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Under the proposed English Health Act regulations most mental health units will have to be smoke-free, although patients will be able to smoke outside. Implementing the regulations will be challenging but may also be an opportunity for a more holistic approach focusing on the physical and psychological health of patients.
A perfectly free, competitive medical market would not meet many social goals, such as universal access to health care. Micromanagement of interactions between patients and providers does not guarantee quality care and frequently undermines that relationship, to the frustration of all involved. Furthermore, while some North American health care plans are less expensive than others, none have reduced the medical inflation rate to equal the general inflation rate. Markets have always fixed uneven inflation rates in other domains. The suggested reforms could make elective interactions between patients and providers work more like a free market than did any preceding system. The health and life insurance plan creates cost-sensitive consumers, informed by a corporation with significant research incentives and abilities. The FFEB proposal encourages context-sensitive pricing, established by negotiation processes that weigh labor and benefit. Publication of providers' expected outcomes further enriches the information available to consumers and may reduce defensive medicine incentives. A medical career ladder would ease entry and exit from medical professions. These and complementary reforms do not specifically cap spending yet could have a deflationary impact on elective health care prices, while providing incentives to maintain quality. They accomplish these ends by giving more responsibility, information, incentives, and choice to citizens. We could provide most health care in a marketlike environment. We can incorporate these reforms in any convenient order and allow them to compete with alternative schemes. Our next challenge is to design, implement, and evaluate marketlike health care systems.
Patients and their families struggle with myriad choices concerning medical treatments that frequently precede death. Advance directives have been proposed as a tool to facilitate end-of-life decision making, yet frequently fail to achieve this goal. In the context of the case of a man with metastatic cancer for whom an advance directive was unable to prevent a traumatic death, I review the challenges in creating and implementing advance directives, discuss factors that can affect clear decision making; including trust, uncertainty, emotion, hope, and the presence of multiple medical providers; and offer practical suggestions for physicians. Advance care planning remains a useful tool for approaching conversations with patients about the end of life. However, such planning should occur within a framework that emphasizes responding to patient and family emotions and focuses more on goals for care and less on specific treatments.
Since 1986 there has been substantial progress in developing surveillance systems for occupational disease and injury that meet the goals of surveillance: identification or new diseases and causes of injury; estimation of the magnitude and trend of injuries and illnesses; identification of epidemic clusters; and identification of sentinel cases representing failures of prevention. A quiltwork of surveillance systems for occupational diseases and injury has been implemented by several federal agencies; surveillance systems for many more disease and injuries are being developed by the states. The conceptual basis for "closing the surveillance gap" has been developed; national implementation is the next challenge.
Interest in the elderly population, persons 65 years of age or older, as a target group for cancer control has not been great. Age recommendations rarely are made for prevention and early detection of cancer for elderly persons. However, cancer incidence and mortality rates are known to rise rapidly with increasing age. This paper takes a long-term public-health perspective to look toward the year 2030 to discuss the challenges of organizing and implementing prevention and early detection incentives for our nation's current and future elderly population. Cancer prevalence estimates in the context of the geriatric imperative of the 21st century are provided for three cancers--breast, prostate, and lung and bronchus. The sheer magnitude of numbers created by the aged population expansion can greatly increase the number of cancer survivors and newly diagnosed cases. Current efforts in cancer prevention and early detection should anticipate the health-care demands of the elderly in the first three decades of the next century.
One hundred thirty-one individuals at 50% risk of inheriting Huntington disease (HD) responded to a survey to study their attitudes toward taking a genetic test based on the identification of a genetically linked DNA polymorphism. Ninety-six percent of the respondents believe that presymptomatic testing should be available, and 66% say they will use it themselves. Fewer married individuals, in comparison to those single, separated, and divorced, intend to take the test. Many respondents (40%) said their primary reason for wanting to be tested is to end the uncertainty in their lives. Results suggest that there will be self-selection in test use, with many individuals who believe they will be depressed or possibly suicidal with a positive test result deciding not to be tested or unsure about testing. However, 15% of those who want to be tested acknowledge that they may be at risk for suicide if they are probable gene carriers. Only 12% of all respondents say they will be likely to use prenatal testing, suggesting that initial demand may be low in New England. Implementation of presymptomatic testing challenges health care providers to develop strategies to care for otherwise healthy persons who will be given a diagnosis years before the onset of illness.
BACKGROUND: With health care costs continuing to rise, a variety of process improvement methodologies have been proposed to address the reported inefficiencies in health care delivery. Lean production is one such method. The management philosophy and tools of lean production come from the manufacturing industry, where they were pioneered by Toyota Motor Corporation, which is viewed as the leader in utilizing these performance improvement methods. Lean has already enjoyed tremendous success in improving quality and efficiency in both the manufacturing and the service sector industries. RESULTS: Health care systems have just begun to utilize lean methods, with reports of improvements just beginning to appear in the literature. We describe some of the basic philosophy and principles of lean production methods and how these concepts can be applied in the health care environment. We describe some of the early success stories and ongoing endeavors of lean production in various health care organizations. We believe the hospital is an ideal setting for use of the lean production method, which could significantly affect how health care is delivered to patients. CONCLUSIONS: We conclude by discussing some of the potential challenges in introducing and implementing lean production methods in the health care environment. Lean production is a novel approach to delivering high-quality and efficient care to patients, and we believe that the health care sector can anticipate the same high level of success that the manufacturing and service industries have achieved using this approach. Hospitalists are primed to take action in delivering care of greater quality with more efficiency by applying these new principles in the hospital setting.
