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PubMed2005

Government funded breastfeeding peer support projects: implications for practice.

In 1999, the Government, Department of Health in England, UK established the Infant Feeding Initiative. As part of this initiative, 79 1-year infant feeding projects were selected for funding. The funded projects specifically centred upon practice innovation and evaluation in relation to promoting breastfeeding and supporting breastfeeding women in socially excluded communities. The DH recently commissioned a comprehensive evaluation of the 79 projects (DH 2003). This paper focuses upon the evaluation of the 26 DH funded projects that specifically focused upon breastfeeding peer support schemes. The evaluation illuminated many of the challenges involved in implementing community based breastfeeding peer support schemes. Lessons learnt from the most effective projects in terms of: potential to increase breastfeeding initiation and continuation rates; uptake of the service; comprehensive evaluation; and sustainability are presented here, as a series of steps required for successful operationalization of breastfeeding peer support schemes. When these steps are followed, peer support schemes offer exciting prospects for supporting breastfeeding women and increasing breastfeeding initiation and continuation rates, while respecting diversity, ensuring inclusivity and stimulating community empowerment.

Adult↗

PubMed2005

Nonlinear resonant ultrasound spectroscopy (NRUS) applied to damage assessment in bone.

Nonlinear resonant ultrasound spectroscopy (NRUS) is a resonance-based technique exploiting the significant nonlinear behavior of damaged materials. In NRUS, the resonant frequency(ies) of an object is studied as a function of the excitation level. As the excitation level increases, the elastic nonlinearity is manifest by a shift in the resonance frequency. This study shows the feasibility of this technique for application to damage assessment in bone. Two samples of bovine cortical bone were subjected to progressive damage induced by application of mechanical cycling. Before cycling commenced, and at each step in the cycling process, NRUS was applied for damage assessment. For independent assessment of damage, high-energy x-ray computed tomography imaging was performed but was only useful in identifying the prominent cracks. As the integral quantity of damage increased, NRUS revealed a corresponding increase in the nonlinear response. The measured change in nonlinear response is much more sensitive than the change in linear modulus. The results suggest that NRUS could be a potential tool for micro-damage assessment in bone. Further work must be carried out for a better understanding of the physical nature of damaged bone and for the ultimate goal of the challenging in vivo implementation of the technique.

Animals↗

PubMedDate not supplied

Medical informatics and the science of cognition.

Recent developments in medical informatics research have afforded possibilities for great advances in health care delivery. These exciting opportunities also present formidable challenges to the implementation and integration of technologies in the workplace. As in most domains, there is a gulf between technologic artifacts and end users. Since medical practice is a human endeavor, there is a need for bridging disciplines to enable clinicians to benefit from rapid technologic advances. This is turn necessitates a broadening of disciplinary boundaries to consider cognitive and social factors pertaining to the design and use of technology. The authors argue for a place of prominence for cognitive science. Cognitive science provides a framework for the analysis and modeling of complex human performance and has considerable applicability to a range of issues in informatics. Its methods have been employed to illuminate different facets of design and implementation. This approach has also yielded insights into the mechanisms and processes involved in collaborative design. Cognitive scientific methods and theories are illustrated in the context of two examples that examine human-computer interaction in medical contexts and computer-mediated collaborative processes. The framework outlined in this paper can be used to refine the process of iterative design, end-user training, and productive practice.

Cognitive Science↗

PubMed2004

Nutritional genomics.

Nutritional genomics has tremendous potential to change the future of dietary guidelines and personal recommendations. Nutrigenetics will provide the basis for personalized dietary recommendations based on the individual's genetic make up. This approach has been used for decades for certain monogenic diseases; however, the challenge is to implement a similar concept for common multifactorial disorders and to develop tools to detect genetic predisposition and to prevent common disorders decades before their manifestation. The preliminary results involving gene-diet interactions for cardiovascular diseases and cancer are promising, but mostly inconclusive. Success in this area will require the integration of different disciplines and investigators working on large population studies designed to adequately investigate gene-environment interactions. Despite the current difficulties, preliminary evidence strongly suggests that the concept should work and that we will be able to harness the information contained in our genomes to achieve successful aging using behavioral changes; nutrition will be the cornerstone of this endeavor.

