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[Historical Archives of Italian Nephrology. The form, evocative of function. A short historical review about the discovery of drugs from the most remote times to new trends in pharmacological sciences].

The image, the imaginary and the imagined are more than ever the guide in pharmacological research, and predominate in the expectations of discovering, designing and producing a potential drug. The concept of ""form"" is now corroborated and implemented by the most recent and astounding acquisitions on the existing relationship in biology between form, structure and function. This article is a brief historical reconstruction of how the ""form"" has represented, from the most remote times, a fundamental guiding criterion in the choice of potential pharmacological remedies, and how in times of biotechnology and informatics the design and development of new drugs is based on the assumption that the form-function requisite is among the most promising trends in pharmacological sciences and drug discovery, in the nephrology field too.

History, 18th Century↗

Problem-Based Learning in Entry-Level Athletic Training Professional-Education Programs: A Model for Developing Critical-Thinking and Decision-Making Skills.

OBJECTIVE: To establish the underlying theory and benefits and describe the implementation of a problem-based learning curriculum. DATA SOURCES: I searched MEDLINE, SPORT Discus, and nursing, evidence-based medicine, and educational psychology databases from 1987 through 2002 using the terms problem-based learning, physical therapy, nursing, and medicine. DATA SYNTHESIS: In the problem-based learning process, students encounter a problem, bring to it their preconceived understanding (accurate or not), learn to identify what they need to learn to better understand the problem, engage in self-directed study, and begin to resolve the problem. Problem-based learning has its origins in medical education but is widely used in K-12 education, social sciences, health professions education, law, business administration, engineering, and aviation. An entry-level master of science degree program in athletic training based on problem-based learning and integrated clinical education is described. CONCLUSIONS/RECOMMENDATIONS: Problem-based learning curricula, if implemented correctly, can facilitate the entry-level athletic training student's professional development into that of a life-long learner who bases clinical decisions and procedures on the best available evidence.

Journal Article↗

The social and environmental dimensions of nutrition science.

OBJECTIVE: To emphasise the importance of defining a new nutrition science and food policy that includes social and environmental dimensions. DESIGN: Nutrition science and food policy is put in the context of sustainable development. Examples are presented to show that a number of factors including exploitation of resources, disrespect for land and food insecurity contribute to the decline of a culture. The fate of cultures that lack implemented sustainable development strategies is discussed. CONCLUSION: Pressure from low-income and economically challenged countries combined with the efforts of not-for-profit private institutions is proposed. The goal is to produce and provide science-based evidence and guidelines to be used as a tool to encourage institutions and organisations to redefine their policies to deal effectively with global issues.

Economics↗

Health promotion mini-grants: grassroots implementation in New Mexico.

The populations of New Mexico are ethnically diverse, with large Hispanic and Native American components, and live in communities that are geographically dispersed and economically challenged. The University of New Mexico is located in Albuquerque, the state's only major urban area, and houses the state's only academic health sciences center. In 1986, the University received a grant from the W.K. Kellogg Foundation to establish health promotion/disease prevention curricula for health science students and create two Wellness Centers on campus. The Wellness Centers train students to be providers of health information and learn how to counsel and assist people with changing health-related behaviors. A campus-wide employee health promotion program was also implemented. Most of the instructional and service programs initiated by the grant have continued with stable institutional support. A later phase of the project was to encourage other agencies and organizations throughout New Mexico to adopt or expand their own health promotion initiatives. An operating premise of this phase was that local initiatives should respond to locally perceived priorities. To accomplish this, a program of mini-grants was designed to assist in creating health promotion programs within a variety of topic areas. Thirteen mini-grants were awarded to agencies representing diverse groups and cultures throughout New Mexico. Our experience with the mini-grants and the ability of organizations to sustain the activities past the period of grant support are described. The successful use of mini-grants has been reported elsewhere in the literature.

Health Planning Support↗

A framework for understanding "evidence" in prevention research and programs.

