of change were associated with increased LV volume post-PVR. Complex ventricular ectopy was associated with lower LV EF, and significant atrial ectopy was associated with higher LV mass-to-volume ratio. Conclusions: Substantial ventricular ectopy occurs in adolescents and young adults after repair of TOF. Electrophysiologic changes included QRSd prolongation that progressively slowed. QRSd and its rate of change were associated with published risk factors for arrhythmia and sudden cardiac death, and with indications for PVR. Our ongoing research aims to identify an optimal threshold of pre-PVR QRSd and its rate of change that preserves bi-ventricular electrical-mechanical coupling post-PVR.

scholarly journals Net protein contribution of beef feedlots from 2006 to 2017

2019 ◽  
Vol 3 (4) ◽  
pp. 1575-1584 ◽  
Author(s):  
Jessica R Baber ◽  
Jason E Sawyer ◽  
Ben P Holland ◽  
Kendall J Karr ◽  
Alyssa B Word ◽  
...  
Keyword(s):  
Conversion Efficiency ◽  
Protein Quality ◽  
Rate Of Change ◽  
Parameter Estimates ◽  
Protein Requirements ◽  
High Quality Protein ◽  
Cereal Grain ◽  
Net Protein ◽  
Over Time ◽  
Edible Protein

Abstract: Feedlot efficiency increases as technologies are adopted and new feed ingredients, especially byproducts, become available and incorporated into diets. Byproduct availability increased in response to the renewable fuels standard of 2005, creating substantial amounts of feedstuffs best used by ruminants. Cereal grains have been partially replaced with human-inedible byproducts, as they provide comparable levels of energy in cattle diets. To evaluate the effects of changes in diet and feedlot production practices on net protein contribution (NPC) and human-edible protein conversion efficiency (HePCE) across time, a deterministic NPC model was used. NPC was assessed for the feedlot industry using lot level production data from 2006 to 2017 for eight commercial feedlots. Ingredient and nutrient composition was collected for a representative starter and finisher diet fed for each year from each feedlot. NPC was calculated by multiplying human-edible protein (HeP) in beef produced per unit of HeP in feed by the protein quality ratio (PQR). Systems with NPC &gt;1 positively contribute to meeting human protein requirements; NPC &lt; 1 indicates competition with humans for HeP. NPC was regressed on year to evaluate temporal change in NPC. Feedlots were categorized as increasing NPC (INC; slope &gt; 0) or constant NPC (CON; slope = 0) according to regression parameter estimates. Four feedlots were categorized as INC and four were CON. The rate of change in PQR was similar for CON and INC (P ≥ 0.79), although rates of change among INC and CON differed for byproduct and cereal grain inclusion (P ≤ 0.01) across years evaluated. Feedlots categorized as INC reduced HeP consumed by 2.39% per year, but CON feedlots did not reduce HeP consumed each year (0.28%). Cattle received and shipped by INC were lighter than those in CON feedlots (P &lt; 0.01). Across years, INC produced more HeP (20.9 vs. 19.2 kg/hd) than CON (P &lt; 0.01), and both feedlot types tended to improve HeP gained over time (0.1 kg per year; P = 0.10). Differences in slope over time for INC and CON were observed for conversion efficiency of HeP (P &lt; 0.01). NPC increased 0.027 units per year for INC (P &lt; 0.01) and was 0.94 in 2017. NPC by the feedlot sector improved from 2006 to 2017, decreasing the amount of human-edible feeds required to produce more high-quality protein from beef.

Loading Strategies in Acute Mania

CNS Spectrums ◽  
2001 ◽  
Vol 6 (11) ◽  
pp. 919-922, 930 ◽  
Author(s):  
Brendan T. Carroll ◽  
Arthur Thalassinos ◽  
Jay D. Fawver
Keyword(s):  
Valproic Acid ◽  
Length Of Stay ◽  
Adverse Effects ◽  
Patient Selection ◽  
High Light ◽  
Acute Mania ◽  
Divalproex Sodium ◽  
Haloperidol Decanoate ◽  
Potential Benefits ◽  
Selection For

AbstractTreatment of acute mania has been greatly influenced by loading strategies. Loading has potential benefits, including rapid symptom reduction in mania and a shortened length of stay. Disadvantages include an increased likelihood of adverse effects of the medications. Loading strategies for lithium, valproic acid (divalproex sodium), carbamazepine, oxcarbazepine, olanzapine, and haloperidol decanoate in the treatment of acute mania are discussed. Recent studies high-light this treatment option for selected patients. It is the unique properties of the medications that influence their use in loading. Issues in patient selection for loading strategies with each medication are also considered.

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