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PubMed2002

A test of two training interventions to prevent work-related musculoskeletal disorders of the upper extremity.

We investigated, on behalf of a large electronics manufacturer, two types of worker training interventions for their efficacy in preventing unnecessary muscle tension and the symptoms of work-related musculoskeletal disorders. The first intervention, Muscle Learning Therapy (MLT), used electromyographic (sEMG) feedback and operant conditioning to decrease muscle tension during complex work tasks. The second intervention used adult learning and cognitive behavioral techniques in small group discussion to advance the worker's capabilities for symptom and stress management and problem-solving. Workers were randomly assigned to a control group or one of the two treatment conditions. Prior to training, baseline data were collected using symptom diaries and sEMG recordings of the trapezius and forearm muscles of the left and right arms. The training interventions were conducted for 6 weeks with reinforcement training provided at 18 and 32 weeks post-baseline. Follow-up data were collected after the initial 6-week training period and at 32 weeks, prior to the reinforcement training. Symptom outcomes demonstrated significant differences at 6 weeks, increasing in severity for the control group and declining modestly for the educational group, with little change for the MLT group. These differences were not maintained at further follow-up. The MLT group was consistently effective in reducing muscle tension in the trapezius areas after 6 and 32 weeks, and was partially effective for the forearms. Further testing is recommended of these training interventions, especially with the inclusion of strategic, periodic reinforcement of the worker's learning.

Adult↗

PubMed2002

[Predictive genetic testing - change in paradigms for prevention and health care?].

The post-genomic era promises to offer new insights into the nature of disease, its prevention, and treatment. But now that there is a draft code of the human genome, what does this knowledge mean and how might it be applied? How to use genetic information to promote health and prevent disease - the fundamental mission of public health - will be one of the most challenging tasks in future. Assessing the benefits and risks of predictive genetic testing and the efficacy of early interventions as well as exploring complex issues that have emerged (e. g., rapid commercialization of genetic tests, availability of and access to interventions, and potencial discrimination) call for public health leadership.

Forecasting↗

PubMed1987

Feeding the handicapped child--a review of intervention strategies.

Feeding the handicapped child occurs three or four times per day, every day of the year, despite the child's feeding problems and, in the vast majority of cases, without life threatening consequences. Yet the need for adequate feeding therapy for these children is becoming increasingly recognised. This paper seeks to explore why intervention is so important. The complex causes of feeding problems will be reviewed briefly followed by a discussion of the reasons for intervention. Feeding therapy techniques, strategies and approaches will be reviewed with the need for parent involvement, early intervention and a 'feeding-team' being stressed throughout. This paper highlights the need for intervention in feeding problems, whether or not they are life threatening, particularly in view of their effect upon quality of life of both the child and his family.

Child↗

PubMed1990

Clinical manifestations of benign prostatic hyperplasia and indications for therapeutic intervention.

The symptomatology of benign prostatic hyperplasia is a complex issue, and the clear-cut indications for therapeutic intervention are few. Overflow incontinence is a clear indication for treatment, and it seems prudent to recommend surgical intervention for patients with large postvoiding residual volumes. Acute urinary retention, recurrent infection, azotemia, and severe hematuria are other strong indications. When the indications are less clear, the patient's perspective on the impact of prostate disease on his life is important.

Humans↗

PubMed1992

Children's beliefs about strategies to reduce parental anger.

Age and sex differences in beliefs about strategies for reducing parental anger were assessed. The central question was whether direct intervention strategies are the most effective for, and reflect more advanced understanding of, anger reduction. In Study 1, 120 children ages 4-9 years generated strategies they believed would lessen a parent's anger elicited by 3 situations of increasing complexity. Across ages children proposed direct intervention strategies for the simplest situation, and there was an age increase in suggesting direct intervention strategies for the more complex situations. In Study 2, 180 children, ages 4-12 years, and their parents rated the effectiveness of the strategies generated for the most complex situation (interparental argument). There was no longer a unilinear age increase in believing direct intervention strategies effective. Unlike with older and younger children, there was no agreement between 7-9-year-olds and their parents on the efficacy of direct intervention strategies.

Age Factors↗

PubMedDate not supplied

Disease coding errors by health care organizations: effects of a government quality intervention.

Disease coding errors in claims data can cause serious problems for financing, reimbursement systems, public health surveillance and health research. This study analysed a government intervention to improve coding accuracy of health care organizations in South Korea. The intervention was implemented in 1997 by 226 organizations that had submitted erroneous claims in 1996 for five selected diseases. In 1998, 94% of these organizations eliminated coding errors for these diseases. Those organizations least responsive to the intervention were tertiary hospitals, those publicly owned, and those with other complex organizational characteristics. Overall, this simple intervention appeared extremely effective, and wider adoption of such techniques should be explored.