This report provides a multidimensional framework for understanding the meaning of evidence in prevention science. Six themes comprise the framework, each with impact on the meaning of evidence. (1) There are rigorous prevention scientific strategies now in use; each has shared but also unique requirements for the meaning of evidence. Some are directed at individuals, others at small social contexts, others at larger societal structures. (2) The phases of prevention research have shared but also unique requirements for evidence. These include efficacy, effectiveness, sustainability, going-to-scale, and sustaining programs systemwide. (3) Prevention programs address different segments of the population defined by levels of risk: the total population; a smaller subpopulation at increased risk; or a still smaller subpopulation at very high risk. The levels influence the meaning of evidence. (4) Economic analysis and economic evidence must become a central part of prevention research. These are needed for appropriate policy decision making and for assessing long-term benefits. (5) Collaboration is required for rigor in prevention research: including researchers, but also policy makers, program advocates and leaders, and community and institutional leaders. Broad ownership is critical for implementing rigorous research and for sustaining program fidelity. (6) Acceptance of a multidimensional framework for understanding "evidence" is essential across those agencies and institutions that carry out and/or use prevention science. The more widely the vision of the prevention field is shared, and the more the various qualities and rules of evidence are accepted and implemented, the better the quality will be of prevention research and programs.

Evidence-Based Medicine↗

Noninvasive vascular testing--a 35-year reflection.

Noninvasive vascular testing has made a major contribution to the care of vascular surgery patients. This article a reflection on a 35-year corroborative association with Doctor Norman Rich, during which many of the advances in noninvasive vascular testing have been witnessed and effected. I served my vascular surgery fellowship under Doctor Rich in 1967-68 at Walter Reed Army Hospital. The only noninvasive vascular equipment then was a pencil probe Doppler. The value of the Doppler in the management of peripheral vascular disease that year and in determining limb viability in combat surgery in Vietnam the following year was established, and both experiences were published. Later, Doctor Rich established the annual Military Vascular Surgery Meeting and was appointed as the first Chair of the Department of Surgery at the Uniformed Services University for Health Sciences (USU). I entered private practice in Central California in 1976, and ultrasonic imaging was developed which allowed noninvasive examination of the carotid arteries. I then developed a protocol to screen for the three silent, immediate causes of stroke, employing a "a quick carotid scan" for carotid artery disease, a lead II rhythm strip for atrial fibrillation, and blood pressure determination for hypertension so that these common causes of strokes could be recognized and treated, and potentially prevent the majority of strokes. My association with USU, Doctor Rich, and others involved proved instrumental in initiating implementation of stroke prevention screening. The structure established at USU provides a means of establishing the protocol nationally. Noninvasive vascular testing is an addition to Medical Science that has led to significant improvements in individual patient care and that has the potential of allowing a major reduction in death and disability from stroke and other vascular diseases. Throughout a 35-year collaborative association with Doctor Norman M. Rich, I have witnessed and developed many of these advances. These contributions to noninvasive vascular testing reflect the value of our collaboration.

History, 20th Century↗

Analysis of reproductive toxicity and classification of glufosinate-ammonium.

