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PubMedDate not supplied

A primer on dynamic optimization and optimal control in pharmacoeconomics.

Pharmacoeconomic analyses employ a wide range of techniques and methods to help societies allocate scarce health-care resources wisely, fairly, and efficiently. Techniques such as dynamic optimization and optimal control, however, have yet to be exploited by this field. Although control theory has a long history in mathematical biology and disease management, its application to economic costs in these disciplines has not yet been explored. Pharmacoeconomics therefore may offer a particularly promising starting point because of the emphasis this field places on the economic perspective. Although challenges may exist to implementing these techniques in practice (at least in some settings), there will nevertheless be value to considering the dynamic perspective these techniques offer, which requires thinking more critically about the optimal allocation of scare health-care resources over time. Therefore, our article serves as a primer to introduce this dynamic perspective from an economic standpoint within the context of two examples of treating of hyperlipidemia.

Cost Control↗

PubMed2007

Analysis of adverse drug reactions for preventability.

Although preventability criteria have been assessed for all adverse drug reactions (ADRs) investigated at our institution over the past 12 years, a systematic evaluation of the data had not been performed. This project analysed preventability data previously collected to identify the potential areas for process improvements. A 3-year retrospective analysis was performed. All ADRs were categorised by drug, drug class, severity, probability of causality and preventability. Factors involved in preventability were assessed and tallied. Descriptive statistics was used to analyse the data. Most ADRs occurred prior to admission. In the outpatient setting, anticoagulants and anticonvulsants were associated with more preventable ADRs (pADRs) than other drug classes, followed by cardiotonic agents and non-steroidal anti-inflammatory drugs (NSAIDs). For ADRs that occurred in hospitalised patients, antibiotics and opiates were associated with approximately half of all pADRs. The preventability categories most frequently associated with ADRs prior to admission were presence of a toxic drug level and drug-drug interactions, while inappropriate dose, route or frequency was the most common preventability category for inpatient ADRs. The majority of pADRs were moderate in severity in both the in- and outpatient settings. Drugs and drug classes involved in pADRs differ in the in- and outpatient settings. Preventability categories also differ by setting. Most pADRs occur prior to admission in our healthcare system. This presents a challenge in terms of implementing the process changes to reduce the pADRs, as patients in the community are outside our control.

Ambulatory Care↗

PubMed2006

Ethical considerations in the conduct of electronic surveillance research.

The extant clinical literature indicates profound problems in the assessment, monitoring, and documentation of care in long-term care facilities. The lack of adequate resources to accommodate higher staff-to-resident ratios adds additional urgency to the goal of identifying more cost-effective mechanisms to provide care oversight. The ever expanding array of electronic monitoring technologies in the clinical research arena demands a conceptual and pragmatic framework for the resolution of ethical tensions inherent in the use of such innovative tools. CareMedia is a project that explores the utility of video, audio and sensor technologies as a continuous real-time assessment and outcomes measurement tool. In this paper, the authors describe the seminal ethical challenges encountered during the implementation phase of this project, namely privacy and confidentiality protection, and the strategies employed to resolve the ethical tensions by applying principles of the interest theory of rights.

Aged↗

PubMed2004

A program of research with Hispanic and African American families: three decades of intervention development and testing influenced by the changing cultural context of Miami.

In this article we summarize work with poor, inner-city Hispanic and African American families conducted at the University of Miami Center for Family Studies. We elucidate ways in which this research program has paralleled the treatment development paradigm and has been responsive to changes in local demographics. Specific cultural issues pertaining to Hispanics and African Americans are discussed in light of treatment development and implementation. Future directions and challenges for working with poor, inner-city minority families are addressed.

Black or African American↗

PubMed2005

Challenges in using the dietary reference intakes to plan diets for groups.

