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PubMed1991

Shifting paradigms of international health.

The evolution of international health is showing increasing symptoms of decline. The paradigms of world health crystallized into a clear system of international health relations in the post-war period (1945-1960), based upon the tenet to preserve and promote peace, culminating in the establishment and effectiveness of the World Health Organization (WHO). The last decades have witnessed the emergence of Primary Health Care (PHC) and the subsequent objective of "Health for All" (HFA) as the guiding principles of the field. By the 1990s, however, the strategic weakness of these paradigms has become apparent, yet no realistic substitute is in sight. Unless a serious and urgent attempt is undertaken at reformulating its basic conceptual tenets, the field of international health, and with it WHO, is risking a major decline and could ultimately pass into obscurity and oblivion.

Forecasting↗
PubMed2003

A paradigm shift in patient satisfaction assessment.

The authors investigated the relationships between patients' reactions to health care attributes and their overall satisfaction with primary care. The study found the following: (1) patients' overall satisfaction levels are disproportionately influenced by low levels of their reactions (less satisfied) to the primary care attribute, rather than simply averaged out among attribute reactions. This is a noncompensatory relationship. (2) The marginal impact of primary care attributes on overall satisfaction decreases at higher levels of patients' reactions (more satisfied) to primary care attributes, indicating a nonlinear relationship. Patients combine their reactions to the health care attributes by means of noncompensatory and nonlinear models to form their overall satisfaction. Decision makers should selectively concentrate training resources on those areas of attributes showing high dissatisfaction rather than attempt to improve an attribute that showed the largest parameter estimate. This approach would not only save resources but result in better outcomes of patient satisfaction.

Adult↗
PubMed2004

Strengthening community-based programming for juvenile sexual offenders: key concepts and paradigm shifts.

The past decade has been witness to a sharp increase in residential placement of adjudicated delinquent youth, including juvenile sexual offenders. It is argued that this trend has fiscal implications and may be clinically contraindicated for less characterologically disturbed and dangerous youth. The authors advocate greater investment of public funds in the development and refinement of community-based intervention programs. It is believed that clinically and legally integrated programming, using newer social-ecological methodologies and supports, offers promise of reducing the number of youth who require residential placement, shortening residential lengths of stay and improving the transition of residentially treated youth back into community settings. Key concepts relevant to bolstering community-based programming for juvenile sexual offenders are identified and discussed. Two programs are described, and program evaluation data reviewed, in support of the viability of innovative community-based approaches to the management of this population.

Community Mental Health Services↗
PubMedDate not supplied

Endovascular repair of thoracic aortic aneurysms: a paradigm shift in standard of care.

The standard open surgical treatment of thoracic aortic aneurysms is associated with significant morbidity and mortality. Endovascular repair is less invasive and potentially less morbid for patients with multiple risk factors. The authors report their results in 9 consecutive high-risk patients treated with endovascular grafts from January 1998 through June 2000. There were 7 men and 2 women patients with an average age of 75 years. Mean aneurysm diameter was 7.1 cm. All aneurysms were repaired with Gianturco Z-stent polytetrafluoroethylene prostheses. There were no perioperative deaths. Mean length of stay was 6.3 days. Technical success was achieved in all 9 patients. Two patients had neurologic complications following repair (1 patient with transient lower extremity numbness related to spinal arthritis and 1 patient with bowel and bladder incontinence). Both patients were independent with ambulation. Mean follow-up was 15.8 months. There was no evidence of endoleak or stent migration during the follow-up period. These findings support endovascular treatment of high-risk patients with thoracic aneurysm.

Aged↗
PubMedDate not supplied

Endovascular repair of small abdominal aortic aneurysms: a paradigm shift?

