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PubMedDate not supplied

Malaria control in Papua New Guinea results in complex epidemiological changes.

With a renewed interest in large-scale malaria interventions, knowledge about the possible long-term effects of such interventions on the nature of malaria transmission is essential. We document complex changes in malaria epidemiology over the last 40 years associated with changing malaria control activities in Karimui, an isolated area in Papua New Guinea. An initially equal distribution of Plasmodium falciparum, P. vivax and P. malariae changed to currently 68% P. falciparum, after passing through a phase of transitory P. vivax dominance, when control started to fail. Initial drops in malaria prevalence proved difficult to sustain and present post-control levels are significantly higher than pre-control levels. The example of Karimui indicates that unsustained control can lead to changes in malaria patterns that may leave a population worse off.

Animals↗
PubMed1997

The changing face of coronary interventional practice. The Mayo Clinic experience.

BACKGROUND: Devices designed to facilitate or replace conventional percutaneous transluminal coronary angioplasty have been introduced in recent years. OBJECTIVES: To characterize the changes in percutaneous coronary interventional practice over 16 years and to assess the relative use of these new devices. METHODS: We performed a retrospective analysis of all patients who underwent percutaneous coronary revascularization at Mayo Clinic, Rochester, Minn, during a 16-year period (1980-1995) and characterized the changes in procedural and clinical factors. RESULTS: The number of coronary interventional procedures performed increased from 38 in 1980 to 1284 in 1995. Atherectomy and laser angioplasty were incorporated in 1988; their use peaked in 1994 (17% of procedures) but decreased to 9.9% by 1995. In contrast, the use of intracoronary stents has increased steadily since 1990. By 1995, intracoronary stents were placed in 48.2% of procedures. The success rate improved from 55.3% in 1980 to 91.4% in 1995, although patients were older (51 +/- 10 [mean +/- SD] years in 1980 vs 63 +/- 12 years in 1995), had more extensive coronary artery disease (0% with multivessel disease in 1980 vs 47.4% in 1995), had more complex lesions, and often underwent intervention in the peri-infarction setting (2.6% of procedures in 1980 vs 17% in 1995). The rate of referral to emergency coronary bypass surgery after percutaneous procedures declined from 5.2% in 1980 to 0.4% in 1995. CONCLUSIONS: Current coronary interventional practice is expanding and improving. In contrast to intracoronary stents that have greatly affected current practice, other new devices are used infrequently. Conventional angioplasty, with or without intracoronary stents, remains the dominant treatment strategy.

Adult↗
PubMed2005

Skin dose measurements on patients for diagnostic and interventional neuroradiology: a multicentre study.

The present study reports on the skin dose measurements on patients undergoing diagnostic and interventional neuroradiology procedures. Grids of thermoluminescence dosemeters were attached on the head of the patient. The exposure parameters of the X-ray systems and the clinical procedures were fully documented. While for the diagnostic procedure, the dose threshold of 2 Gy for deterministic effects was not reached, this situation was much different for the embolisations. For angiography of the carotid arteries, no skin doses were measured >320 mGy. For the cerebral embolisations, maximum skin doses up to 5.4 Gy were measured. Doses to the patients varied largely between different hospitals and within the same hospital for similar procedures. On the one hand, the complexity of the pathology for interventional procedures was responsible for the large variability in dose. On the other hand, large differences in clinical protocol and technical parameters of the X-ray systems, explaining the dose variations, were also observed. A correlation was found between the maximum skin dose measured on a patient and the total dose-area product (DAP) value for cerebral embolisations. This correlation makes it possible to estimate the maximum skin dose from these DAP values and to determine a trigger level. In conclusion, management of patient doses in interventional radiology requires training, specialisation and well-documented procedure guidelines.

Brain↗
PubMedDate not supplied

Web-based assistance for physicians caring for children with ADHD.

CONTEXT: The clinical management of children with attention deficit/hyperactivity disorder (ADHD) requires measurement of behavioral outcomes at home and at school. This information is difficult to obtain. GENERAL QUESTION: Could a Web site that facilitates exchange of information between parents, teachers, and health care professionals improve behavioral outcomes for children with ADHD? SPECIFIC RESEARCH CHALLENGE: Designing a pragmatic intervention and evaluation strategy. PROPOSED APPROACH: Establish a secure Web site to share observations on a child with ADHD. Access to a child's electronic record will be limited to team members defined by the parents. The record will contain documentation of consent for team members to communicate both diagnostic and treatment information. The record will feature two methods of communication: 1) the ability to input and graphically view structured behavioral questionnaire data that measure levels of attention and hyperactivity/impulsivity, and 2) an electronic bulletin board that allows users to post and respond to text messages that specifically describe behavior. The Web site would be tested in a randomized trial. UNANSWERED QUESTIONS: Given its complexity, which part of the intervention should be isolated for study? What is the appropriate unit of analysis (individual, practice, or school)? Can an unbiased assessment of behavior be obtained when parents and teachers are not blinded to intervention status?