A recent report describes a new paradigm for planning the dietary intakes of groups, the goals of which are to achieve low prevalences of both inadequate and excessive intakes. However, there are many challenges involved in properly implementing these methods, and pilot studies are urgently needed. For individuals, the target for nutrient intakes is usually the Recommended Dietary Allowance (RDA); for nutrients without an RDA, the Adequate Intake (AI) can be used. Intakes should be planned so they do not exceed the Tolerable Upper Intake Level (UL). Several applications illustrating how to use the DRIs for planning the diets of individuals have been published, so this review will focus primarily on the methods that are recommended for planning the diets of groups.

Adolescent↗

PubMed2005

Characterization of rotavirus strains in a Danish population: high frequency of mixed infections and diversity within the VP4 gene of P[8] strains.

We characterized the G and P types from 162 rotavirus-positive stool specimens collected from 162 persons in Denmark (134 children and 28 adults) with acute diarrhea in 1998, 2000, and 2002. Samples were obtained during outpatient consultations (73%) and from hospitalized patients (27%). Although more than 20 different G-P combinations were identified, only 52% represented the globally most common types G1P[8], G2P[4], and G4P[8]. The G9 genotype, which is emerging worldwide, was identified in 12% of all samples. Twenty-one percent of the samples were of mixed genotypic origin, which is the highest frequency reported in any European population. The standard reverse transcription-PCR methods initially failed to identify a considerable fraction of the rotavirus P strains due to mutations at the VP4 primer-binding sites of P[8] strains. The application of a degenerate P[8] primer resulted in typing of most VP4 strains. There was considerable year-to-year variation among the circulating G-P types, and whereas G1P[8] was predominant in 1998 (42% of samples) and 2002 (26%), G2P[4] was the strain that was most frequently detected in 2000 (26% of samples). Our findings might implicate challenges for rotavirus vaccine implementation in a European population and underscore the importance of extensive strain surveillance prior to, during, and after introduction of any vaccine candidate.

Adolescent↗

PubMed2004

Primary prevention of cardiovascular disease: managing hypertension and hyperlipidaemia.

Cardiovascular medicine has a sound evidence base upon which health professionals can base their interventions to modify risk among the British public. For primary prevention of cardiovascular disease, however, while there is considerable evidence on what to do, data are limited on how the evidence should be implemented in practice. The challenge will be to learn by experience which interventions directed at reducing blood pressure and lipids levels work best in different settings. There is a need to structure care to identify individuals who are at risk. Current targets are explicit and achievable for both hypertension and lipids. Effective treatment is likely to require multiple drug treatment.

Attitude to Health↗

PubMed2006

Emergency department screening for risk for post-traumatic stress disorder among injured children.

OBJECTIVE: To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED). METHODS: The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained. RESULTS: The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered. CONCLUSIONS: Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.

Accidents, Traffic↗

PubMed2006

Immunotherapy of lung cancer: an update.

In Germany lung cancer is the leading cause of cancer-associated death in men. Surgery, chemotherapy and radiation may enhance survival of patients suffering from lung cancer but the enhancement is typically transient and mostly absent with advanced disease; eventually more than 90% of lung cancer patients will die of disease. New approaches to the treatment of lung cancer are urgently needed. Immunotherapy may represent one new approach with low toxicity and high specificity but implementation has been a challenge because of the poor antigenic characterization of these tumors and their ability to escape immune responses. Several different immunotherapeutic treatment strategies have been developed. This review examines the current state of development and recent advances with respect to non-specific immune stimulation, cellular immunotherapy (specific and non-specific), therapeutic cancer vaccines and gene therapy for lung cancer. The focus is primarily placed on immunotherapeutic cancer treatments that are already in clinical trial or well progressed in preclinical studies. Although there seems to be a promising future for immunotherapy in lung cancer, presently there is not standard immunotherapy available for clinical routine.

Cancer Vaccines↗

PubMedDate not supplied

Lessons learned while developing "Clinical Trials Education for Native Americans" curriculum.

