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PubMed2003

The public health implications of world trade negotiations on the general agreement on trade in services and public services.

Trade ministries from the World Trade Organization's (WTO's) 144 member states are presently deciding which public services to open to foreign competition under the complex liberalisation rules of the general agreement on trade in services (GATS). A frequent criticism of the WTO system is that it reduces national autonomy over public policy. However, respect for national sovereignty is asserted in the GATS treaty. Here, we examine claims made by the WTO and others that GATS exempts public services and does not require their privatisation. We discuss trade treaty processes that can subject public services to commercial rules, the treaty's flexibility with respect to national autonomy, and the effect of GATS in situations in which national autonomy is not protected. We conclude that national autonomy over health policy is not preserved under GATS, and that accordingly, there is a role for international standards that protect public services from the adverse effect of trade and market forces.

Commerce↗
PubMed1998

Shared understandings: negotiating the meanings of health via concept mapping.

This paper discusses a project undertaken to explore the effectiveness of concept mapping in assisting students to develop positive concepts of health. Positive concepts of health are central to the notion of health promotion. While strategies for health promotion are included in all nursing education programmes in Australia, to date there have been few strategies that are oriented towards promoting the development of positive concepts of health discussed in the literature. If student nurses are to become health-promoting practitioners, health teaching in nursing education must employ teaching strategies which clarify for students the differences between positive and negative concepts of health. One such strategy is concept mapping, which was developed as an educational tool to foster meaningful learning. Concept maps work to identify misconceptions in relation to a topic by clarifying the essential points, thus opening the way for concept change. This paper discusses the results of using concept mapping within the context of an abstract subject such as health, identifies difficulties in evaluating the strategy and makes recommendations about how these might be overcome.

Algorithms↗
PubMed2003

Immunopotentiating heat shock proteins: negotiators between innate danger and control of autoimmunity.

Heat shock proteins (hsps) are known to be immunodominant antigens of bacteria. Hsps are evolutionarily strongly conserved proteins present in all eukaryotic and prokaryotic cellular organisms and upregulated by several forms of stress. Despite (the paradigm of) self-tolerance, hsp-epitopes homologous to endogenous host hsp sequences have been implicated as T cell epitopes to endow crossreactive, hsp-specific T cells with the capacity to regulate inflammation, such as in experimentally induced autoimmune diseases. Such T cells were found to produce regulatory cytokines like IL10, in contrast to T cells induced with other conserved microbial proteins that are not upregulated by stress. Hsps have been implicated in immune regulation not only as upregulated targets of adaptive immunity during inflammatory stress, but recently also as triggering factors for innate immunity through activation via Toll-like receptors (TLRs).

Adjuvants, Immunologic↗
PubMed2001

Negotiating control and meaning: home birth as a self-constructed choice in Finland.

Each society has its own consensual understanding of birth and its determinants: caregivers, location, participants and loci of decision-making, which in the Western world are based on biomedical knowledge. However, two competing cultural models of childbirth, the biomedical/technocratic model and natural/holistic model, mediate women's choices and preferences for the place and caregiver in childbirth. This article explores the way in which these cultural models of birth and the existing practical possibilities for choices shape women's and men's understanding of home birth. Based on interviews with 21 Finnish women and 12 Finnish men, the reasons for and experiences of planning and building toward a home birth are examined through an analysis of birth narratives. The analysis focuses especially on the women's definitions of what is 'natural' and their relationship with health services where biomedical practices and knowledge are the norm. The analysis shows that the notion of 'natural birth' holds various meanings in Finnish women's narratives namely self-determination, control, and trust in one's intuition. I seek to demonstrate that just as the biomedical management of childbirth exhibits distinct cross-cultural variation, so also does resistance to biomedical hegemony, as such resistance is strongly embedded in the local socio-cultural situation.

Anecdotes as Topic↗
PubMed1999

When is a shared decision not (quite) a shared decision? Negotiating preferences in a general practice encounter.

We consider whether there are situations in which 'shared decision making' in primary care is inherently problematic, such as in the demand for antibiotics to treat viral disorders. In such an instance there might be a lack of the equipoise necessary for a decision-making context in which apparent choices are genuine options. Using the techniques of discourse analysis on the transcript of a consultation with the parents of an infant with tonsillitis, we illustrate how a general practitioner's (GP's) efforts to reach a 'shared decision' come unstuck through a combination of the embedded power imbalance and the conflict between the GP's own prescription preferences and those of the parent.

Decision Making↗
PubMed2000

"That original tension". Negotiating abstinence in clinicians' accounts of harm reduction in nonresidential treatment of heroin withdrawal.

The aim of this article is to examine how drug and alcohol clinicians, guided by a policy of harm reduction, approach their withdrawal work in their encounter with injecting heroin users seeking nonmethadone withdrawal treatment. The study, qualitative in design, involved detailed interviews with all seven clinicians who worked in the nonmethadone withdrawal program of a nonresidential drug and alcohol center in Melbourne, Australia. I draw attention to the difficulties that these clinicians have in their withdrawal work, especially concerning the place of abstinence in withdrawal and in harm reduction. Abstinence is a legitimate goal of harm reduction. Yet, how harm-reduction knowledge is practiced and reproduced in the clinical encounter is underpinned by dominant and taken-for-granted assumptions about abstinence as 'other' to harm reduction. The ideal of abstinence in drug and alcohol treatment and its decentering within the concept of harm reduction, make introducing harm-reduction strategies in the clinical encounter precarious. The work of withdrawal is compromised with an unresolved tension brought about through the paradox of legitimating illicit drug use in one context (the medical) when it is not legitimate in another context (the sociopolitical).

