scholarly journals On the Brink of Disaster

2021 ◽  
Vol 2 (2) ◽  
Author(s):  
Valentina Petrolini
Keyword(s):  
At Risk ◽  
Clinical Practice ◽  
Clinical Relevance ◽  
Complex Nature ◽  
Philosophy Of Psychiatry

The notions of at-risk and subthreshold conditions are increasingly discussed in psychiatry to describe mild, brief, or otherwise atypical syndromes that fail to meet the criteria for clinical relevance. However, the concept of vulnerability is still underexplored in philosophy of psychiatry. This article discusses psychiatric vulnerability to clarify some conceptual issues about the various factors contributing to vulnerability, the notions of risk and protection, and the idea that there are multiple ways of crossing the threshold to clinical relevance. My goal is to lay the groundwork for a finer-grained discussion on psychiatric vulnerability that reflects the complex nature of mental conditions and illustrates the kind of thinking needed in clinical practice.

scholarly journals Clinically Applicable Segmentation of Head and Neck Anatomy for Radiotherapy: Deep Learning Algorithm Development and Validation Study

10.2196/26151 ◽  
2021 ◽  
Vol 23 (7) ◽  
pp. e26151
Author(s):  
Stanislav Nikolov ◽  
Sam Blackwell ◽  
Alexei Zverovitch ◽  
Ruheena Mendes ◽  
Michelle Livne ◽  
...  
Keyword(s):  
Computed Tomography ◽  
At Risk ◽  
Deep Learning ◽  
Clinical Practice ◽  
Head And Neck ◽  
Organs At Risk ◽  
Data Set ◽  
Computed Tomography Scans ◽  
Neck Anatomy ◽  
Organ At Risk

Background Over half a million individuals are diagnosed with head and neck cancer each year globally. Radiotherapy is an important curative treatment for this disease, but it requires manual time to delineate radiosensitive organs at risk. This planning process can delay treatment while also introducing interoperator variability, resulting in downstream radiation dose differences. Although auto-segmentation algorithms offer a potentially time-saving solution, the challenges in defining, quantifying, and achieving expert performance remain. Objective Adopting a deep learning approach, we aim to demonstrate a 3D U-Net architecture that achieves expert-level performance in delineating 21 distinct head and neck organs at risk commonly segmented in clinical practice. Methods The model was trained on a data set of 663 deidentified computed tomography scans acquired in routine clinical practice and with both segmentations taken from clinical practice and segmentations created by experienced radiographers as part of this research, all in accordance with consensus organ at risk definitions. Results We demonstrated the model’s clinical applicability by assessing its performance on a test set of 21 computed tomography scans from clinical practice, each with 21 organs at risk segmented by 2 independent experts. We also introduced surface Dice similarity coefficient, a new metric for the comparison of organ delineation, to quantify the deviation between organ at risk surface contours rather than volumes, better reflecting the clinical task of correcting errors in automated organ segmentations. The model’s generalizability was then demonstrated on 2 distinct open-source data sets, reflecting different centers and countries to model training. Conclusions Deep learning is an effective and clinically applicable technique for the segmentation of the head and neck anatomy for radiotherapy. With appropriate validation studies and regulatory approvals, this system could improve the efficiency, consistency, and safety of radiotherapy pathways.

Measuring Visualized Joint Surface in Hallux Metatarsophalangeal Arthroscopy

2018 ◽  
Vol 39 (8) ◽  
pp. 978-983
Author(s):  
Michael Hull ◽  
John T. Campbell ◽  
Clifford L. Jeng ◽  
R. Frank Henn ◽  
Rebecca A. Cerrato
Keyword(s):  
Clinical Practice ◽  
Clinical Relevance ◽  
Articular Surface ◽  
Proximal Phalanx ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Lateral View ◽  
Joint Surface ◽  
Foot And Ankle ◽  
Kirschner Wires