The development and use of in vivo techniques for strictly experimental applications in animals has been very successful, and these results now have made possible some very attractive potential clinical applications. The area with the most obvious immediate, effective and widespread clinical use is oximetry, where EPR almost uniquely can make repeated and accurate measurements of pO2 in tissues. Such measurements can provide clinicians with information that can impact directly on diagnosis and therapy, especially for oncology, peripheral vascular disease and wound healing. The other area of immediate and timely importance is the unique ability of in vivo EPR to measure clinically significant exposures to ionizing radiation 'after-the-fact', such as may occur due to accidents, terrorism or nuclear war. There are a number of other capabilities of in vivo EPR that also potentially could become extensively used in human subjects. In pharmacology the unique capabilities of in vivo EPR to detect and characterize free radicals could be applied to measure free radical intermediates from drugs and oxidative process. A closely related area of potential widespread applications is the use of EPR to measure nitric oxide. These often unique capabilities, combined with the sensitivity of EPR spectra to the immediate environment (e.g. pH, molecular motion, charge) have already resulted in some very productive applications in animals and these are likely to expand substantially in the near future. They should provide a continually developing base for extending clinical uses of in vivo EPR. The challenges for achieving full implementation include adapting the spectrometer for safe and comfortable measurements in human subjects, achieving sufficient sensitivity for measurements at the sites of the pathophysiological processes that are being measured, and establishing a consensus on the clinical value of the measurements.
Five years ago, many critics questioned the value of lipid-lowering therapy. Today, the clinical benefits of statins are well documented, but the challenge remains to fully implement these benefits across the wide spectrum of the at-risk population, and continue to advance our understanding regarding the potential for the benefits of statins across an even broader range of select patient populations.
Despite some improvements in diabetes treatment processes, outcomes for many patients remain inadequate. Interactive health technologies (IHTs) can address many of the challenges that diabetes patients and their health systems face, and research on IHT applications for diabetes care are intensifying. This article describes recent evidence regarding the feasibility and impact of 1) clinic-based CD-ROM systems supporting behavior change; 2) automated telephone diabetes management allowing for ongoing monitoring and patient education between face-to-face clinical encounters; and 3) Web-based systems focusing on a range of diabetes management goals such as enhanced emotional support for patients and improved clinician adherence to treatment guidelines. Studies in each of these areas have been somewhat encouraging. However, intervention effects have been moderate, and researchers face significant challenges in designing and implementing definitive studies.
A system called MAGPIE (Multipurpose Automated Genome Project Investigation Environment) has been designed and implemented to meet the challenges of automated whole genome analysis. The system initiates large numbers of remote and local transactions, each depending on evolving criteria and on changing remote and local conditions. Transactions are requested from different types of remote and local resources. The remote request load is fairly balanced with other community demands on server resources. Local decision modules monitor and obey user preferences and combine evidence from multiple sources to formulate credible hypotheses about sequence function. Consistency checks from multiple types of data are integrated into the ongoing local analysis. The system performs reliably on local UNIX workstations and communicates with remote resources through standard networking protocols.
The application of rigorous epidemiologic methods to clinical questions has broadened the scope of research in epidemiology and enhanced the quality of clinical research. The International Clinical Epidemiology Network (INCLEN) has enabled physicians from developing countries to obtain training in epidemiologic methods and to provide leadership in clinical epidemiology in their home schools of medicine. The INCLEN program has recently incorporated another major theme of research training, clinical economics, which introduces research related to the effective use of limited resources. This article describes the rationale for the development of the INCLEN Clinical Economics program, outlines its organization and curriculum, and explores the challenges to its successful implementation.
This article describes the research design of the Multisite Violence Prevention Project (MVPP), organized and funded by the National Center for Injury Prevention and Control (NCIPC) at the Centers for Disease Control and Prevention (CDC). CDC's objectives, refined in the course of collaboration among investigators, were to evaluate the efficacy of universal and targeted interventions designed to produce change at the school level. The project's design was developed collaboratively, and is a 2 x 2 cluster-randomized true experimental design in which schools within four separate sites were assigned randomly to four conditions: (1) no-intervention control group, (2) universal intervention, (3) targeted intervention, and (4) combined universal and targeted interventions. A total of 37 schools are participating in this study with 8-12 schools per site. The impact of the interventions on two successive cohorts of sixth-grade students will be assessed based on multiple waves of data from multiple sources of information, including teachers, students, parents, and archival data. The nesting of students within teachers, families, schools and sites created a number of challenges for designing and implementing the study. The final design represents both resolution and compromise on a number of creative tensions existing in large-scale prevention trials, including tensions between cost and statistical power, and between internal and external validity. Strengths and limitations of the final design are discussed.