CONCLUSION REGARDING CLASSIFICATION OF GLUFOSINATE-AMMONIUM: Science Partners' Evaluation Group (Evaluation Group) has conducted an independent analysis of the herbicide glufosinate-ammonium (GA) relative to its potential to cause reproductive toxicity in humans. Further, the Evaluation Group has evaluated the implementation of Annex 6 of Commission Directive 2001/59/EC (28th ATP of Council Directive 67/548/EEC) and Council Directive 91/414/EEC, with respect to classification of chemicals posing potential reproductive hazards. After consideration of all information available to us relevant to the potential of glufosinate-ammonium (GA) to cause reproductive toxicity, the Science Partners Evaluation Group concludes that no classification of GA is justified. The following form the basis of this conclusion. There are no human data to suggest that GA causes reproductive toxicity in women or in their conceptus. The issue concerning possible reproductive hazard to humans is raised solely on the basis of positive animal test results that show GA to cause preimplantation or implantation losses in rats. SPECIFICALLY: a. Daily treatment with GA had no detectable effect on the earliest stages of the reproductive sequence including gametogenesis, ovulation, mating and conception; b. Treatment with GA interfered with rat gestation before and at the stage when the conceptus implants into the uterus. This effect occurred at doses of 360 ppm in the feed (corresponding to daily doses of 27.8 mg/kg bw) and above; and c. After implantation, no further effect of GA on prenatal and post-natal development was recognized. Previous concerns that GA might be toxic to embryonic stages after implantation were not supported by the data. Abortions and stillbirth seen were associated with, and regarded as secondary to, maternal toxicity. There was no evidence suggesting the induction of malformations in the offspring. The mechanism underlying this adverse effect in experimental laboratory animals is identified-inhibition of glutamine synthetase. Glutamine is essential to the viability of the embryo. The embryo is dependent on a maternal source of the amino acid. For embryo lethality to occur, a significant reduction of maternal glutamine is required. Such reduction in maternal glutamine depends on a significant inhibition of glutamine synthetase by GA. This can only occur when the mother is exposed to very high levels of GA. SPECIFICALLY: a. The reproductive toxicity of GA is confined to very short, early stages of reproduction, during which the conceptus is dependent on maternal glutamine; and b. In order for the effect to occur, significant reduction in maternal blood glutamine level is required, which in turn depends on a significant inhibition of glutamine synthetase, induced by high levels of GA in the maternal system. There is no evidence for accumulation of GA in the mammalian organism beyond a factor of two and no evidence for its metabolic toxification. To raise a concern in humans, women would have to be exposed to GA during the very limited time frame of preimplantation or implantation and the exposure would have to be to the exceedingly high levels necessary to alter the maternal metabolism and, correspondingly, result in glutamine levels in maternal tissue and blood plasma being drastically reduced. There is no basis to suggest that such exposures would occur under conditions of normal handling and use. SPECIFICALLY: a. Under conditions of normal handling and use, operators would never be exposed to GA levels that could potentially inhibit glutamine synthetase to the extent that this inhibition could impair preimplantation or implantation. b. All acceptable exposure measurements and predictive calculations confirm this conclusion, and in fact demonstrate that reasonably foreseeable exposure of workers would be to levels significantly below the AOEL. c. The evidence is also clear that there is no reproductive toxicity hazard to workers upon reentry tosprayed fields, bystanders, consumers or toddlers. The safety margin compared to the NOAEL in animal studies is sufficiently large to assure protection of the health of workers using GA as well as bystanders, consumers, and toddlers. Pursuant to Annex 6 of Commission Directive 2001/59/EC (28th ATP of Council Directive 67/548/EEC), to justify a classification of category 2 there must be sufficient evidence to produce a strong presumption that human exposure to the substance may result in impaired fertility in humans. It is the conclusion of the Science Partners Evaluation Group that there is no reasonable evidence to suggest a strong presumption of impairment. To the contrary, there is clear evidence demonstrating a strong presumption that exposure to GA would not cause the adverse effect demonstrated in rats. Pursuant to Annex 6 of Commission Directive 2001/59/EC (28th ATP of Council Directive 67/548/EEC), to justify a classification of category 3, there must be sufficient evidence to provide a strong suspicion of impaired fertility in humans. There is no basis to conclude that the animal data demonstrating impaired preimplantation or implantation has any relevance to humans in that the effect found in rats only occurs at levels which would never be experienced by workers under conditions of normal handling and use or by bystanders, consumers, or toddlers.

Aminobutyrates↗

An interdisciplinary course in women's health integrating basic and clinical sciences: clinical anatomy and women's health.

Traditionally, undergraduate medical education is divided into preclinical and clinical years, with basic sciences taught during the first years and clinical sciences taught during the latter years. In an effort to better integrate the basic and clinical sciences in undergraduate medical education, and focus on women's health, we have developed a new interdisciplinary fourth-year elective at the University of Michigan Medical School. The elective, titled "Clinical Anatomy and Women's Health," is a joint effort between the Division of Anatomical Sciences and the Department of Obstetrics and Gynecology at the University of Michigan Health System. During the course students participate in didactic, laboratory, cadaveric dissection, and clinical-correlate sessions that focus on gynecologic anatomy and clinical issues in women's health. Educational goals and learning objectives were used to assess the effectiveness of the curriculum; revisions, based on outcomes of the educational assessment, will be implemented in the next offering of the course. Preliminary data from the first offering of the course in February 2002 are provided. The goals of this course include integrating basic science and clinical concepts while reducing the division between preclinical and clinical medical education, addressing issues of women's health, and encouraging lifelong learning by using basic science concepts and techniques of discovery in clinical practice.

