Tailor-made Strategy Research Articles

New Minimally Invasive and Tailor-Made Strategy for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation

The optimal dosage for cryoballoon ablation (CBA) of atrial fibrillation (AF) is still unknown. This study aimed to evaluate the clinical implications of a reduction in the freezing duration to <180 seconds during CBA guided by the time to the target temperature. This study enrolled 325 consecutive paroxysmal AF patients who underwent CBA. It was a retrospective observational study in a single centre. It compared 164 patients who underwent a tailor-made CBA procedure (group T) with 161 who had a standard CBA procedure (group S). In group T, the freezing duration was reduced to 150 seconds when the temperature reached ≤ -40 °C within 40 seconds. Furthermore, it was reduced to 120 seconds when it reached ≤ -50 °C within 60 seconds. In the other patients, the freezing duration was 180 seconds, except for excessive freezing of ≤ -60 °C and/or emergent situations while monitoring the oesophageal temperature, and for phrenic nerve injury, as in group S. In group T, 89 patients (83%) underwent CBA with a reduction in the freezing duration. The total freezing time for each pulmonary vein was significantly shorter in group T than group S, and the total procedure time in group T decreased by an average of 4 minutes compared with group S. The rate of requiring additional radio frequency ablation following the CBA was significantly lower in group T than group S. The AF-free survival rate during the follow-up period (median, 366 days) was similar between the two groups. The safety and efficacy of the new CBA strategy were non-inferior to the standard procedure.

Perceived Efficiency Outcomes, Sources and Awareness of Online Health Information among the Elderly during COVID-19.

The Internet and social media are crucial platforms for health information. Factors such as the efficiency of online health information, the outcomes of seeking online health information and the awareness of reliable sources have become increasingly important for the elderly during the COVID-19 pandemic. This study aimed to examine differences between elderly individuals’ income above and below the average monthly wage in relation to their online health information efficiency and the outcomes of seeking online health information; to evaluate types of online information sources with online health information efficiency and the outcomes of seeking online health information; and to explore online health information efficiency as a mediator between health status and awareness of online sources. A cross-sectional study design was conducted with 336 elderly participants age 65 or older. The participants volunteered to complete a questionnaire. No differences were found between the two groups regarding efficiency in retrieving health information from official online health sites and Google. Perceived efficiency mediated health status and awareness of online sources. In these challenging times, it is important to provide a tailor-made education strategy plan for reliable sources of online health information for the elderly, in order to enhance their technology safety skills. It is also important to explore other mediating variables between health status and awareness of online sources.

India on foot: Internal migrants during COVID-19 in India

India, home to a population of 1.2 billion, is the country fourth worst hit by COVID-19 in terms of the total number of cases. Within this humongous population is the category of internal migrant workers who have been hit to the extent that their survival is at stake. Introducing this catastrophic hit, this policy brief purposefully elaborates on the challenges faced by India in dealing with this pandemic. The number of internal migrants in India is greater than the total population of the United Kingdom, France, and Germany put together. This unmasks the need for deliberation on the issue of social security of these migrant workers and the role of the state in providing it. Despite measures like the ‘Inter-state workmen act, 1979’, ‘Unorganised Sector Workers Social Security Act, 2008’, and findings of multiple committees, the migrant workers have not been able to integrate into their destination regions to a satisfactory level. Through this paper, the loopholes in these provisions have been highlighted and it has been explained how these provisions failed miserably when put to test by a global pandemic. The authors point out that given the diversity in India’s states, a one-size-fits approach is bound to fail and thus they endorse the demand for greater decentralisation in decision making when it comes to managing a health crisis. The authors recommend a tailor-made and feasible data collection and maintenance strategy as the base on which new provisions for migrant workers could be formulated.

Unique Hungarian way of cross-cultural management Through an example of a multinational company in the oil and gas industry

Multiculturalism is a new phenomenon in Central-East European countries and has a different meaning than in Western Europe. There are many historical and cultural differences within Europe, as the Eastern countries cannot duplicate the West regarding cross-cultural management, and so they have to make their own tailor-made strategy. The countries that later joined the EU have their own unique position in business in accordance with the Muslim countries. One of the biggest multinational company in Central-East Europe is able to make an entrance into the overruled oil industry successfully. Content analyses of the company published documents, websites are summarized in this current paper in order to highlight the uniqueness of their CCM.