Recent reports have documented poor long-term results following endovascular aneurysm repair (EVAR) of large abdominal aortic aneurysms (AAA). EVAR of small AAAs may result in improved long-term results compared to large AAAs. It is not known whether the frequency of anatomic suitability for EVAR is increased for small compared to large AAAs. This study compared the anatomic suitability of large and small AAAs for EVAR in an unselected patient population. Radiology reports for all computed tomography (CT) scans in a single hospital over a recent 3-year period were reviewed. AAAs diagnosed by contrasted CT scans with cuts >7 mm were excluded. Suitability for EVAR was determined by neck diameter, length, and angulation. In addition, iliac diameters and common iliac distal landing zone lengths were determined. Computerized 3-dimensional (3D) reconstruction was used to measure neck angulation and total aortic tortuosity. One hundred ninety-one patients were found to have AAAs with adequate CT scans for evaluation. Suitability for EVAR was highest in patients with AAA diameters of 3-4 cm and declined with increasing size of the AAA. Dividing AAAs into sizes greater than or less than 5.5 cm revealed that small AAAs had significantly longer necks, less neck angulation, longer common iliac landing zones, and less total aortic tortuosity. Multivariable analysis revealed that maximal aortic diameter was the only independent predictor of suitability for EVAR (p = 0.005, odds ratio 1.67, CI 95% = 1.17 to 2.38). The odds ratio predicts that with each 1 cm increase in size, the likelihood of suitability decreased by 5.3-fold. Small AAAs have less complex anatomy with longer aortic necks, less neck angulation, and less tortuosity. The poor outcomes following the treatment of large AAAs is thought to be due to complex anatomy. EVAR of less anatomically challenging small AAAs may improve long-term outcomes.

Aged↗
PubMed2005

Beyond the Evidence of the New Hypertension Guidelines. Blood pressure measurement - is it good enough for accurate diagnosis of hypertension? Time might be in, for a paradigm shift (I).

Despite widespread availability of a large body of evidence in the area of hypertension, the translation of that evidence into viable recommendations aimed at improving the quality of health care is very difficult, sometimes to the point of questionable acceptability and overall credibility of the guidelines advocating those recommendations.The scientific community world-wide and especially professionals interested in the topic of hypertension are witnessing currently an unprecedented debate over the issue of appropriateness of using different drugs/drug classes for the treatment of hypertension. An endless supply of recent and less recent "drug-news", some in support of, others against the current guidelines, justifying the use of selected types of drug treatment or criticising other, are coming out in the scientific literature on an almost weekly basis. The latest of such debate (at the time of writing this paper) pertains the safety profile of ARBs vs ACE inhibitors.To great extent, the factual situation has been fuelled by the new hypertension guidelines (different for USA, Europe, New Zeeland and UK) through, apparently small inconsistencies and conflicting messages, that might have generated substantial and perpetuating confusion among both prescribing physicians and their patients, regardless of their country of origin.The overwhelming message conveyed by most guidelines and opinion leaders is the widespread use of diuretics as first-line agents in all patients with blood pressure above a certain cut-off level and the increasingly aggressive approach towards diagnosis and treatment of hypertension. This, apparently well-justified, logical and easily comprehensible message is unfortunately miss-obeyed by most physicians, on both parts of the Atlantic.Amazingly, the message assumes a universal simplicity of both diagnosis and treatment of hypertension, while ignoring several hypertension-specific variables, commonly known to have high level of complexity, such as:- accuracy of recorded blood pressure and the great inter-observer variability,- diversity in the competency and training of diagnosing physician,- individual patient/disease profile with highly subjective preferences,- difficulty in reaching consensus among opinion leaders,- pharmaceutical industry's influence, and, nonetheless,- the large variability in the efficacy and safety of the antihypertensive drugs.The present 2-series article attempts to identify and review possible causes that might have, at least in part, generated the current healthcare anachronism (I); to highlight the current trend to account for the uncertainties related to the fixed blood pressure cut-off point and the possible solutions to improve accuracy of diagnosis and treatment of hypertension (II).

Journal Article↗
PubMed2006

The continuing HIV vaccine saga: is a paradigm shift necessary?

As pointed out in previous editorials, the development of an effective vaccine for the Human Immunodeficiency Virus capable of preventing infection, or even one capable of preventing the Acquired Immunodeficiency Disease Syndrome, has eluded investigators for the past 20 years. Now Reche and Keskin and their co-workers have provided evidence that an entirely new approach, based upon modern bioinformatics methods and skillful in vitro immunological experiments, may result in an effective way to prime the T cell immune response of normal individuals against conserved peptide epitopes.

Comment↗
PubMed2001

Clinical review: a paradigm shift: the bidirectional effect of inflammation on bacterial growth. Clinical implications for patients with acute respiratory distress syndrome.