Communicable Diseases↗

PubMed2001

GPIIb-IIIa receptor inhibitors: what the interventional radiologist needs to know.

The glycoprotein IIb-IIIa (GPIIb-IIIa) receptor inhibitors have established themselves as first line therapy in the treatment of acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI). The benefit of these agents rests in their ability to attenuate the deleterious effects of platelet activation, both at the site of an inflamed vessel wall (due to a ruptured plaque or PCI) and in the microcirculation as a result of embolization. Based on these results, interventional radiologists are beginning to explore the potential of using GPIIb-IIIa inhibitors during interventions in the peripheral circulation. This paper reviews the molecular biology of the GPIIb-IIIa receptor, the pharmacology of the GPIIb-IIIa receptor inhibitors, the current coronary and peripheral vascular literature as it pertains to the GPIIb-IIIa receptor inhibitors, and potential future applications of the GPIIb-IIIa receptor inhibitors in the peripheral circulation.

Acute Disease↗

PubMed2005

Using a brief intervention to improve decisional capacity in schizophrenia research.

Studies have shown that individuals with psychiatric or general medical illness can benefit from interventions designed to enhance decisional capacity for research informed consent. In some cases, interventions have been rather lengthy or complex. The current study was designed to determine whether a brief intervention could improve decisional capacity in people with schizophrenia. Thirty individuals with schizophrenia and 30 healthy comparison participants were presented with a hypothetical research scenario. Decisional capacity was assessed with the MacArthur Competence Assessment Tool-Clinical Research version. Those with schizophrenia received a brief intervention aimed at improving understanding of the research protocol, after which decisional capacity was reassessed. A neuropsychological battery and symptom rating scales were also administered. At baseline, the schizophrenia group earned significantly lower scores than the comparison group on 2 aspects of decisional capacity (understanding, appreciation). At follow-up, the schizophrenia group had improved significantly on understanding and was no longer significantly different from the comparison group on any of the 4 dimensions of decisional capacity. Follow-up analyses also showed a significant effect of the intervention on a subset of the schizophrenia group who had performed most poorly at baseline. Participants with schizophrenia earned significantly lower scores than those in the comparison group across multiple neuropsychological domains. These findings add to the existing literature indicating that brief interventions can improve decisional capacity in individuals with schizophrenia, despite the fact that the illness typically causes significant cognitive dysfunction. The use of such interventions will enable a larger number of people with schizophrenia to make informed decisions regarding research participation.

Adult↗

PubMed2001

Use of abciximab for mediation of thromboembolic complications of endovascular therapy.

We describe four cases in which abciximab was used as a thrombolytic rescue agent in the setting of thrombotic events complicating interventional neuroradiologic procedures. After IV administration of abciximab, the thrombus resolved within 30 min in three cases, whereas no thrombolysis occurred in the fourth case despite the addition of intraarterial tissue plasminogen activator. Further evaluation of glycoprotein IIb-IIIa inhibitors in patients with cerebral thromboembolic events is necessary to prove clinical efficacy.

Abciximab↗

PubMed2001

Parent to child transmission of HIV: policy considerations in the Asia-Pacific region.

BACKGROUND: As HIV spreads through many countries in Asia and the Pacific, women of reproductive age are becoming infected and we can expect increasing numbers of infants to be infected. Rapid advances in knowledge about mother to child transmission (MTCT), new findings from intervention studies, recognition of complex ethical implications, and changing attitudes and behaviours combine to create uncertainty for policy makers. OBJECTIVE: Policy makers need sound advice but MTCT and its prevention are complicated topics. We aim to provide an overview of MTCT of HIV and suggest some key points to consider in the allocation of resources. STUDY DESIGN: This is a policy analysis based on review of the literature, consultation with policy makers and researchers, and observations in the context of projects in developing countries. RESULTS: The risk of MTCT is between 15 and 40%, but the use of antiretroviral prophylaxis, elective caesarean section, and replacement of breastfeeding can reduce this to less than 4%. But most infected women in developing countries are unaware that they are HIV-infected and do not yet have access to these 'test-dependent' interventions (interventions based on testing for HIV infection). Population-based strategies that address known influences on the risk of MTCT can be implemented with benefits for the health of both men and women. The test-dependent interventions can have adverse effects as well as benefits, careful preparation is necessary before they are introduced in resource poor settings. The public health impact of test-dependent interventions is limited by difficulties in achieving wide coverage and because they miss women who become infected late in pregnancy or during lactation who have the highest risk of MTCT. CONCLUSIONS: We argue for a broad response to the problems raised by MTCT of HIV that includes gathering information to inform the introduction of strategies that do not depend on testing for HIV infection as well as the test-dependent interventions, community education that reaches men as well as women; strengthening of reproductive health services; and mobilising communities to care for infected women, their families, and orphans.