Hay fever and the effect of influenza vaccines

Hay fever is an increasing disease in Japan, and the prevalence of cedar pollinosis exceeds 20% nationwide. More than 50 kinds of pollen have been reported so far in Japan. Pollinosis often complicated other allergic conditions. Since patients with allergic diseases have lower s-IgA levels than healthy subjects, patients with hay fever have less weak mucosal immunity so that it would affect the efficacy of the influenza vaccine. Eight thousand three hundred thirty-seven (3885 men and 4452 women) participated in this survey to clarify the relationship between allergic diseases and the influenza vaccine's efficacy. In the no hay fever group, the effective vaccine rate against influenza disease was 0.2%, and in the hay fever group, it was 0.21%. No effect of the influenza vaccine was present in this population. Rather, vaccination seemed to increase influenza incidence in people with hay fever. The basic presence of allergic condition influenza vaccination increased susceptibility to influenza infection. (12.9% vs. 13.89%) (p&lt;0.001). A tailor-made strategy for these patients should be necessary for preventing influenza.

Anatomy of the Republic of Korea’s Niche Strategic Engagement in the Greater Mekong Sub-region (GMS): ROK’s Tailor-Made Strategy and its Security Policy Implication

Republic of Korea’s engagement in Southeast Asia could be generally understood as its Official Development Aid (ODA) strategy in most academic interpretation. Nonetheless, this article examines not only Korea’s traditional ODA approach toward Southeast Asia but also Korea’s uniquely tailor-made strategy toward Indo-China Peninsula in particular as well as what is to be done. In other words, this article intends to take further step beyond ODA interpretation of this particular subject over this region. This study specifically provides with multi-dimensional analysis of Republic of Korea’s involvement in Mekong River Sub-region as well as its regional and global security policy implication. The main thesis of this study is that Korea had no choice but to pursue Niche diplomacy toward the region because Korea did not possess full capacity enough to compete against Japan or China. In this sense, Korea’s own development experience is very unique and perhaps the only experience that no other country in the world has possessed. This article contends that Korea’s knowledge based capacity building projects toward Greater Mekong Sub-region such as KSP, CIAT, special Master’s degree training projects, local capacity building process, and etc. will continue to increase and diversify in terms of scale and contents. Again, based upon Knowledge based capacity building projects, Korea is in the process of producing a wide range of its unique tailor- made ODA programs for each member states of GMS. Unlike Japan International Cooperation Agency (JICA), Korea also tends to put more emphasis on creating exclusive Master’s degree Training Program which is centered on trainees of ODA Recipient countries. In this regard, Korea’s approach is aiming at strengthening discrimination by introducing a systemic evaluation system for training projects. This program will also turn out linchpin of ROK’s new strategy toward Mekong River area.

P4760New minimally invasive and tailor-made strategy for cryoballoon ablation in patients with paroxysmal atrial fibrillation