Genetic Diseases, Inborn↗

PubMed2003

Saccade adaptation in response to altered arm dynamics.

The delays in sensorimotor pathways pose a formidable challenge to the implementation of stable error feedback control, and yet the intact brain has little trouble maintaining limb stability. How is this achieved? One idea is that feedback control depends not only on delayed proprioceptive feedback but also on internal models of limb dynamics. In theory, an internal model allows the brain to predict limb position. Earlier we had found that during reaching, the brain estimates hand position in real-time in a coordinate system that can be used for generating saccades. Here we tested the idea that the estimate of hand position, as expressed through saccades, depends on an internal model that adapts to dynamics of the arm. We focused on the behavior of the eyes as perturbations were applied to the unseen hand. We found that when the hand was perturbed from stable posture with a 100-ms force pulse of random direction and magnitude, a saccade was generated on average at 182 ms postpulse onset to a position that was an unbiased estimate of real-time hand position. To test whether planning of saccades depended on an internal model of arm dynamics, arm dynamics were altered either predictably or unpredictably during the postpulse period. When arm dynamics were predictable, saccade amplitudes changed to reflect the change in the arm's behavior. We suggest that proprioceptive feedback from the arm is integrated into an adaptable internal model that computes an estimate of current hand position in eye-centered coordinates.

Adaptation, Physiological↗

PubMed2006

Dialysis and nanotechnology: now, 10 years, or never?

Nanotechnology, defined as the science of material features between 10(-9) and 10(-7) of a meter, has received extensive attention in the popular press as proof-of-concept experiments in the laboratory are published. The inevitable delay between feature articles and clinical endpoints has led to unwarranted skepticism about the applicability of the technology to current medical therapy. The theoretic advantages of micro- and nanometer scale engineering to renal replacement include the manufacture of high-hydraulic permeability membranes with implanted sensing and control structures. Recent data in membrane design and testing is presented, with a review of the challenges remaining in implementation of this technology.

Extracellular Fluid↗

PubMed2006

Preparing K-12 students for the new interdisciplinary world of science.

The increasing importance of interdisciplinary science brings with it the need to consider what impact this has on the educational process. Such considerations extend even to the earliest educational years of K-12, and also exhibit a strong overlap with many issues involved in improving science education across the board. I will offer some general remarks, followed by a focus on three educational objectives of importance to interdisciplinary science as well as to improved science education as a whole. I will close with a brief discussion of the challenges involved in implementing such ideas in the educational system.

Adolescent↗

PubMed2003

Molecular diagnostics.

It is increasingly evident that molecular diagnostics, that is, the use of diagnostic testing to understand the molecular mechanisms of an individual patient's disease, will be pivotal in the delivery of safe and effective therapy for many diseases in the future. A huge body of new information on the genetic, genomic and proteomic profiles of different hematopoietic diseases is accumulating. This chapter focuses on new technologies and advancements in understanding the molecular basis of hematologic disorders, providing an overview of new information and its significance to patient care. In Section I, Dr. Braziel discusses the impact of new genetic information and research technologies on the actual practice of diagnostic molecular hematopathology. Recent and projected changes in methodologies and analytical strategies used by clinical molecular diagnostics laboratories for the evaluation of hematologic disorders will be discussed, and some of the challenges to clinical implementation of new molecular information and techniques will be highlighted. In Section II, Dr. Shipp provides an update on current scientific knowledge in the genomic profiling of malignant lymphomas, and describes some of the technical aspects of gene expression profiling. Analysis methods and the actual and potential clinical and therapeutic applications of information obtained from genomic profiling of malignant lymphomas are discussed. In Section III, Dr. Liotta presents an update on proteomic analysis, a new and very active area of research in hematopoietic malignancies. He describes new technologies for rapid identification of different important proteins and protein networks, and the potential therapeutic and prognostic value of the elucidation of these proteins and protein pathways in the clinical care of patients with malignant lymphomas.