This paper highlights lessons learned while developing the Clinical Trials Education for Native Americans (CTENA) curriculum. The CTENA is a culturally specific clinical trials education curriculum that evolved from another ongoing NCI-supported project, Clinical Trials Education for Colorado Providers. The multicultural team learned many lessons while developing, pretesting, and revising this curriculum. These include allocating sufficient time and resources to tailor presentations for diverse tribal settings and workshop participants, addressing barriers to participation in clinical trials through culturally appropriate strategies, providing information to foster informed decision making related to participation, and writing as a team to increase cultural breadth of examples and interactive experiences. There are multiple challenges to developing and implementing a culturally acceptable curriculum on clinical trials within medically underserved communities. Both the multicultural team and the curriculum benefited from the collaborative process, resulting in a culturally relevant clinical trials curriculum that will assist Native Americans to make informed choices about clinical trials participation. The lessons shared here, which may need to be modified to be culturally relevant to other underrepresented communities, may be beneficial to others developing similar curricula for other medically underserved populations.

Clinical Trials as Topic↗

PubMed1998

The development of faith community nursing programs as a response to changing Australian health policy.

This article discusses the context of Australian health care and the policy directions being implemented to meet current challenges. It demonstrates why and how faith community nursing/nurses (FCN) programs commenced within Australia as an innovative response to health policy, changing health needs and altering social and economic trends. The FCN demonstration project is described, and the unfolding FCN role and its relationship to the evolving health care continuum is discussed. Faith community (parish/pastoral) nursing fosters community participation in health and promotes whole person health, within the supported social and culturally specific context of a faith community. The FCN provides individuals and communities with health promotion and illness prevention activities, as well as care management services, and helps clarify and nurture the relationship between faith and health.

Australia↗

PubMed2002

Hypertension and diabetes.

Hypertension is common in people with diabetes with an estimated prevalence using the new criteria (> or = 140/90) at 70%. The recent large randomized controlled studies in diabetic subjects has clearly shown the benefit of blood pressure lowering with reduction in cardiovascular endpoints and microvascular disease. ACE inhibitors, calcium antagonists, thiazide diuretics and beta-blocking agents have been the agents validated by the trials. The challenge now is to implement antihypertensive therapy to achieve tight blood pressure targets (< or = 140/80), usually requiring dual or even triple therapeutic regimens.

Antihypertensive Agents↗

PubMed2026

Recent advances in molecular mechanisms to improve the efficacy of CAR-T cell therapy for viral diseases, cancer, and autoimmune diseases.

Chimeric antigen receptor (CAR)-T cell therapy has transformed the treatment of hematological malignancies, yet its broader application to solid tumors, chronic viral infections, and autoimmune diseases remains constrained by antigen heterogeneity, immunosuppressive tissue microenvironments, T-cell exhaustion, limited persistence, and treatment-associated toxicities. These challenges have shifted the field from optimizing individual receptor constructs toward engineering CAR-T cells as programmable immune systems capable of adapting to diverse disease contexts. This review synthesizes recent advances in molecular engineering strategies that enhance CAR-T cell function beyond conventional receptor design. We discuss how receptor engineering, genome editing, transcriptional and epigenetic regulation, metabolic reprogramming, synthetic gene circuits, and safety-control platforms collectively reshape CAR-T cell fate, persistence, and therapeutic efficacy. Rather than functioning independently, these engineering strategies are increasingly integrated to generate context-specific cellular therapies capable of adapting to diverse disease environments, including cancer, autoimmune diseases, and chronic viral infections. We also highlight the potential for translation into clinical practice or clinical translation and discuss the major challenges associated with clinical implementation. Next-generation CAR-T therapies will increasingly integrate molecular engineering strategies or will rely on molecular engineering strategies to integrate antigen recognition, cellular fitness, immune regulation, and longevity rather than simply maximizing cytotoxic activity. Recent advances in programmable cellular engineering coupled with rigorous clinical evaluation as well as scalable manufacturing technologies or scalable manufacturing platforms in the treatment of other diseases beyond oncology will facilitate the development of safer, more durable, and broadly applicable cellular therapies.