Competition with well-established, fine-tuned chemical processes is a major challenge for the industrial implementation of the enzymatic synthesis of beta-lactam antibiotics. Enzyme-based routes are acknowledged as an environmental-friendly approach, avoiding organochloride solvents and working at room temperatures. Among different alternatives, the kinetically controlled synthesis, using immobilized penicillin G acylase (PGA) in aqueous environment, with the simultaneous crystallization of the product, is the most promising one. However, PGA may act either as a transferase or as a hydrolase, catalyzing two undesired side reactions: the hydrolysis of the acyl side-chain precursor (an ester or amide, a parallel reaction) and the hydrolysis of the antibiotic itself (a consecutive reaction). This review focuses specially on aspects of the reactions' kinetics that may affect the performance of the enzymatic reactor.
The ICU patient with burns, neurotrauma, sepsis, or major surgery typifies the classic hypermetabolic patient. These patients have increased energy and nutrient needs as a result of their injuries and require early nutrition support. Although these patients are likely to benefit from nutritional intervention, the complexity of the stress response to injury and subsequent changes in nutrient metabolism make the design and implementation of nutrition care challenging. This article reviews the pathophysiology of common hypermetabolic conditions and provides strategies to manage the complications associated with nutrition support.
OBJECTIVES: For establishing trustworthiness in advanced architectures for future-proof health information systems being open, flexible, scaleable, portable, and semantically interoperable, security and privacy services needed must be designed as an inherent part of the architecture. Such architecture has to meet the paradigms of distribution, component orientation, formal modelling, separation of logical and technological aspects, etc. METHODS: In model-driven architectures components providing security and privacy services have to be specified using the same methodology of formal models with meta-languages as expression means, as deployed in computational, technical, or medical domains. The resulting approach must be based on the ISO Reference Model-Open Distributed Processing. RESULTS: Currently, standards developing organisation are defining emerging tasks and standards for semantic interoperability and trustworthy collaboration for advanced health information systems. Communication security issues have been specified and implemented, while application security challenges such as privilege management and access control are still under development. Therefore, a series of formal models have been developed by the authors covering, e.g. domains, service delegation, claims control, policies, roles, authorisations, and access control. The required models are introduced and interpreted in a generic way. The crucial concept of security policy and its relationship to the other concepts has been considered in detail. CONCLUSION: Based on formal models, security services can be integrated into advanced systems architectures enabling semantic interoperability in the context of trustworthiness of communication and co-operation.
The presence of noise and absence of contrast in electron micrographs lead to a reduced resolution of the final 3D reconstruction, due to the inherent limitations of single-particle image alignment. The fast rotational matching (FRM) algorithm was introduced recently for an accurate alignment of 2D images under such challenging conditions. Here, we implemented this algorithm for the first time in a standard 3D reconstruction package used in electron microscopy. This allowed us to carry out exhaustive tests of the robustness and reliability in iterative orientation determination, classification, and 3D reconstruction on simulated and experimental image data. A classification test on GroEL chaperonin images demonstrates that FRM assigns up to 13% more images to their correct reference orientation, compared to the classical self-correlation function method. Moreover, at sub-nanometer resolution, GroEL and rice dwarf virus reconstructions exhibit a remarkable resolution gain of 10-20% that is attributed to the novel image alignment kernel.
BACKGROUND: This paper describes decisions about the experimental design for the Youth, Osteoporosis, and Understanding Total Health Project (YOUTH), a trial designed to test the efficacy of a health plan-based lifestyle intervention for increasing bone mineral density among adolescent women 14 to 16 years of age. METHODS: This randomized controlled trial recruited adolescent women who were at higher risk for developing osteoporosis (body mass index 16-23) from a large HMO in the Pacific Northwest. The intervention focused on improving diet (high calcium foods, fruits, and vegetables) and increasing physical activity (high impact and spinal motion). The intervention included both group and individual activities. The primary endpoint in the study was total bone mineral density as measured by dual-energy X-ray absorptiometry (DEXA). RESULTS: Baseline data were collected on the trial cohort of 228 adolescent women and their families. This paper discusses how researchers met the following challenges in designing and implementing the trial: determining appropriate dietary and exercise targets to affect bone mineral density in adolescents; choosing suitable assessments; and developing an intervention well suited for implementation in a non-school (health plan) setting. We also discuss the rationale for the specific study population chosen (females, younger adolescents). CONCLUSIONS: The YOUTH project is one of very few preventive research interventions with adolescents conducted in a health plan setting. Many of the recruitment and intervention strategies used in this trial may be appropriate for adoption in other health plan-based prevention studies.