Abstract Background Currently, cryoballoon ablation (CBA) has proven to be highly effective in achieving free from atrial fibrillation (AF), especially paroxysmal AF. However, the optimal freezing protocol for each patient to achieve successful pulmonary vein isolation by only CBA is still uncertain. The aim of this study was to evaluate the clinical implications of a reduction in the freezing duration (&lt;180s) during CBA guided by the time to target temperature. Methods From November 2015 to August 2018, 286 consecutive paroxysmal AF patients undergoing CBA were enrolled. We compared 107 patients undergoing a tailor-made CBA procedure (Group A; August 2017-August 2018) to 179 patients with a standard CBA procedure (Group B; November 2015–July 2017). In Group A, the freezing duration was reduced to 150s when the temperature reached ≤−40°C within 40s. Furthermore, we reduced it to 120s when it reached ≤−50°C within 60s. In the other patients, the freezing time was 180s except for excessive freezing over −60°C and/or emergent situations while monitoring the esophageal temperature and for phrenic nerve injury as in Group B. Results The baseline clinical characteristics were similar between two groups. In Group A, 89 patients (83%) underwent CBA with a reduction in the freezing time. The rate of having reduction time in left inferior PV (LIPV) and right inferior PV (RIPV) was lower compared with left superior PV (LSPV) and right superior PV (RSPV) (respectively 17%, 29%, 56%, and 63.5%). However, for right inferior PV, in 31 patients having the reduced freezing time, none of them required touch-up ablation. Although the procedure time and frequency of touch-up ablation did not differ between the 2 groups, total freezing time for each PV was significantly shorter in Group A than Group B as shown in figure (LSPV: 164±28s vs. 216±67s; p&lt;0.001, LIPV: 187±44s vs. 218±69s; p&lt;0.001, RSPV: 147±31s vs. 192±51s; p&lt;0.001, RIPV: 180±50 vs. 218±73s; p&lt;0.001). The AF free survival rate during the follow-up period (356±167 days) was similar between the 2 groups (log-rank test, p=0.38). Furthermore, the complication rate was similar 2 groups. The freezing time for each PV Conclusion The safety and efficacy of the new tailor-made CBA strategy were non-inferior to the standard procedure. This study showed that the unnecessary freezing time could be reduced in most of paroxysmal AF patients.

Screening of perfused combinatorial 3D microenvironments for cell culture

Biomaterials combining biochemical and biophysical cues to establish close-to-extracellular matrix (ECM) models have been explored for cell expansion and differentiation purposes. Multivariate arrays are used as material-saving and rapid-to-analyze platforms, which enable selecting hit-spotted formulations targeting specific cellular responses. However, these systems often lack the ability to emulate dynamic mechanical aspects that occur in specific biological milieus and affect physiological phenomena including stem cells differentiation, tumor progression, or matrix modulation. We report a tailor-made strategy to address the combined effect of flow and biochemical composition of three-dimensional (3D) biomaterials on cellular response. We suggest a simple-to-implement device comprising (i) a perforated platform accommodating miniaturized 3D biomaterials and (ii) a bioreactor that enables the incorporation of the biomaterial-containing array into a disposable perfusion chamber. The system was upscaled to parallelizable setups, increasing the number of analyzed platforms per independent experiment. As a proof-of-concept, porous chitosan scaffolds with 1 mm diameter were functionalized with combinations of 5 ECM and cell-cell contact-mediating proteins, relevant for bone and dental regeneration, corresponding to 32 protein combinatorial formulations. Mesenchymal stem cells adhesion and production of an early osteogenic marker were assessed on-chip on static and under-flow dynamic perfusion conditions. Different hit-spotted biomaterial formulations were detected for the different flow regimes using direct image analysis. Cell-binding proteins still poorly explored as biomaterials components – amelogenin and E-cadherin – were here shown as relevant cell response modulators. Their combination with ECM cell-binding proteins – fibronectin, vitronectin, and type 1 collagen – rendered specific biomaterial combinations with high cell adhesion and ALP production under flow. The developed versatile system may be targeted at widespread tissue regeneration applications, and as a disease model/drug screening platform. Statement of SignificanceA perfusion system that enables cell culture in arrays of three-dimensional biomaterials under dynamic flow is reported. The effect of 31 cell-binding protein combinations in the adhesion and alkaline phosphatase (ALP) production of mesenchymal stem cells was assessed using a single bioreactor chamber. Flow perfusion was not only assessed as a classical enhancer/accelerator of cell growth and early osteogenic differentiation. We hypothesized that flow may affect cell-protein interactions, and that key components driving cell response may differ under static or dynamic regimes. Indeed, hit-spotted formulations that elicited highest cell attachment and ALP production on static cell culture differed from the ones detected for dynamic flow assays. The impacting role of poorly studied proteins as E-cadherin and amelogenin as biomaterial components was highlighted.