Clinical studies have shown positive associations among sustained and intense inflammatory responses and the incidence of bacterial infections. We hypothesized that cytokines secreted by the host during acute respiratory distress syndrome may indeed favor the growth of bacteria and explain the association between exaggerated and protracted systemic inflammation and the frequent development of nosocomial infections. To test this hypothesis, we conducted in vitro studies evaluating the extracellular and intracellular growth response of three clinically relevant bacteria in response to graded concentrations of pro-inflammatory cytokines tumor necrosis factor-alpha, IL-1beta, and IL-6. In these studies, we identified a U-shaped response of bacterial growth to pro-inflammatory cytokines. When the bacteria were exposed in vitro to a lower concentration of cytokines, extracellular and intracellular bacterial growth was not promoted and human monocytic cells were efficient in killing the ingested bacteria. Conversely, when bacteria were exposed to higher concentrations of pro-inflammatory cytokines, intracellular and extracellular bacterial growth was enhanced in a dose-dependent manner. The bidirectional effects of proinflammatory cytokines on bacterial growth may help to explain the frequent occurrence of nosocomial infections in patients with unresolving acute respiratory distress syndrome.

Acinetobacter↗
PubMed2006

Hormone-refractory prostate cancer: a shifting paradigm in treatment.

Prostate cancer, the most common male cancer, affects one in eight American men. Risk factors for the disease include increased age, race, and family history of prostate cancer. To date, surgery, radiation, and hormonal therapy have been the mainstays of treatment. In the past, chemotherapy served only a palliative role for men with prostate cancer and failed to produce a survival advantage or any significant measurable disease response. However, for the first time, docetaxel-based regimens have demonstrated improved survival in men with hormone-refractory prostate cancer in two different, large, phase III studies. Additionally, a number of novel agents are being developed with the hope that treatment for men with hormone-refractory prostate cancer will be improved. Oncology nurses provide critical symptom management strategies as well as education to men with prostate cancer and their partners. Therefore, maintaining current state of the knowledge about best practices and treatment for prostate cancer is crucial. This, in turn, directs efforts to educate patients and family members about treatments and management of side effects.

Androgen Antagonists↗
PubMedDate not supplied

Tendinopathies in the upper extremity: a paradigm shift.

Epicondylitis and de Quervain's tenosynovitis are two common diagnoses seen by hand therapists in clinical practice. Traditionally, these conditions have been viewed as being due to an inflammatory process and treated as such. New research shows that tendons exhibit areas of degeneration and a distinct lack of inflammatory cells. Tendinosis is degeneration of the collagen tissue due to aging, microtrauma, or vascular compromise. This article reviews key literature related to tendinopathies in the lower extremity and comments on the dearth of similar articles for the elbow and forearm. Hand therapists are encouraged to embrace this new terminology and to engage in research in this difficult area to improve treatment regimens and outcome measures.

Humans↗
PubMed1997

Second-line hormonal therapy for advanced prostate cancer: a shifting paradigm.

PURPOSE: To discuss the evolution of new concepts in the Use of second-line hormonal therapy for patients with progressive prostate cancer despite androgen deprivation. DESIGN: Pertinent contemporary prostate-specific antigen (PSA)-based reports of the utility of secondary hormonal maneuvers after treatment with combined androgen blockade (CAB) were reviewed. RESULTS: The use of PSA as an end point in hormonerefractory prostate cancer (HRPC) trials is more widely accepted, but still remains somewhat controversial. Using PSA as an end point, it is clear that a variety of secondary hormonal maneuvers can result in responses. Antiandrogen withdrawal is efficacious in approximately 20% of patients and can be observed with a variety of antiandrogens, including flutamide, bicalutamide, and megestrol acetate. A variety of regimens, including megestrol, bicalutamide, glucocorticoids, aminoglutethimide, and ketoconazole, retain activity (14% to 75% PSA response proportion) even in patients who have failed to respond to CAB and flutamide withdrawal. CONCLUSION: Once CAB (suppression of gonadal and adrenal androgen) is undertaken, further hormonal maneuvers remain efficacious in some patients with progressive prostate cancer. Antiandrogen withdrawal is now a mandatory maneuver before proceeding to other regimens. It is clear that certain patients will continue to respond to hormonal maneuvers even after antiandrogen withdrawal. An understanding of the molecular basis of these responses may result in the development of a more targeted therapy in the future.

Androgen Antagonists↗