Adolescent↗

PubMedDate not supplied

Development of steerable instruments for minimal invasive surgery in modular conception.

The augmenting complexity of minimal invasive interventions requests a continuous improvement of technologies. Extended endoscopic procedures, e.g. laparoscopic-transanal sigmoidectomy or thoracoscopic esophagus dissection require difficult surgical manipulations like mobilisation, sceletonization as well as ligatures and sutures. They are difficult to perform with the present endo-surgical instruments. A major instrumental weakness is represented by the restricted steerability because of the rigid shaft axis and the resulting low degrees of freedom (DOF). Therefore a series of steerable flexible instruments has been developed in interdisciplinary cooperation between surgeons and engineers. The prototypes provide a multi-joint working as the instrument's elbow, which allows to incline the tip around +/- 280 degrees. The second additional DOF is the rotation of the surgical tool. The prototypes have been experimentally tested in laparoscopy and thoracoscopy, showing a clear improvement in the carrying out of complex operative manipulations. The further development is performed in modular conception, including electric drives.

Animals↗

PubMed1994

Prevention of atherosclerosis and end-organ damage: a basis for antihypertensive interventional strategies.

AIM: To review the nature of the complex relationships between essential hypertension and cardiovascular end-organ damage, with a particular focus on the pathogenesis and prevention of coronary heart disease, the major complication of untreated hypertension. RISK FACTORS FOR CORONARY HEART DISEASE: Both atherosclerosis and hypertension have their origins in childhood; in the second and third decades of life development of the more advanced fibrous plaques accelerates, emphasizing the need for early diagnosis and intervention. Perplexing and complex relationships have been found among the principal risk factors for coronary heart disease, hyperinsulinemia, insulin resistance, dyslipidemia and hypertension. In the pathogenesis of atherosclerosis at the cellular and molecular level, the important features are the effects of monocyte-macrophages, oxidant stress, lipoprotein modification, inflammatory mediators and the focal hemodynamic environment. Even brief periods of experimental hypertension can accentuate atherogenesis, the effects of which are greatest but not limited to the cervical and cerebral arteries. Further, acute hypertension lasting for even a few minutes causes a 'leakage' of plasma proteins and particulate probes into the artery wall, which has far-reaching implications for antihypertensive therapy. Recent work has shown that 24-h blood pressure variability is correlated with target-organ damage in hypertensive patients. THERAPY: Antihypertensive therapy should not only lower blood pressure but also prevent significant short-term blood pressure fluctuations. The trough: peak ratio has been used to assess the effect of antihypertensive treatment on blood pressure variability. CONCLUSION: More intensive research is required to clarify the nature of the interface between hypertension and atherogenesis.

Adolescent↗

PubMed2001

[Congenital coronary fistulas: the most frequent congenital coronary anomaly].

Congenital arteriovenous coronary fistulae are a rare condition of a direct communication between a coronary artery and one of the cardiac chambers, the coronary sinus, the superior vena cava or the pulmonary artery. In most instances the diagnosis is made during heart catheterization for coronary or congenital heart disease. Whether congenital coronary artery fistulae should be treated by transcatheter intervention or surgery and in which patients fistula closure should be performed is controversial. This report summarizes our experience of the surgical treatment of congenital arteriovenous coronary fistulae in 14 patients at the Deutsches Herzzentrum Berlin between March 1988 and April 1997. There were seven females and seven males aged from 3 to 67 years (mean 47 years). We analyzed the symptomatic status (NYHA class) preoperatively and in the late outcome, the preoperative angiographic data and the surgical techniques. The right coronary artery was affected in six, the left in six, and both arteries in two cases. The fistulae drained into the pulmonary artery in eight cases, into the superior vena cava and into the right atrium in two cases, and into the right ventricle and into the coronary sinus once. Fistula closure was unsuccessfully attempted interventionally in two patients and surgically in one patient in another institution. Twelve of the patients exhibited additional cardiac disease requiring surgery: seven cases presented additional coronary artery disease, one mitral valve disease, one persistent ductus arteriosus, one an aneurysm of the right coronary artery, and two an atrial septal defect. We performed fistula closure either by ligating or transsecting the fistula as well as by closure of the fistula's drainage opening. Surgery and postoperative courses were uneventful in all patients. Most of the patients (93%) were in good clinical condition (NYHA I-II) after a mean follow-up period of 6.6 years (range 3-11). Fistula closure should be performed in patients who are symptomatic or who have a hemodynamic relevant shunt. In asymptomatic patients and small left-to-right shunt, fistula closure should also be performed to prevent later complications. Surgical fistula closure should be employed in patients with larger and more complex fistulae, especially if interventional therapy failed, and for patients with additional cardiac conditions that necessitate surgery.