An Empirical Analysis of Korean Traditional Dietary (Hansik) Choices Considering Consumers’ Health Status and Attitude

This study aims to discover the health-related lifestyles about Korean traditional dietary (Hansik) choices. We identified which food items are widely perceived as Hansik based on the 2013~2015 Korea National Health and Nutrition Examination Survey (KNHANS) data and investigated distinct patterns of health-related status and behaviors using cluster analysis. Relying on a Tobit approach, we found that age, region, education level, household income, number of household members and marriage status significantly contributed to individual’s rate of Hansik consumption. We also found that the group with relatively younger people characterized by a busy lifestyle and more social activities, those who showed a higher household income, and people who live in metropolitan areas tended to consume less Hansik dietary. We also highlighted that the group with unhealthy lifestyles and risk-averse(cluster 4) tended to consume more Hansik dietary, while the group with healthy lifestyles and risk-prone habits(cluster 2) were likely to consume less Hansik dietary. Regarding policy implications, the result of our study can be used to develop a tailor-made strategy for each group of clusters aimed at increasing Hansik consumption.

Recent Development and Long-Term Results of Open vs EVAR for Pararenal Abdominal Aortic Aneurysms.

In this article, I would like to discuss on the two different treatment options (Open vs EVAR) for pararenal abdominal aortic aneurysm (the term “PRAAA” is not clearly defined and classified). Recently, complex endovascular treatment [Fenestrated EVAR (F-EVAR), Chimney (Snorkel) EVAR (C-EVAR, S-EVAR), Branched EVAR (B-EVAR)] have been developed and applied in selected patients, with encouraging early results; however, the high rate for secondary reinterventions and long-term results remain uncertain. This article introduce new devices and a new concept with endovascular aneurysm sealing (EVAS) are currently available on the market for the treatment of PRAAA. Open repair of PRAAA can be performed with low mortality and long-term survival is favorable from single-center experience in the real world and others. We conclude that open repair remains the golden standard treatment in most centers for PRAAA. However, EVAR of PRAAA may represent an alternative option in high-risk patients. Because the indications and circumstances for PRAAA vary based on patient-specific comorbidities and anatomy, it is recommended that vascular surgeons should be familiar with both treatment strategies and tailor-made strategy for improved long-term results for PRAAA. (This is a translation of Jpn J Vasc Surg 2018; 27: 303–308.)

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation.

BackgroundOveruse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care.ResultsThe type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients’ preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen.ConclusionWe developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.

Pursuing a flexible approach to tympanomastoidectomy: Benefits of a tailor-made strategy in squamosal otitis media

Introduction: The keystone of definitive management in active squamosal chronic otitis media (COM) is surgical correction. Numerous surgical strategies are in vogue, and the choice of surgery is largely governed by the underlying anatomic and pathologic condition. Of recent, much interest has focused on adopting a flexible approach which combines a number of sequential steps that aim to eradicate the disease and reconstruct the hearing apparatus in a single stage procedure, rather than following a traditional approach of modified radical mastoidectomy. Patients and Methods: This randomized, prospective double-blind study comprised 30 patients of various ages and both sexes, diagnosed with a unilateral or bilateral active squamosal chronic otitis media (COM). Of them, 12 (40%) patients were submitted to canal-wall down mastoidectomy, whereas 18 (60%) underwent a canal-wall up procedure. Each patient was followed up for a period of 6 months. The success of the procedure was measured in terms of achieving dry ear; a successful uptake of graft; and improvement in hearing. Results: Post surgery, at the end of 6 weeks, a dry ear was achieved in 25 (83.33%) patients, while the graft was taken up well in 29 (96.67%) patients. At 6 months, the number of patients with dry ear grew to 27 (90%), while the graft was taken up well in 28 (93.33%) patients. Two (6.66%) patients had graft failure. Of the 12 patients with canal-wall down procedure, 9 (75%) patients recorded a hearing improvement of air bone gap (ABG) ≤30 dBHL, while among the 18 patients who had a canal-wall up procedure, 94% had a hearing improvement of ABG ≤ 30 dBHL. Conclusion: Pursuing a flexible approach to tympanomastoidectomy offers a number of distinct benefits. Because the procedure is tailored to the gravity of otologic disease recognized intraoperatively, it fosters a total eradication of the disease and allows a suitable reconstruction of the auditory mechanism. Because the procedure is completed in a single stage, it reduces the time, effort, cost, and discomfort to the patient, while also diminishing the expense and burden on the public healthcare facility.

Five factors and three characteristics of coronary in-stent restenosis.