Background: Arthroscopy has been increasingly used to evaluate small joints in the foot and ankle. In the hallux metatarsophalangeal (MTP) joint, little data exist evaluating the efficacy of arthroscopy to visualize the articular surface. The goal of this cadaveric study was to determine how much articular surface of the MTP joint could be visualized during joint arthroscopy. Methods: Ten fresh cadaveric foot specimens were evaluated using standard arthroscopy techniques. The edges of the visualized joint surface were marked with curettes and Kirschner wires; the joints were then surgically exposed and imaged. The visualized surface area was measured using ImageJ® software. Results: On the distal 2-dimensional projection of the joint surface, an average 57.5% (range, 49.6%-65.3%) of the metatarsal head and 100% (range, 100%-100%) of the proximal phalanx base were visualized. From a lateral view of the metatarsal head, an average 72 degrees (range, 65-80 degrees) was visualized out of an average total articular arc of 199 degrees (range, 192-206 degrees), for an average 36.5% (range, 32.2%-40.8%) of the articular arc. Conclusion: Complete visualization of the proximal phalanx base was obtained. Incomplete metatarsal head visualization was obtained, but this is limited by technique limitations that may not reflect clinical practice. Clinical Relevance: This information helps to validate the utility of arthrosocpy at the hallux metatarsophalangeal joint.

A multiparametric ICD algorithm for heart failure risk stratification and management: an analysis in clinical practice

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
L Calo" ◽  
V Bianchi ◽  
D Ferraioli ◽  
L Santini ◽  
A Dello Russo ◽  
...  
Keyword(s):  
Heart Failure ◽  
At Risk ◽  
Clinical Practice ◽  
Risk Stratification ◽  
Management Strategies ◽  
Cardiac Resynchronization ◽  
Office Visits ◽  
Increased Risk ◽  
Patients At Risk ◽  
Observation Period

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The HeartLogic algorithm combines multiple implantable cardioverter defibrillator (ICD) sensors to identify patients at risk of heart failure (HF) events. Purpose We sought to evaluate the risk stratification ability of this algorithm in clinical practice. We also analyzed the alert management strategies adopted in the study group and their association with the occurrence of HF events. Methods The HeartLogic feature was activated in 366 ICD and cardiac resynchronization therapy ICD patients at 22 centers. The HeartLogic algorithm automatically calculates a daily HF index and identifies periods IN or OUT of an alert state on the basis of a configurable threshold (in this analysis set to 16). Results The HeartLogic index crossed the threshold value 273 times (0.76 alerts/patient-year) in 150 patients over a median follow-up of 11 months [25-75 percentile: 6-16]. Overall, the time IN the alert state was 11% of the total observation period. Patients experienced 36 HF hospitalizations and 8 patients died of HF (rate: 0.12 events/patient-year) during the observation period. Thirty-five events were associated with the IN alert state (0.92 events/patient-year versus 0.03 events/patient-year in the OUT of alert state). The hazard ratio in the IN/OUT of alert state comparison was (HR: 24.53, 95% CI: 8.55-70.38, p < 0.001), after adjustment for baseline clinical confounders. Alerts followed by clinical actions were associated with a lower rate of HF events (HR: 0.37, 95% CI: 0.14-0.99, p = 0.047). No differences in event rates were observed between in-office and remote alert management. By contrast, verification of HF symptoms during post-alert examination was associated with a higher risk of HF events (HR: 5.23, 95% CI: 1.98-13.83, p < 0.001). Conclusions This multiparametric ICD algorithm identifies patients during periods of significantly increased risk of HF events. The rate of HF events seemed lower when clinical actions were undertaken in response to alerts. Extra in-office visits did not seem to be required in order to effectively manage HeartLogic alerts, while post-alert verification of symptoms seemed useful in order to better stratify patients at risk of HF events.

Neurologist, 30 years’ experience, Italy

2020 ◽  
pp. 257-259
Author(s):  
Markus Reuber ◽  
Gregg H. Rawlings ◽  
Steven C. Schachter
Keyword(s):  
At Risk ◽  
Clinical Practice ◽  
Case Reports ◽  
Epileptic Seizures ◽  
Correct Treatment ◽  
Risk Of Death ◽  
Convulsive Seizures ◽  
Clinical Conditions

This chapter assesses how, in clinical practice, the diagnostic and therapeutic borders between epileptic and Psychogenic Non-Epileptic Seizures (PNES) are ill-defined and sometimes contrast with the schematic views offered by scientific reports. It specifically considers two case reports that illustrate how it is difficult to distinguish the two clinical conditions at the time of the diagnosis and, when the diagnosis is apparently clear, to start the correct treatment. The first patient was referred with seizures characterized by “convulsions” accompanied by loss of awareness. His seizures started when he was caught in an emergency and was at risk of death. The second patient, a 24-year-old girl, was hospitalized because she had experienced “convulsive” seizures. She received contrasting opinions regarding her diagnosis.