Adolescent↗

PubMed2002

Defining standards of care for facilitated and direct percutaneous coronary intervention.

Interventional cardiologists have a variety of options when it comes to facilitated and direct percutaneous coronary intervention (PCI). Over the years, several controversies have surrounded the choices made before and during this process. Questions have been raised over the value of stenting all patients and the use of filters and thrombectomy devices. A number of important clinical trials have also investigated the efficacy of platelet glycoprotein IIb/IIIa inhibitors. Considerable interest is now taking place on how best to reduce reperfusion delays and to improve anticoagulation in the catheterization laboratory. Since direct PCI is often a slow process, better use of existing and future therapies, as well as advances in patient transport, are expected to improve patient outcomes.

Acute Disease↗

PubMed2006

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) study: design, rationale, and run-in phase.

BACKGROUND: Changes in the treatment of coronary artery disease both surgically and percutaneously have rendered the major randomized trials historical. Furthermore, the restrictive criteria of previous trials excluded most patients treated in daily practice. Although coronary surgery is still considered the current, evidence-based, gold-standard treatment of left main (LM) and 3-vessel coronary disease, the added benefit of drug-eluting stents has further expanded the use of percutaneous coronary intervention (PCI) beyond less complex populations in daily practice. STUDY DESIGN: The 1500-patient, prospective, multicenter, multinational (European and North American), randomized SYNTAX study with nested registries will enroll "all-comers." Consecutive patients with de novo 3-vessel disease (3VD) and/or LM disease will be screened for eligibility by the Heart Team (composed of an interventionalist, a cardiac surgeon, and the study coordinator) at each site and then allocated to either (1) the randomized cohort, if comparable revascularization can be achieved by either PCI or coronary artery bypass surgery (CABG), or (2) to one of the nested registries for CABG-ineligible patients (PCI registry) or for PCI-ineligible patients (CABG registry). Randomized patients will be stratified based on LM disease and diabetes by site. The primary end point for the randomized comparison is noninferiority of major adverse cardiac and cerebral events between the 2 groups at 1 year. To adequately project the expected enrollment rate per site, a run-in phase was mandated for each site interested in participating in the trial. Both cardiothoracic and interventional cardiology departments within the same institution were asked to complete a questionnaire regarding their frequency of treatment of LM and 3VD over a retrospective 3-month period. IMPLICATIONS: By replacing most traditional inclusion and exclusion criteria with the real-world decision between the cardiothoracic surgeon and the interventionalist, this study will define the roles of CABG and PCI using drug-eluting stents in the contemporary management of LM and 3VD. Results of the run-in phase were used by the steering committee to determine eligibility and to project enrollment for each site.

Angioplasty, Balloon, Coronary↗

PubMed2000

Pronounced benefit of coronary stenting and adjunctive platelet glycoprotein IIb/IIIa inhibition in complex atherosclerotic lesions.

BACKGROUND: Previous trials testing stents compared with balloon angioplasty excluded patients with complex lesions and did not assess the effect of adjunctive platelet IIb/IIIa inhibition. This analysis sought to assess the effect of stenting and abciximab specifically for patients with complex lesions. METHODS AND RESULTS: Patients with complex lesions (long, tandem, severely calcified, restenotic, thrombotic, or ostial; total occlusions; bifurcations; saphenous vein grafts; and multivessel interventions) from the Evaluation of PTCA to Improve Long-Term Outcome by c7E3 GP IIb/IIIa Receptor Blockade (EPILOG) and the Evaluation of Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT) trials were included in the analysis. The 1-year combined death or myocardial infarction rates in the 4 treatment groups were as follows: balloon angioplasty/placebo, 14.2%; stent/placebo, 15.8%; balloon angioplasty/abciximab, 7.6%; and stent/abciximab, 8.0% (P<0.001). Death rates were 3.2%, 3.1%, 2.1%, and 0.5%, respectively (P=0.03). The incidence of target vessel revascularization at 1 year was 30.5%, 18.0%, 24.4%, and 19.7% in the 4 groups, respectively (P<0.001). After adjustment for baseline differences, multivariate analysis demonstrated that the rate of death or myocardial infarction was independently reduced by balloon angioplasty/abciximab (hazard ratio, 0.51; P<0.001) and stent/abciximab (hazard ratio, 0.60; P=0.02) but was not affected by the use of stents alone. Conversely, target vessel revascularization was reduced by stent/placebo (hazard ratio, 0.53; P<0.001), stent/abciximab (hazard ratio, 0.58; P<0.001), and balloon angioplasty/abciximab (hazard ratio, 0.74; P=0.006) compared with balloon angioplasty/placebo, respectively. CONCLUSIONS: The combination of stenting and abciximab during percutaneous coronary interventions for patients with angiographically complex lesions confers additive long-term benefit with respect to death, myocardial infarction, and target vessel revascularization.