Anatomy↗

Preparing tomorrow's health sciences librarians: feasibility and marketing studies.

The University of North Carolina at Chapel Hill is devising and evaluating five curricular models designed to improve education for health sciences librarianship. These models fit into a continual learning process from the initial professional preparation to lifelong learning opportunities. Three of them enhance existing degree and certificate programs in the School of Information and Library Science (SILS) with a health sciences specialization, and two are new programs for working information professionals. The approaches involve partnerships among SILS, the Health Sciences Library, and the program in Medical Informatics. The planning process will study the feasibility of the proposed programs, test the marketability of the models to potential students and employers, and make recommendations about implementation.

Certification↗

Computing probabilities of homozygosity by descent.

A person is autozygous at a locus if the person inherits the same allele twice identical by descent along two distinct paths from the same ancestor. Autozygosity is a common cause of recessive diseases in inbred populations. Homozygosity mapping uses this fact to locate the genes that cause recessive diseases. The probability of autozygosity can be used to estimate the probability of a true positive and of a false positive in homozygosity mapping. Thompson [1994] and Guo [1997] therefore studied the problem of computing the prior, unconditional (multilocus) probability of autozygosity (MPA). I consider a different quantity: the interval probability of autozygosity (IPA). The two measures are identical in the single-locus case. IPA has two notable advantages over MPA: 1. IPA does not include the possibility of heterozygous regions between the homozygous markers. 2. IPA can be computed in time that is polynomial in the pedigree size. My polynomial-time algorithm for the single-locus case solves a problem mentioned by Guo. I implemented a program to compute the IPA. The contribution of this work is the application of basic, abstract methods from computer science to address a problem in genetics.

Algorithms↗

Real-time Kalman filter applied to biomechanical data for state estimation and numerical differentiation.

This study focused on the application of real-time Kalman filters to biomechanical data and, in particular, the simulation environment used to compare the performance of modified and standard two-state Kalman filters when estimating displacement and velocity from noisy displacement data. The modification proposed in this paper was the numerical tachometer, augmented by a median smoother. The numerical tachometer integrated the derivative estimates from finite differences of noisy sampled data into the Kalman filter structure; the median smoother acted before differentiation, to protect from grossly erroneous measurements. The numerical tachometer allowed better fits to the simulated data than can be achieved without it: the root mean square errors decreased by 10% in the displacement domain and by 54% in the velocity domain, for sampling frequencies and signal contamination levels that were typical in human movement sciences. The sensitivity to errors in the modelling of the signal and noise characteristics was less than in the standard filter implementation. The use of the median smoother improved the robustness of the filtering algorithm against additive white Gaussian measurement noise and allowed the cancellation of isolated noise spikes.

Algorithms↗

A relational database for trial-based behavioral experiments.

We describe a relational database (RDB) structure suitable for trial-based experiments such as human psychophysics and neural recording studies in trained animals. An RDB is a collection of tables, each composed of columns. Some of the tables contain columns that reference specific columns of other tables. This referencing system links the tables to each other and makes it possible to extract any subset of the data with trivial commands. An equally important advantage of an RDB is that it imposes a consistent data format on applications that generate and analyze data. The result is a centralization and standardization of data storage that facilitates the pooling, cross-checking and re-analysis of data from various experiments. We present a robust RDB structure originally designed for neurophysiological data; however, it is abstract enough to accommodate data from a variety of trial-based experimental designs. Moreover, we demonstrated the advantages of this RDB structure and indicated its implementation in other laboratories.

Algorithms↗

Achieving clinical behaviour change: a case of becoming indeterminate.

This paper is based on an empirical study of attempts to achieve change in clinical behaviour across a United Kingdom National Health Service (NHS) Health Authority (HA). We suggest that the evidence based medicine (EBM) movement underpinning such attempts is premised upon a highly rationalistic conception of change. Here the generation and implementation of research findings into clinical practice is understood as movement between discrete entities. Drawing upon poststructural philosophy, social studies of science and technology, social anthropology, and gender studies, we challenge such linear perspectives through a more immanent alternative. We conceive of change as movement within indeterminate or ambiguous relationships. We then proceed to discuss the implications of this modality for the management of clinical behaviour change.

