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PubMed2004

A case of a BB-gun pellet injury to the ethmoid sinus in a child.

Injuries caused by BB and pellet guns remain common among children. These guns fire low-velocity missiles that can cause considerable harm when fired at close range. Most injuries occur in adolescents as a result of accidental or careless shooting. Such injuries to head and neck sites are common, second only to injuries to the extremities. We report the case of a 10-year-old girl who was accidentally shot by a BB gun. The BB pierced the skin of her right cheek, traversed the right maxillary sinus walls, and lodged at the junction of the right ethmoid sinus and septum. Preoperative radiology combined with endoscopic surgery techniques and instrumentation allowed us to precisely locate and remove the steel ball from the paranasal sinus while the patient was under general anesthesia. We review the scope of maxillofacial injuries caused by BB and pellet guns, and we discuss their presentation, diagnosis, and management. Although these guns are easily bought and sold as toys, they are weapons capable of causing significant injury.

Child↗
PubMed2006

[Complementary medicine research in Israel between the years 1994-2004].

Alternative and complementary medicine (CAM) is gaining the attention of the medical academic community due to increased public use and ongoing concern of efficacy, safety and quality of CAM treatments. The aim of this work was to review the scope of research that was performed in Israel during the past 10 years. We detected 91 works that focus on clinical research: RCT's, pilot studies, comparative studies, surveys of prevalence & patterns of use, and the attitudes of the medical establishment and of medical students. The results of this work indicate considerable progress in the research of CAM within medical establishments in Israel. We believe that future research will benefit from an upgrading of quality of research that will further focus on cost-effectiveness as well as on possible adverse effects of CAM. This goal can be achieved through appropriate research training of MD's and CAM therapists, and by governmental funding of the research.

Complementary Therapies↗
PubMed2006

The Law Reform (Epidemic Preparedness) Bill--a proper response to the pandemic threat?

The ethical frameworks for public health practice are not as clearly articulated as those used in clinical medicine. This poses problems when Medical Officers of Health are required to exercise coercive powers over individuals in the context of communicable disease control. Proposed legislation exacerbates this problem. The Law Reform (Epidemic Preparedness) Bill, recently introduced into Parliament, extends coercive powers but does not provide legal protection for individuals subject to such powers. A framework exists to critique the legitimacy of coercive public health powers and includes the principles of necessity, effectiveness, proportionality, and fairness. The fairness principle is under threat in the draft Bill, which fails to provide "due process" procedures to protect the rights of individuals. Experience in managing the SARS epidemic suggests that coercive powers alone will not enhance the response to public health crises. Respect for individual rights, a positive relationship between government and the community, and the scope for review of decisions are more consistent with modern public health practice and are likely to lead to improved outcomes. In our view, the Bill should be amended to include legal protection for individuals before it is passed into law.

Coercion↗
PubMed2006

Resilience in homeless adults: a review of literature.

Although the concept of resilience has been studied for the past three decades, a paucity of research has focused on this concept in homeless adults, particularly among homeless adults who are persons of color African-Americans have been characterized as being resilient and it has been reported that African-Americans are disproportionately represented among the homeless population nationwide. The purpose of this article is to review the scope of research previously done in the area of resilience in homeless adults and to highlight the importance of the concept of resilience in the lives and existence of this at-risk group. Homeless adults face enormous stressors on a daily basis as they navigate a minefield of mental, physical, and environmental risks. How they respond and how they adapt to these stressors can potentially affect their health outcomes as well as their quality of life. The seven articles retrieved for this article support the contention that further research is needed to increase the understanding of how the concept of resilience impacts the ability of homeless adults, and in particular persons of color to endure and survive despite their adverse conditions.

Adaptation, Psychological↗
PubMed1990

The grief process in those admitted to regional secure units following homicide.

Although there is considerable literature on grief and grief work, there have been few studies of the grief process in those who have killed someone. This paper reviews the scope of this problem in England and Wales and examines a number of issues in connection with the grieving process in those who have killed but, because they were found to be suffering from an "abnormality of mind" at the time of the offence, were found not guilty of murder. Increasingly, these patients are referred for treatment to Regional Secure Units, under hospital orders of the Mental Health Act of 1983.

Adult↗
PubMed1990

[Family physician: problems and realities].

The experience gained in the Soviet Union and abroad with family physician service is reviewed. The scope of his duties is outlined which are to be adjusted for specific conditions of rural and city health care. The family physician is to be neither a particular specialist nor an expert in all fields of medicine, rather a broad-minded and skilled internist informed about social and psychological matters and able to attend both adults and adolescents. The chief goal of his practice should be prophylaxis medicine, regular check-ups. Extensive experimental research is needed to adopt the system of family physician in this country as it necessitates revision of conventional principles of industrial, school, outpatient services, training of medical staff, etc.