Abciximab↗

PubMed2006

Ethnographically informed community evaluation: a framework and approach for evaluating community-based initiatives.

OBJECTIVES: This paper describes ethnographically informed community evaluation (EICE), a framework for evaluating complex community-based interventions, and illustrates its use in the evaluation of Baltimore City Healthy Start, a federally funded infant mortality prevention project. EICE, which is influenced by cultural anthropology and assets-based community assessment, supports continuous program improvement, resident involvement, and measurement of community-level change. This approach takes into account both individual and contextual levels of analysis. METHODS: The evaluation coupled a participatory approach with qualitative and survey research methods to study community context and how it might contribute to infant mortality and influence program implementation, and to assess community change resulting from the program. Data collection included focus groups, key informant interviews, surveys, neighborhood mapping, journaling, and a study of community problem-solving. RESULTS: The evaluation provided program-related feedback to staff, contributed to a collective understanding of the local context, validated and augmented outcome findings, and imparted skills and a sense of empowerment to the neighborhood. Results reveal a community burdened by crime and social problems, yet showing great diversity in physical and social conditions when examined at the census block group level. Nevertheless, these social and physical hazards in the community are more salient than any specific health issue such as infant mortality. CONCLUSIONS: EICE is a powerful evaluation approach able to respond to the complexities of community-based maternal and child health initiatives designed to institute changes across multiple domains. EICE may be used, in whole or in part, as a supplement to traditional designs.

Anthropology, Cultural↗

PubMed1996

Thrombolysis or peripheral arterial surgery: phase I results. TOPAS Investigators.

PURPOSE: Thrombolytic therapy is widely used in the treatment of peripheral arterial occlusion, but prospective, randomized comparisons with standard therapy remain few. A multicenter trial of thrombolysis or peripheral arterial surgery (TOPAS) was organized to compare critically the use of recombinant urokinase (rUK) or surgery for the initial treatment of acute lower-extremity ischemia. Phase I of the trial was designed as a dose-ranging trial to evaluate the safety and efficacy of three doses of rUK in comparison with surgery. METHODS: In a multicenter, prospective, double-blind comparison, 213 patients who had acute lower-extremity ischemia for 14 days or fewer were randomized to one of two groups. The first group received one of three dosages of rUK (catheter-directed at 2000, 4000, or 6000 IU/min for 4 hours, then 2000 IU/min to a maximum of 48 hours). The second group underwent surgery. Successful thrombolysis was followed by surgical or endovascular interventions when anatomic lesions responsible for the occlusion were unmasked. Patients were followed-up for 1 year; data were evaluated on an intent-to-treat basis. RESULTS: The 4000 IU/min rUK dosage was chosen as the most appropriate thrombolytic regimen because it maximized lytic efficacy against the risk of bleeding. Complete (> 95%) lysis of thrombus was achieved in 71% of the 49 patients who were randomized to the 4000 IU/min group, with a mean infusion time of 23 hours. In contrast, complete lysis was achieved in 67% of patients who received 2000 IU/min and in 60% of patients who received 6000 IU/min. Hemorrhagic complications occurred in 2% of the 4000 IU/min group versus 13% of the 2000 IU/min group (p = 0.05) and 16% of the 6000 IU/min group (p = 0.03). In a comparison of the 4000 IU/min group with the surgical group, the 1-year mortality rate (14% vs 16%) or amputation-free survival rate (75% vs 65%) did not differ significantly. The frequency and magnitude of surgery in the patients randomized to rUK were decreased (p < 0.001). CONCLUSION: The preliminary results suggest that an initial rUK dose of 4000 IU/min is safe and efficacious in the treatment of acute lower-extremity ischemia. rUK therapy is associated with limb salvage and patient survival rates similar to those achieved with surgery, concurrent with a reduced requirement for complex surgery after thrombolytic intervention.

Acute Disease↗