Delivery of Health Care↗

Issues for consideration in the establishment of a program management structure.

In a product management structure, the management of separate products is moved down in the organization to achieve greater participatory management as well as greater effectiveness in the identification of factors most relevant to the survival of the product. For the business industry, managing products as separate entities enables more effective competition in the marketplace. This approach has been used in U.S. hospitals in managing programs and services. Described here are the initial attempts at program management undertaken at the Health Sciences Centre in Winnipeg, a highly specialized, provincial 1,100-bed teaching and referral hospital. Some issues important in developing and implementing the program management approach are discussed.

Decision Making, Organizational↗

The scope of gene therapy in humans: scientific, safety and ethical considerations.

Gene therapy entails the introduction of specific, functional genes into cells for therapeutic or preventive purposes. Therapeutic genes may be introduced into cells in vitro (and the treated cells then introduced into the patient) or directly in vivo. Gene therapy may be used for several purposes including: (a) Gene replacement in genetic diseases; (b) Destroying malignant cells in neoplastic diseases; (c) Modifying immune responses; (d) Providing trophic molecules; (e) Immunisation against infectious diseases. In designing gene therapy strategies the following major items need to be investigated and optimised: (1) Relevant biological characteristics of the treatable cells and tissues; (2) Gene vectors (viral or non-viral); (3) The gene expression cassette (promoter+cDNA+poly A signal); (4) The safest and most effective route of administration; (5) Longevity of the transgene expression. Before human trials for gene therapy can commence for a given disease, extensive preclinical studies are to be carried out in an appropriate experimental models to assure the feasibility, safety and efficiency of the enterprise. For each disease or application, the risk/benefit ratio must be determined. Permission by regulatory agencies, institutional review boards (IRB) and thorough informed consent are essential. Although gene therapy holds great promise for many human diseases, it is still too early to predict the extent and timetable of its successful implementation in individual diseases.

Ethics, Medical↗

Interactive lecturing for meaningful learning in large groups.

In order to enhance the quality of integration of physiological basic concepts with clinical sciences and to facilitate problem solving skills, a 'structured integrated interactive' two-hour block lecture on growth hormone physiology was implemented. A template showing the central regulation of growth hormone release and its peripheral effects was developed as an advanced organizer. Based on this template, new information was presented. Student feedback demonstrated that the lecture, based on the expository teaching model and enhanced by different forms of question and problem solving activities, was successful and interactive. It was also more motivating and was able to keep the attention of the students in relatively higher levels throughout the lecture. Furthermore, students felt that they had made important gains in transferable problem solving skills and this opinion was supported by their performance in clinical cases. These findings reinforced the idea that systematic incorporation of active learning strategies into lectures may minimize many of the weaknesses of traditional lectures.

Education, Medical, Undergraduate↗

Prospects for the future.

The worldwide impact of the AIDS epidemic will be considerable as millions of deaths occur. We can assume that for the next 5 years there will be no cure to treat infections and no vaccine to prevent them. There will be, however, palliative treatments that will prolong life to some extent. These, however, most likely will be quite expensive and carry considerable side effects. As for vaccines, there most likely will be prototypes under study, but no generally available product. In the United States and western Europe, most of the cases will continue to occur in the "first wave" groups, but over decades increased blurring of epidemiologic boundaries will occur as sexual partners of infected people develop the disease. Ultimately, if nothing is done to stop transmission, the epidemiology in these areas will parallel that of hepatitis B virus. But something will be done. Programs will be designed and carried out to care for patients and prevent further transmission. In the United States, the National Academy of Sciences (1) and the surgeon general (2) have outlined approaches to take. In places where well-planned programs have been implemented, improved health care and decreased transmission of the virus have resulted. Areas of the world and individuals in those areas which put forth effective treatment and prevention programs will no doubt fare better than those that do not.

Acquired Immunodeficiency Syndrome↗