Adult↗
PubMed1998

Time-domain analysis of foot-ground reaction forces in negotiating obstacles.

In recent years there has been increasing interest in the kinetic and kinematic characteristics of adaptations to obstacles and the contribution of these measures to understanding processes of gait control. This study investigated the lead and trail foot kinetic characteristics of unobstructed walking and stepping over obstacles for unimpaired, healthy adult males (n=6) and females (n=6). Two strain-gauged force platforms were employed during free-speed ambulation and stepping over obstacles adjusted to 10, 20 and 30% of leg length. In stepping over obstacles subjects increased obstacle-crossing step lengths and reduced obstacle-crossing speed as a function of obstacle height. The force-time data revealed that, compared with the lead foot, the trail foot generated greater vertical and anterior-posterior force during the push-off/propulsive phase across all obstacle conditions, had lower vertical peak force during mid-stance and produced greater vertical and anterior posterior impulses. While maximum propulsive force increased with obstacle height, its timing in the normalized step cycle was uninfluenced by height. Collectively, the results showed that the constraints of stepping over obstacles imposed different kinetic demands on the lead and trail foot; this is reflected in a complex interaction of braking and propulsive forces. Regulation of the step in this task was not mediated by a single parameter, such as vertical impulse. Copyright 1997 Elsevier Science B.V.

Journal Article↗
PubMed2003

Safe evolution towards routine off-pump coronary artery bypass: negotiating the learning curve.

OBJECTIVE: Off-pump coronary artery bypass (OPCAB) hopes to avoid morbidity associated with cardiopulmonary bypass, improving clinical outcomes. Yet its technical difficulty and unfamiliarity raise concern that adoption of OPCAB might be associated with poorer outcomes during each surgeon's 'learning curve'. We examined trends in patient selection over time as a single surgeon's practice evolved to routine OPCAB. METHODS: Between 10-1-96 and 12-31-01, 1479 consecutive patients had isolated coronary artery bypass grafting (CABG). Clinical data were gathered prospectively and reviewed retrospectively. Trends in adoption of OPCAB and clinical outcomes were examined. RESULTS: There were 756 OPCAB and 723 CABG/cardiopulmonary bypass patients. The practice evolved from 90% conventional CABG to 93% OPCAB. An abrupt transition coincided with evolution of techniques to expose the obtuse marginal arteries, and improvements in suction-based coronary stabilizers. Mortality was 1.0% for the off-pump group and 2.1% for the on-pump group. Careful patient selection helped maintain acceptable outcomes during the 'learning curve'. Patients with depressed left ventricular ejection fraction, left main disease, and complex three vessel disease were excluded from OPCAB until significant experience (>200 cases) was attained. Presently, all isolated coronary bypass cases are candidates for OPCAB except patients with ischemic ventricular arrhythmias, those in cardiac arrest, and those for whom previous left pneumonectomy or deep pectus excavatum prevent rightward mobilization of heart. CONCLUSIONS: Despite a significant learning curve, evolution to routine OPCAB can be achieved while maintaining good patient outcomes. The development of specialized techniques, coronary stabilizers, and apical suction devices allows the application of OPCAB to virtually all coronary bypass patients, as surgeon experience matures.

Aged↗
PubMed2002

Neoglycopeptides as inhibitors of oligosaccharyl transferase: insight into negotiating product inhibition.

Linear hexapeptides featuring the asparagine mimetics alanine-beta-hydrazide, alanine-beta-hydroxylamine, and 1,3-diaminobutanoic acid have been synthesized as oligosaccharyl transferase (OT) substrate mimetics and chemoselectively N-glycosylated to obtain the corresponding neoglycopeptides as OT product mimetics. The effect of glycosylation on the binding of these asparagine surrogates is in stark contrast with the effect of modification of native asparagine. In native N-linked glycosylation, product inhibition is minimal and glycopeptides show very low affinity for OT. In contrast, glycosylation of the substrate mimetics maintains or even improves affinity of the corresponding product mimetic for OT. Conformational considerations suggest that the flexibility of the N-glycosyl linkage in these neoglycopeptides allows them to be accommodated in the OT binding site while the native trans glycosyl amide linkage is rejected. These results provide insight into how OT minimizes product inhibition, thereby ensuring effective substrate turnover.

Binding, Competitive↗
PubMed2000

Negotiations between animals and bacteria: the 'diplomacy' of the squid-vibrio symbiosis.

A shared characteristic among animals is their propensity to form stable, beneficial relationships with prokaryotes. Usually these associations occur in the form of consortia, i.e. a diverse assemblage of bacteria interacting with a single animal host. These complex communities, while common, have been difficult to characterize. The two-partner symbiosis between the squid Euprymna scolopes and the marine luminous bacterium Vibrio fischeri offers the opportunity to study the interaction between animal and bacterial cells, because both partners can be cultured in the laboratory and the symbiosis can be manipulated experimentally. This system is being used to characterize the mechanisms by which animals establish, develop and maintain stable alliances with bacteria. This review summarizes the progress to date on the development of this model.

Animals↗
PubMed2001

The safe journeys of an enterprising school: negotiating landscapes of opportunity and risk.

In this paper, we discuss recent efforts to improve the safety of children travelling to and from New Zealand's largest primary school. The results of a travel survey completed by parents and pupils are reported, together with our recommendations for reducing congestion at the school gate and promoting healthy alternatives to car travel. Reflecting on this research, we find that market-oriented education reforms have provided schools with strong incentives for increasing their rolls--a course of action which may endanger pupils' well-being. At the same time, they have provided some schools with opportunities for resisting the present urban (dis)order and promoting community health.

Accidents, Traffic↗