Humans↗

PubMed1999

Factors that may influence the implementation of nurse-centred telemedicine services.

A qualitative study of four UK telemedicine sites was carried out to explore reactions to nurse-centred telemedicine services and their possible implications. Using semistructured schedules, 36 people directly involved in these services were interviewed--25 nurses, four general practitioners, two advising medical consultants, three service managers and two researchers. Factors identified which may influence successful implementation included: early involvement of all groups affected, prior consideration of the practical implications, thorough initial equipment testing, good technical support, imaginative training and clarity of the purpose of the service. The study showed that all those involved must be prepared for the rapid learning that is implicit in the implementation of change. The challenge is to maximize the potential for the primary operator to use new techniques. In respect of nurse-centred services, the nurse must not be viewed as a technician, nor should telemedicine be seen as a substitute for an available doctor.

Clinical Competence↗

PubMed2004

Shared decision-making in nursing education.

Shared decision-making is an effective management strategy that may have positive implications for nurse educators facing curricular and course delivery issues. Use of shared or participative decision-making recognizes that decisions made for the overall good of the organization should include those integrally involved, i.e., faculty, students and administration. Ultimately, effective student learning should be the outcome of decisions related to curricular and content delivery. In this anecdotal paper, the authors present shared decision-making (SDM) as a management strategy that may be effectively utilized in a range of situations in educational settings. An exemplar is presented regarding changes in course delivery methods at two sister schools of nursing. Strategies to promote successful implementation, as well as challenges in initiating SDM, are discussed. The information presented in this paper can benefit nurse educators by offering a collaborative approach to the issues of evolving nursing curricula and content delivery.

Canada↗

PubMed2000

Statins: where are we now?

Statin therapy reduces the risk of cardiac events by 30% in both primary and secondary prevention. Although fine-tuning of the evidence will occur as more clinical trials report, the challenge is now to implement the evidence to the benefit of patients.

Aged↗

PubMed2002

Social security reform in Latin America: policy challenges.

Over the last decade Latin American countries have served as the world's laboratory for pension systems based on individual retirement savings accounts. Some countries have adopted defined-contribution individual accounts as a replacement for state-run pension systems; other countries have embraced mixed systems of have made individual accounts optional and supplementary. This article outlines some of the most significant elements of recent Latin American pension reforms and examines some of the most serious policy challenges faced by governments implementing the new systems of individual accounts, including the need to reduce administrative costs, limit evasion, incorporate new categories of workers into the system, and improve competition in the pension fund industry. The authors conclude that there is no single Latin America model, and that reform itself has been and will continue to be an incremental process.

Aged↗

PubMed1983

Emergency medical personnel training: II. Components of training.

Nationwide Emergency Medical Technician (EMT) training programs at both basic and advanced levels are in flux, confronting similar challenges in design and implementation. There currently exist the 81-hour Department of Transportation course of instruction as the basis for EMT-Ambulance (EMT-A) certification and the National Standard Training Curriculum (NSTC) 15-module course for training the EMT-Paramedic (EMT-P). The National Registry of EMTs has established examination and recertification guidelines as well as requirements for both levels of training. The two national training courses reflect a difference in disease focus (ie, trauma vs cardiac) and thus a difference in care rendered by the two EMT levels. Variations in both EMT-A and EMT-P training programs at the state level in areas such as length of training and requirements for certification point out a need for greater consistency in training of emergency medical personnel. Evaluation of current training programs based on the NSTC has resulted in updating the EMT-P curriculum. The proposed curriculum includes new course material with behavioral and performance objectives. An ongoing system of training, evaluation, and incorporation of new techniques found clinically relevant is recommended.

Allied Health Personnel↗