In the field of interventional cardiology, several patient subsets still present with poor clinical and angiographic outcomes after drug-eluting stent (DES) implantation. The author of this editorial comment supports the idea that in-stent restenosis (ISR) includes three characteristics (severity and extent of stenosis, and tissue characteristics) that are caused by five factors (device, patient, anatomy, procedure, and history). To reduce further revascularization, a tailor-made strategy may be considered in accordance with the factors and characteristics of the individual ISR lesion.

Modelling behavioural change for sustainable transport in Mauritius

Public bus transport is one sustainable option to mobility. However, there is a general negative attitude to its use in many countries. People's preferences and personality traits with respect to the public transport system differ and understanding these differences could be a key to implementing sustainable transport policies. This paper seeks to model the causal determinants of potential behavioural change when car-oriented users face an extended travel choice-set towards public bus transport. A questionnaire is administered to a sample of car-users in Mauritius - a small island state - and using the stated preference econometric method, it is observed that respondents' attitudes for modal change differ according to their socio-economic characteristics such as gender, age, marital status, family size, trip characteristics and geographical locations. The study concludes that improvements in the public transport system are not a panacea for behavioural change. A tailor-made strategy may be essential for changing behaviour towards sustainable mobility.

Phase II study of S-1 monotherapy in patients over 75 years of age with advanced gastric cancer (OGSG0404)

Background: S-1+cisplatin (CDDP) is the standard treatment for advanced gastric cancer (AGC) in Japan and Korea. However, the usefulness of S-1 based chemotherapy for elderly patients is unclear. Therefore, we conducted a multicenter phase II study of S-1 monotherapy for AGC in elderly patients.Materials and Methods: Chemotherapy-naïve patients aged over 75 years with AGC were enrolled. The starting dose of S-1 was determined on the basis of body surface area and modified according to the creatinine clearance value. S-1 was administered twice a day during a 4-week period followed by a 2-week rest period.Results: Thirty-five patients were enrolled. The response rate (RR) was 14·3% and the median overall survival was 14·6 months. Grade 3 or more severe adverse events consisted of anaemia (3%), neutropaenia (3%), anorexia (3%), and fatigue (6%). There were no treatment-related deaths.Conclusion: Our study indicates that S-1 monotherapy is safe and well tolerated in chemotherapy-naïve elderly patients with AGC, but exerts limited activity when given using a tailor-made dosing strategy based on renal function.

P244 Development Of A Tailor-Made Implementation Strategy To Facilitate Adherence To The Dutch Postpartum Hemorrhage Guideline And Moet-Instructions

BackgroundDespite the introduction of a national guideline and the Managing Obstetric Emergencies and Trauma (MOET) course the incidence of postpartum haemorrhage (PPH) is increasing. We suspected inadequate guideline implementation to...

Does institutional delivery help in improving infant and child health care practices and health promotion related parameters? A study from Bellary, Karnataka

Introduction Inspite of emphasis on institutional delivery, a considerable number of births are being conducted at home and by traditional birth attendant (TBA). Institutional delivery is hypothesized to improve the health seeking behavior and health care practices related to infant and child care. In this paper we report that in a poorly performing district institutional delivery does not seem to change the health care practices of the people. Methods The data presented here is a part of a larger two years long study funded by ICMR and conducted at Bellary and Dakshina Kannada district of Karnataka. The results reported pertain to the cross sectional community based house to house survey carried out among 2158 households at Bellary regarding births during the five-year period before survey to ever-married women. The Institutional Ethics Committee had approved this study. Results A total of 1010 deliveries were at the institution while 1148 deliveries took place at home, of which 891 deliveries were conducted by the dais. Majority of mothers who delivered with the help of a dai had not been explained about breastfeeding and its importance. Delayed breastfeeding beyond 2 hours after birth was seen in 38% of institutional deliveries as opposed to 62% home deliveries. Though 79% babies delivered at home were given pre-lacteal feeds, a large number (57%) of those delivered at institution also received pre-lacteal feeds. The weaning practices were also very similar in both the groups. Majority of the women delivered at home (by dais) had undergone antenatal check up by either a doctor (Private 41% and government 21%) or a nurse (12.7%). More than half of the houses where delivery was at home or by a dai were in close proximity (within 5Km in 62 %) to a health facility. Treatment seeking behavior for childhood illness was similar in the institutional and the home birth group. The majority went to private clinic or hospitals (55% home delivery vs 60% hospital) followed by chemist shop (without prescription) and alternate system of medicine. Discussion The health seeking behavior and health care practices depend on the beliefs and awareness among people. Availing antenatal care is hypothesised to promote institutional delivery but this did not seem to be the case in Bellary. Institutional deliveries too did not help in doing away with practices related to delayed breastfeeding and supplementary feeding as well as pre-lacteal feeds. Mere emphasis on institutional delivery seemed to be ineffective in changing the perception and beliefs of people leading to practices which may be harmful to child’s health. Non-utilization of health facilities for delivery in spite of proximity calls for a relook at the availability, affordability and quality of services at these facilities. Institutional delivery per se may not be the answer for infant and child care practices. Sustained efforts by means of campaigns and awareness activities coupled with the use of mass media may help in improving the health care practices. Health systems research and study of local traditions are needed before implementing a tailor-made strategy for improving the health care practices and behavior in a district/region. [509 words]