Cytogenetic Analysis↗

PubMed2004

Antiretroviral therapy in sub-Saharan Africa: adherence lessons from tuberculosis and leprosy.

Declining drug costs and increases in international donor interest are leading to greater availability of antiretroviral treatment programmes for persons living with the human immunodeficiency virus in parts of sub-Saharan Africa. Ensuring adequate adherence to antiretroviral drug therapy is one of the principal challenges facing successful implementation in Africa, where 70% of the world's infected persons live. Tuberculosis and leprosy are two diseases of global importance whose control programmes can provide important lessons for developing antiretroviral drug adherence strategies. This paper examines various approaches used in tuberculosis and leprosy control which could help enhance adherence to antiretroviral therapy in resource-limited settings.

Africa South of the Sahara↗

PubMed2006

Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine.

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.

Attitude of Health Personnel↗

PubMed2006

Nurses' perceptions of medication safety and medication reconciliation practices.

Medication reconciliation (MR) involves the accurate transfer of medication information across the continuum of care. The aim of this study was to measure nurses perceptions of patient safety, medication safety and current MR practice at transition points in a patient's hospital stay. Surveys were distributed to 111 nursing staff in three general medicine units at Capital Health District, Nova Scotia, in August 2005. A total of 39 nurses (35% response rate) completed the survey. "Teamwork within units" was the safety culture dimension with the highest positive response (98.1%), while the processes of handoffs and transitions received the lowest positive response (42.8%). Key areas identified for improvement relative to the current level of MR practice include institutional patient safety systems (e.g., low confidence in existing systems and procedures), inconsistent practices (e.g., wide variation in whether community pharmacists are contacted to verify medication profiles), lack of communication (e.g., between healthcare professionals) and staffing resources (e.g., MR is perceived as a very time-consuming process). Addressing these challenges prior to implementing a formalized MR program should help to ensure success of the project. The insights gained through the use of this survey may prove valuable to other Canadian healthcare organizations that are implementing MR services.

Attitude of Health Personnel↗

PubMedDate not supplied

Filling the GAPS: description and evaluation of a primary care intervention for children with chronic health conditions.

OBJECTIVES: Consistent with the "medical home" model, the GAPS program was developed to provide expanded care for children with a range of chronic health conditions within the context of primary care pediatric offices. Parents, pediatricians, and representatives from local Title V agencies participated to assess the child's and family's needs and to identify ways of addressing them. METHODS: Eleven pediatricians in 5 pediatric practices participated in the 4 main activities of the GAPS project: a) needs assessment; b) planning meeting among parents and pediatricians; c) practice-based advisory group; and d) Department of Public Health consultation. A telephone interview of parents and 2 needs assessment questionnaires completed by families were the 2 evaluation methods used. RESULTS: Parents were able to meet desires for "information" and "specific help." Moderate amounts of success were reported for meeting "contact" and "counseling" needs. Parents' explanations of unmet needs included lack of follow-through in obtaining services, unavailability of services, change of mind regarding needs, and pragmatic barriers. Socioeconomic status, the diagnosis and severity of the child's condition, and maternal psychological status were not significant predictors of success in families' ability to get their needs met. CONCLUSIONS: Active collaboration among parents, pediatricians, and Department of Public Health staff helps to ensure comprehensive coordinated care for families of children with chronic health conditions. Considerable challenges remain in implementing effective medical homes.

Child↗

PubMedDate not supplied

Training in community pediatrics: a national survey of program directors.