Sexual behaviour

2020 ◽  
pp. 1597-1599
Author(s):  
Catherine H. Mercer ◽  
Anne M. Johnson
Keyword(s):  
At Risk ◽  
Human Immunodeficiency Virus ◽  
Clinical Practice ◽  
Sexual Behaviour ◽  
Sexual Partners ◽  
Sexual History ◽  
Sexually Transmitted ◽  
Immunodeficiency Virus ◽  
Effective Contraception ◽  
People First

Discussion of sexual lifestyle and the ability to take a sexual history are relevant to many types of clinical practice. The age at which people first have sex has decreased and the age at which people start cohabiting has become later in recent decades, increasing the time available to accumulate sexual partners and thus be at risk of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). While many people have few partners, a small proportion of the population has many. People with many partners are most at risk of STIs, but there are many other influences including the gender, age, and ethnicity of their partners and the type of sexual practice. This chapter covers the adverse consequences of sexual behaviour (including STIs and unintended pregnancy), and initiatives to encourage reducing partner numbers, using condoms and effective contraception, and engaging in less risky practices.

Cardiovascular genetics: the role of genetic testing in diagnosis and management of patients with hypertrophic cardiomyopathy

Heart ◽  
2020 ◽  
pp. heartjnl-2020-316798
Author(s):  
Monica Ahluwalia ◽  
Carolyn Y Ho
Keyword(s):  
At Risk ◽  
Clinical Practice ◽  
Genetic Testing ◽  
Hypertrophic Cardiomyopathy ◽  
Clinical Manifestations ◽  
Left Ventricular ◽  
Family Management ◽  
Panel Testing ◽  
Pathogenic Variants ◽  
Gene Panel Testing

Genetic testing in hypertrophic cardiomyopathy (HCM) is a valuable tool to manage patients and their families. Genetic testing can help inform diagnosis and differentiate HCM from other disorders that also result in increased left ventricular wall thickness, thereby directly impacting treatment. Moreover, genetic testing can definitively identify at-risk relatives and focus family management. Pathogenic variants in sarcomere and sarcomere-related genes have been implicated in causing HCM, and targeted gene panel testing is recommended for patients once a clinical diagnosis has been established. If a pathogenic or likely pathogenic variant is identified in a patient with HCM, predictive genetic testing is recommended for their at-risk relatives to determine who is at risk and to guide longitudinal screening and risk stratification. However, there are important challenges and considerations to implementing genetic testing in clinical practice. Genetic testing results can have psychological and other implications for patients and their families, emphasising the importance of genetic counselling before and after genetic testing. Determining the clinical relevance of genetic testing results is also complex and requires expertise in understanding of human genetic variation and clinical manifestations of the disease. In this review, we discuss the genetics of HCM and how to integrate genetic testing in clinical practice.

137 Fall-Risk Increasing Drugs

2019 ◽  
Vol 48 (Supplement_4) ◽  
pp. iv34-iv39
Author(s):  
Nathalie Van Der Velde
Keyword(s):  
Risk Factors ◽  
Clinical Practice ◽  
Clinical Relevance ◽  
Fall Risk ◽  
Drug Withdrawal ◽  
Complex Interactions ◽  
Optimal Drug ◽  
Lowering Drug ◽  
Risk Factors For Falls

Abstract Use of certain drugs (psychotropic and cardiovascular) has been indicated as one of the major risk factors for falls. However, in clinical practice, physicians struggle with withdrawal of fall-risk-increasing drugs. At the heart of this struggle lies the inadequacy of our knowledge pertaining to the effectiveness of drug withdrawal for individual patients. Complex interactions between risk factors for falls can be expected, especially for drug-related fall incidents, as both drug-drug interactions as well as drug-disease interactions are known to be of clinical relevance. Also, specific biomarkers may be of importance, such as genetic variations as was recently shown by our group. By lowering drug-related fall risk, loss of quality of life, institutionalization and death can be prevented. For optimal drug withdrawal in clinical practice, better understanding and prediction of drug-related fall risk is essential. The presentation will address identification of fall-risk increasing drugs and specifically predictive factors that may be of clinical relevance such as the effect of genetic variation on medication-related falls.

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