Estonia↗
PubMed1989

Suicidal behavior in adolescents and young adults: the international picture.

This chapter has reviewed the scope of suicide and attempted suicide among the young from an international perspective. Socio-demographic trends have been analyzed and explanatory theories for international differences proposed. An international strategy for prevention is discussed and specific recommendations are presented. Efforts are to be made to translate international strategies to prevent youth suicide into community, clinical, and research programs that can be effectively implemented around the world.

Adolescent↗
PubMed1996

Summary of track D: social science: research, policy and action.

SCOPE: This review summarizes the main issues discussed during Track D, which examined the societal impact of HIV/AIDS, and responses to the epidemic by individuals, families, communities and societies worldwide. Micro- and macrolevel issues addressed included the development, implementation and evaluation of programmes for prevention and care; policy development and implementation; structural issues such as the impact of gender relations, development and migration on the development of the epidemic; and the social and economic impact of HIV/AIDS on affected societies and communities. RECURRENT THEMES: Presentations provided strong evidence that peer-led, community-based programmes offer particularly effective ways of working, and that participatory research involving affected communities provides useful results for the design and evaluation of programmes and policies. This is the case across settings, issues, populations and countries. FUTURE DIRECTIONS: Emerging needs include how best to ensure sustainability of national and international responses, how best to scale up successful interventions for wider reach, and how best to work with systematically marginalized, neglected groups and populations. Research priorities include the characterization of the multiple determinants of HIV-related vulnerability, and the evaluation of interventions that take these complex determinants as their starting point. A more coherent and strategic response requires less separation between the different constituencies involved in AIDS work, and the more sustained involvement of people living with HIV/AIDS themselves.

Community Health Services↗
PubMed1992

PRO update. Transition from the third to fourth scope of work.

The Health Care Financing Administration (HCFA) began implementation of the transition from the Third Peer Review Organization (PRO) Scope of Work to the Fourth PRO Scope of Work on October 1, 1991. PROs in 11 states are currently implementing newly-established medical review requirements under the "Scope of Work," the contract by which PROs are obligated to carry out their statutorily-mandated duties of determining the medical necessity, appropriateness and quality of care delivered to Medicare beneficiaries. Michigan's PRO (MPRO) is scheduled to implement requirements outlined in the Fourth Scope of Work beginning April 1, 1992. This article discusses the American Medical Association's (AMA) relationship to the PRO program and the transition from the Third to the Fourth Scope of Work including the status of the Uniform Clinical Data Set.

American Medical Association↗
PubMed1998

From consultation-liaison psychiatry to psychosocial advocacy: maintaining psychiatry's scope.

OBJECTIVE: To review the status of consultation-liaison (C-L) psychiatry and the forces shaping it, and to propose strategies for dealing with the crisis in which it finds itself. METHOD: A Medline search of C-L psychiatry and related terms, together with hand-searching of C-L psychiatry and psychosomatic journals and bibliographies of found articles, was used for the literature base. The experience of membership of the committees of national and international C-L psychiatry organisations and their interaction with health care administrators was used as the basis for the discussion of strategies. RESULTS: It is argued that patients with physical/psychiatric comorbidity and somatisation have been marginalised by application of narrow definitions of what constitutes 'serious mental disorder' in the public sector. Evidence is presented to support the argument that physical/psychiatric comorbidity is the most common form of psychiatric presentation in the community, that such comorbidity has serious consequences in terms of morbidity, mortality and health-care costs, and that even subthreshold psychiatric symptoms have serious implications when physical comorbidity exists. CONCLUSION: It is concluded that a number of strategies, including pre-admission screening, integrated discharge planning, liaison, as well as shared care with general practitioners, advanced training in C-L psychiatry and more research to establish practice guidelines, are required if psychiatry is to remain a broad-based discipline rather than retreat to being a specialty for psychosis. Consultation-liaison psychiatrists must become the advocates for the psychosocial system.

Australia↗
PubMed2006

Microelectronic array system for molecular diagnostic genotyping: Nanogen NanoChip 400 and molecular biology workstation.