Targeting tumor microenvironment: the key role of immune system.

In recent years, huge investigations on cancer progression and invasion have led to under-stand the pivotal role of tumor microenvironment. The current era of cancer therapy is based on the concept of simply targeting precise mechanisms to kill or to suppress the growth and expansion of malignant cells. Clinical data clearly correlate with in-vitro re-sults, emphasizing the direct impact of cancer environment on disease progression. This provides the opportunity to advance cancer therapy by virtue of targeting cancerous cells and non-cancerous component of tumor in a combinatorial manner. This tailor-made strategy demands the profound knowledge of cross talk between the bio-factors of tumor environment and corresponding pharmacology of drug candidates. The neighborhood of tumor is critical for how cancer cells grow and invade surrounding tissues. It appears that the tumor microenvironment as a "co-op" includes malignant cells, blood vessels, im-mune/inflammatory factors and extracellular matrix. As a longstanding dilemma, it is well-proved that immune system plays a direct role in the existence and progression of such coop. In some cases, immune cells e.g. tumor associated macrophages (TAMs) infiltrate into tumor and instead of fighting cancer cells, support them to grow. As an important fact, this tumor complexity should not be taken as granted where it can be advantageous in cancer therapy as well as early detection and prevention. The central aim of this editorial article is to highlight the importance of tumor microenvironment for successful cancer therapy.

Derivatives Hedging: SASOL (Pty) Ltd. as an Example

The empirical study analyzes derivative hedging strategies that can be implemented for an investor who has been holding SASOL (Pty) Ltd.’s stocks before February 1999, in relation to that of JSE Top 40 Index. Moreover, as the relationship between SASOL’s stock and the JSE Top 40 Index changes, this empirical report recommends a different derivative hedging strategy based on calculations and the relationship of the two variables-SASOL (Pty) Ltd. and the JSE Top 40 Index. A correct execution of a derivative hedging strategy does not mean that no losses will be incurred, but that ideally, the overall net position of the derivative hedging strategy should be positive. Each investment portfolio needs a tailor-made derivative strategy that fits it well. Furthermore, for hedging strategy to work well, it needs proper monitoring by a skilled professional.

Disaster after the plaster. Fentanyl withdrawal symptoms in a curable hospice patient

Opioids have been used for thousands of years for pain relief. Transdermal fentanyl (TDF) is a synthetic opioid that is prescribed for the treatment of chronic pain. This clinical lesson demonstrates that TDF may be easy to start but sometimes difficult to stop. Like any other opioid there is a substantial risk of physical dependence and subsequent withdrawal symptoms after discontinuation of the drug. Here, we present a case of a hospice patient who developed withdrawal symptoms after a first TDF tapering attempt according to the manufacturer's instructions. A second, more gradual tapering regimen did not result in withdrawal symptoms. The mechanisms and treatment modalities for physical dependence along with a tailor-made tapering strategy that is suitable for general practice are presented in this clinical lesson.