OBJECTIVE: To describe the spectrum of residency training in community-based settings, assess the extent of resident education on community pediatrics topics, and determine whether educational activities vary by program size or availability of primary care tracks. METHODS: Survey of US pediatric residency program directors from May-September 2002. A 10-item self-administered questionnaire assessed the programs' extent of resident involvement in 15 selected community-based settings and inclusion of didactic or practical education regarding 13 community health topics. RESULTS: Of 168 programs surveyed (81% response rate), 40% were small (< or =30 residents), 35% were medium (31-50 residents), 25% were large (>50 residents), and 15% had primary care tracks. Frequently required community-based settings included schools (69%), child protection teams (62%), day care centers (57%), and home visiting (48%). Of 15 community-based settings, 28% required involvement in fewer than 4, 41% required involvement in 4-6, and 31% required involvement in 7 or more. More than two-thirds offered didactic teaching and practical experience on issues related to managed care, cultural competency, and the mental health and social service systems. There were no differences in the number of required community-based settings by program size or presence of primary care tracks. CONCLUSIONS: Most pediatric residency programs require exposure to community-based settings and provide education on various community health topics. Ongoing challenges include continued implementation amid work duty hour limitations, best practice models for practical implementation of community-based experience into residency training, and the impact of such training on future involvement in the community and physician practice.

Community Health Services↗

PubMed2006

Emerging lessons from the drug effectiveness review project.

The Drug Effectiveness Review Project (DERP) is an alliance of fifteen states and two private organizations, which have pooled resources to synthesize and judge clinical evidence for drug-class reviews. The experience shines a bright light on challenges involved in implementing an evidence-based medicine process to inform drug formulary decisions: When should evidence reviewers accept surrogate markers and assume therapeutic class effects? How open and participatory should review procedures be? Should reviewers consider cost-effectiveness information? What is the appropriate role of the public sector in judging evidence? The DERP illustrates that attempts to undertake evidence-based reviews, apart from the methods themselves, which continue to evolve, involve questions of organization, process, and leadership.

Cost-Benefit Analysis↗

PubMed2006

Massachusetts: more mirage than miracle.

Enactment of the Massachusetts health reform plan stemmed primarily from several factors unique to the state. They were augmented by a questionable rationale that this latest version of health reform would forestall even greater threats ahead to the interests of the state's business community, private insurance policyholders, and taxpayers. The plan's foremost achievement involves development of a "Connector" mechanism to facilitate pooling and purchasing beyond the workplace. However, its successful implementation will be challenged by the complexities of enforcing an individual mandate and changing the long-standing course of an overregulated and high-cost health market.

Health Care Reform↗

PubMedDate not supplied

Medicare advantage: déjà vu all over again?

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expands the role of private health plans in Medicare through prescription drug plans and a revised Medicare+Choice (M+C), renamed Medicare Advantage, program. This paper discusses the factors responsible for the failure of M+C to develop as intended in 1997 and analyzes the challenges for MMA implementation in light of these factors. They include making a complex program understandable to beneficiaries; addressing plans' efforts to avoid enrolling high-cost beneficiaries; ensuring stability of benefits, providers, and plans; dealing with beneficiaries enrolled in unsuitable plans; providing equity of health benefits throughout the country; and controlling overall Medicare costs.

Aged↗

PubMed2004

Monoclonal antibodies for brain tumour treatment.

Conventional treatment of brain tumours includes surgical, radiotherapeutic and chemotherapeutic modalities. Nonetheless, the outcome of patients with brain tumours, in particular glioblastoma, remains poor. Immunotherapy with armed or unarmed monoclonal antibodies targeting tumour-specific antigens has emerged in the last two decades as a novel potential adjuvant treatment for all types of neoplasia. Many challenges to its implementation as a safe and viable therapy for brain tumours still need to be addressed; nevertheless, results from ongoing Phase I/II clinical trials are encouraging, as disease stabilisation and patient survival prolongation have been observed. Advances in preclinical and clinical research indicate that treatment of brain tumours with monoclonal antibodies can be increasingly adjusted to the characteristics of the targeted tumour and its environment. This aspect relies on the careful selection of the target antigen and corresponding specific monoclonal antibody, and antibody format (size, class, affinity), conjugation to the appropriate toxin or radioactive isotope (half-life, range), and proper compartmental administration.

Animals↗

PubMed2004

The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions.

The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs.

Bangladesh↗