Hundreds of gene mutations responsible for Mendelian disorders are currently tested in the clinical laboratory for pre- and postnatal diagnosis, carrier screening and presymptomatic testing. Since human genetic research is currently focused on determining the etiology of complex diseases, including heart disease, diabetes and neuropsychiatric traits, laboratorians will genotype increasing numbers of clinically relevant loci in the future. This will require accurate, high-throughput and cost-effective genotyping platforms, such as the DNA microarray. The Nanogen NanoChip platforms employ hybridization-based technology, using fluorescent detection and electronic control of the target or probe, to obtain clear genotype signal relative to background, and increased flexibility relative to similar chip-based single nucleotide polymorphism genotyping platforms. The scope of this review is intended to describe the operating principle, chips and instrumentation, analyte-specific reagents, published assay protocols, assay development, and clinical use of the NanoChip platforms. It is beyond the scope of this review to describe the use of NanoChip platforms in basic research, and to compare it against all available clinical single nucleotide polymorphism genotyping applications and platforms.

Computational Biology↗
PubMed1975

Management of intractable pain: the scope and role of nerve blocks: review of one year's experience.

This paper presents the first one year's experience of nerve blocking procedures carried out for the relief of intractable pain. The control of pain is complex and has led to the development of Pain Clinics employing the skills of different specialties. The scope and organisation of such a clinic developed at Auckland Hospital is outlined. Some 103 patients were referred with intractable pain from cancer, musculo-skeletal disorders, neurogenic causes and ischaemic causes and ischaemic problems. Of these, 55 percent derived complete relief. Breakdown of results demonstrate that over 70 percent of patients in the groups of pain of neurogenic and ischaemic origin had complete relief of pain. Recognised complications of major nerve blocking procedures were encountered in a small percentage of patients, but these caused no great concern. Nerve blocks have a definite place in the treatment of chronic pain and form an important adjunct to the overall management.

Anesthetics, Local↗
PubMed2004

Autoantibody testing in children with newly diagnosed type 1 diabetes mellitus.

OBJECTIVES: To determine the role of autoantibody tests for autoimmune diseases in children with newly diagnosed type 1 diabetes mellitus. DATA SOURCES: MEDLINE, EMBASE and the Cochrane Library. Citation lists of included studies were scanned and relevant professional and patient websites reviewed. Laboratories and manufacturers were contacted to identify ongoing or unpublished research. REVIEW METHODS: Following scoping searches on thyroid and coeliac autoantibodies, a systematic review of autoantibody tests for diagnosis of coeliac disease was carried out. Studies were included where cohorts of untreated patients with unknown disease status were included, all patients had undergone the reference test (biopsy) and antibody tests, and sensitivity and specificity were reported or calculable. Selected studies were then evaluated against a quality checklist. Summary statistics of diagnostic accuracy, i.e. sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratios, were calculated for all studies. A decision analytic model was developed to evaluate the cost utility of screening for coeliac disease at diagnosis of diabetes. RESULTS: All antibody tests for diagnosis of coeliac disease showed reasonably good diagnostic test accuracy. Studies reported variable measures of test accuracy, which may be due to aspects of study quality, differences in the tests and their execution in the laboratories, different populations and reference standards. The decision analytic model indicated screening for coeliac disease at diagnosis of diabetes was cost-effective. Sensitivity analyses exploring variations in the cost and disutility of gluten-free diet, the utilities attached to treated and untreated coeliac disease and the decrease in life expectancy associated with treated and untreated coeliac disease did substantially affect the cost-effectiveness of the screening strategies considered. CONCLUSIONS: In terms of test accuracy in testing for coeliac disease, immunoglobulin A (IgA) anti-endomysium is the most accurate test. If an enzyme-linked immunoassay test was required, which may be more suitable for screening purposes as it can be semi-automated, testing for IgA tissue transglutaminase is likely to be most accurate. The decision analytic model shows that the most accurate tests combined with confirmatory biopsy are the most cost-effective, whilst combinations of tests add little or no further value. There is limited information regarding test accuracy in screening populations with diabetes, and there is some uncertainty over whether the test characteristics would remain the same. Further research is required regarding the role of screening in silent coeliac disease and regarding long-term outcomes and complications of untreated coeliac disease.

Adolescent↗
PubMed1976

Androgens and male sexual function: a review of human studies.

The scope of this article will be a review and brief discussion of recently gathered information on androgens and sexual behavior in men. It will include experimental observations on the covariance between androgens, mainly testosterone, and sexual functioning in normal heterosexual men and studies on sexual dysfunction and homo-sexual behavior. The effects of castration, hypogonadal conditions, hormonal replacement, and endogenous testosterone variations on sexual behavior are examined. Further psychoendocrine studies, are necessary to evaluate the role of gonadal hormone production in impotency. Current pharmacological research does not furnish specific evidence, that the administration of androgens or preparations that stimulate the secretion of endogenous androgens have beneficial effects on functional impotence. After reviewing the studies on male homosexuality and androgen levels, the article concludes that it has not been established that homosexual men are characterized by abnormalities in plasma testosterone.

Adolescent↗
PubMed2006

Structured treatment interruptions (STI) in chronic unsuppressed HIV infection in adults.

BACKGROUND: Structured treatment interruptions (STI) of antiretroviral therapy (ART) have been investigated as part of novel treatment strategies, with different aims and objectives depending on the populations involved. These populations include: 1) patients who initiate ART during acute HIV infection; 2) patients with chronic HIV infection, on ART, with successfully suppressed viremia; and 3) patients with chronic HIV infection and treatment failure, with persistent viremia due to multi-drug resistant HIV (Hirschel 2001; Deeks 2002; Miller 2003). In an earlier Cochrane review (Pai 2005), we had summarized the evidence about the effects of STI in chronic suppressed HIV infection. In this review, we summarize the evidence on STI in patients with chronic unsuppressed HIV infection due to drug-resistant HIV. Unsuppressed HIV infection describes those patients who cannot suppress viremia, due to the presence of multi-drug-resistant virus. It is also referred to as treatment failure. Drug resistance is identified by the presence of resistant mutations at baseline.STI as a treatment strategy in HIV-infected patients with chronic unsuppressed viremia involves interrupting ART in controlled clinical settings, for a pre-specified duration of time. These interruptions have various aims, including the following: 1) to allow wild virus to re-emerge and replace the resistant mutant virus, with the hope of improving the efficacy of a subsequent ART regimen; 2) to halt development of drug resistance and to preserve subsequent treatment options; 3) to alleviate treatment fatigue and reduce drug-related adverse effects; and 4) to improve quality of life (Miller 2003; Montaner 2001; Vella 2000;). OBJECTIVES: The objective of our systematic review was to synthesize the evidence on the effect of structured treatment interruptions in adult patients with chronic unsuppressed HIV infection. SEARCH STRATEGY: We included all available intervention studies (randomized controlled trials and non-randomized trials) conducted in HIV-infected patients worldwide. We searched nine databases, covering the period from January 1996 to February 2006. We also scanned bibliographies of relevant studies and contacted experts in the field to identify unpublished research, abstracts and ongoing trials. In the first screen, a total of 3186 potentially eligible citations from nine databases and sources were identified, of which 2047 duplicate citations were excluded. The remaining 1139 citations were examined in detail, and we further excluded 951 citations that were modeling studies, animal studies, case reports, and opinion pieces. As shown in Figure 01, 188 citations were identified in the second screen as relevant for full-text screening. Of these, 60 basic science studies, editorials and abstracts were excluded and 128 full-text articles were retrieved. In the third screen, all full-text articles were examined for eligibility in our review. These were subclassified into three categories: 1) chronic suppressed HIV infection; 2) chronic unsuppressed HIV infection; and 3) acute HIV infection. Studies were further excluded if their abstracts did not contain enough information for inclusion in our reviews. A total of 62 studies were finally classified into chronic suppressed, acute, and chronic unsuppressed categories. Of these, 17 trials met the eligibility criteria for this review. SELECTION CRITERIA: Inclusion criteriaAll available randomized or non-randomized controlled trials investigating planned treatment interruptions among patients with chronic unsuppressed HIV infection. Early pilot non-randomized prospective studies on treatment interruptions of fixed and variable durations were also included. Relevant abstracts on randomized controlled trials were also included if they contained sufficient information. Exclusion criteriaEditorials, reviews, modeling studies, and basic science studies were excluded. Studies on STI among patients with chronic suppressed HIV infection were summarized in a separate review. Studies on STI in primary HIV infection were beyond the scope of this review. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, evaluated study eligibility and quality. Disagreements were resolved in consultation with a third reviewer.A total of seventeen studies on STI were included in our review. However, due to significant heterogeneity across studies (i.e. in study design, populations, baseline characteristics, and reported outcomes; and in reporting of measures of effect, hazard ratios, and risk ratios), we considered it inappropriate to perform a meta-analysis. MAIN RESULTS: In early pilot non-randomized trials, a pattern was evident across studies. During treatment interruption, a decline in CD4 cell counts, increase in viral load, and a shift in the level of genotypic drug resistance towards more of a wild-type HIV virus was reported. This suggests that STI may be used to increase drug susceptibility to an optimized salvage regimen upon treatment re-initiation. These studies generated useful data and hypotheses that were later tested in randomized controlled trials. Randomized controlled trials rated high on quality. Of the eight randomized controlled trials reviewed, seven had been completed while one was ongoing and remains blinded. Of the seven completed randomized controlled trials, six have reported consistent virologic and immunologic patterns, and found no significant benefit in virologic response to subsequent ART in the STI arm, compared to the control arm. In addition, the largest completed randomized trial reported greater numbers of clinical disease progression events and evidence of prolonged negative impact on CD4 cell counts in the STI arm (Beatty 2005; Benson 2004; Deeks 2001; Lawrence 2003; Walmsley 2005; Ruiz 2003). The single RCT with divergent findings from the others (GigHAART), reporting a significant virologic and immunologic benefit due to STI, was different in prescribing a shorter STI duration and a salvage ART regimen of 8-9 drugs. There were also differences in the patient population characteristics with this study, targeting those with very advanced HIV disease (Katlama 2004). Although we await the unblinded results of the eighth RCT (OPTIMA), the evidence so far does not support STI in the setting of chronic unsuppressed HIV infection with antiretroviral treatment failure (Brown 2004; Holodniy 2004; Kyriakides 2002; Singer 2006). AUTHORS' CONCLUSIONS: The current available evidence primarily supports a lack of benefit of STI before switching therapy in patients with unsuppressed HIV viremia despite ART. There is evidence of harm in attempting STI in patients with relatively advanced HIV disease, due to the associated CD4 cell decline and the increased risk of clinical disease progression. At this time, there is no evidence to recommend the use of STI in this clinical category of patients with treatment failure.

Adult↗
PubMed1984

Utilization and quality control Peer Review Program; solicitation of comments on proposed scope of work for waivered and exempt PRO areas--HCFA. Notice.

This notice does not constitute a request for proposal (RFP). The purpose of this notice is to solicit comments on the Scopes of Work prepared as part of the RFPs for Utilization and Quality Control Peer Review Organizations (PROs) for PRO areas waivered or exempted from the Medicare prospective payment system. These areas include Maryland, Massachusetts, New Jersey, New York, Guam, Puerto Rico, and the Virgin Islands.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2004

Chiropractic and geriatrics: a review of the training, role, and scope of chiropractic in caring for aging patients.

Chiropractors may be well-positioned to play an important role in health promotion, injury and disease prevention, and on geriatric care teams, due to their practice style and holistic philosophy. The bottom line in aging care is that someone in the health-care world must provide health promotion and preventive services to older patients before the wave of aged patients profoundly overwhelms our health-care system. Chiropractic services are safe and relatively low-cost, and patient satisfaction with them is very high. In the managed-care environment, time pressures on allopathic providers may preclude them from spending sufficient time discussing health promotion and illness prevention with their patients. Chiropractic, when paid for out-of-pocket, is not as affected by these extreme pressures. With the hands-on nature of chiropractic care, a strong doctor-patient relationship is forged in which health and lifestyle recommendations may be comfortably and effectively discussed. Relative to musculoskeletal care in elderly patients, chiropractic adjustments (spinal manipulative therapy) are recommended by the Agency for Health Care Policy and Research for the care of acute low back pain, and the American Geriatric Society Panel Guidelines for the Management of Chronic Pain state that non-pharmaceutical interventions such as chiropractic may be appropriate. Most geriatric health-care providers have a limited number of options to offer patients with these complaints. Various lower-force chiropractic techniques are available as safe alternatives to drugs and surgery for musculoskeletal complaints in the older patient. Due to the prevalence of these conditions in older patients, and the success of chiropractic in caring for these patients, interdisciplinary geriatric health care teams should include the doctor of chiropractic. Chiropractors, well trained in health assessment, diagnosis, radiographic studies, health promotion, and illness prevention, are well-positioned to provide many primary health-care services to aging patients. This is particularly important to a nation that is straining to provide adequate geriatric health care in rural areas and areas with a shortage of health-care professionals. Continued improvements in geriatric education, and an increase in research and publication on chiropractic care of the aging patient are essential. As stated by Montes and Johnston in the Journal of Health Education: Training, as well as continual upgrading of the competencies for health educators, must include ways of dealing with the great disparities in health among populations, especially those most vulnerable and underserved. Faculty too must be prepared in ... this ever-changing health care delivery system. In a rapidly aging society, chiropractors, (along with all health professions)must prepare themselves to provide optimal health care to this important segment of our society, through excellence in chiropractic education, training,and practice.

Aged↗