Attention Deficit Disorder with Hyperactivity↗
PubMed2003

Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications.

Although the mortality rate after pancreaticoduodenectomy has decreased, the morbidity rate remains high. Major morbidity is often managed with the aid of interventional radiologists. The objective of this study was to evaluate the cooperative roles of interventional radiologists and pancreatic surgeons in complex pancreatic surgery, specifically pancreaticoduodenectomy. Our pancreaticoduodenectomy database was reviewed for all patients undergoing pancreaticoduodenectomy between January 1, 1995 and December 31, 2000. The interventional radiologic procedures for each patient were evaluated. A total of 1061 patients underwent pancreaticoduodenectomy. The overall mortality and morbidity rates were 2.3% and 35%, respectively. Five hundred ninety patients (56%) had no interventional radiologic procedures, whereas 471 patients (44%) had interventional radiologic procedures. Of those, 342 (32%) had preoperative biliary drainage (PBD) and 129 (12%) required postoperative interventional radiologic procedures. Percutaneous aspiration/catheter drainage was required in 84 patients for intra-abdominal abscess, biloma, or lymphocele, with 24 requiring two or more abscess drains. Thirty-nine patients underwent postoperative PBD for bile leaks due to anastomotic disruption, undrained biliary segments, or T-tube/bile stent dislodgment. Eighteen patients had hemobilia/gastrointestinal bleeding treated by angiography with embolization. The reoperation rate for the entire cohort of 1061 patients was 4.1% (n = 43). Nineteen of the 129 patients (15%) requiring postoperative radiologic intervention required reoperation. Although 4 of 18 patients who required embolization for bleeding subsequently required surgical intervention for the same reason, only 4 of 84 patients undergoing abscess drainage later required operation for anastomotic disruption or unsuccessful percutaneous drainage. As would be expected, the patients who required postoperative radiologic intervention (n = 129) had a higher incidence of postoperative complications including pancreatic fistula (20% vs. 6%, P < 0.01), bile leakage (22% vs. 1%, P < 0.01), and wound infection (16% vs. 8%, P < 0.01). With the complications in these 129 patients, the postoperative mortality rate was only 6.2% compared to 1.7% in patients who did not require radiologic intervention (n = 932, P < 0.01). The median postoperative length of stay was 15 days in those patients requiring postoperative radiologic intervention, 10 days in those not requiring intervention (P < 0.01; postoperative interventional radiology vs. no postoperative interventional radiology), and 29.5 days for patients needing reoperation. Interventional radiologists play a critical role in the management of some patients undergoing pancreaticoduodenectomy. Although complications such as anastomotic leaks, abscess formation, and bleeding can result in increased mortality and a longer hospital stay, the skills of the interventional radiology team provide expert management of some life-threatening complications, thus avoiding reoperation, speeding recovery times, and minimizing morbidity.

Adenocarcinoma↗
PubMed2005

[Endoscopic treatment of chronic pancreatitis].

Progress in understanding the etiology and pathogenesis of pancreatitis has not yet opened significant new therapeutic options. Apart from dietetic and analgesic concepts, interventional endoscopy and pancreatic surgery are the mainstays of therapy. The often complex pathological anatomy requires the complete armamentarium of interventional endoscopy including endoscopic ultrasound. Stenoses, fistulae, pseudocysts and retroperitoneal necroses can be treated endoscopically. Failures of endoscopic treatment, relapses and inflammatory tumors of the pancreatic head as well as suspected malignancy should be operated. Endoscopic as well as surgical procedures are demanding and should be carried out by experienced teams with a sufficient case volume.

Biopsy, Fine-Needle↗
PubMed2005

Why have academic medical centers survived?

Over the past decade, many observers predicted the demise of the academic medical center (AMC) due to competition from community hospitals and physicians, fragile finances, inefficiency, and organizational complexity. In 2004, we interviewed 23 AMC and community hospital administrators to determine why those predictions have proven unfounded, learn the leaders' current concerns and priorities, and to identify desirable changes. Chief concerns were reimbursement uncertainty, federal research policy, ineffective internal decision-making, and clinical quality (mentioned in more than 75% of interviews). Priorities included ensuring sufficient investment capital, revising undergraduate and graduate curricula, strengthening ties with physicians and community hospitals, attracting faculty, and meeting regulatory requirements. We advocate that the AMC: (1) modify the research model to allow greater collaboration with institutions and researchers; (2) enhance free and open export of new and proven clinical techniques and knowledge; (3) devote greater attention to meeting patients' increasing needs for counsel and guidance, not just intervention, given the plethora of complex new technologies and their promotion in the popular media; and (4) simplify their organizations. To accomplish this, it is desirable for future leaders to gain experience outside the AMC, and for faculty and institutions to be less inwardly focused and more attentive to preserving the public's trust.

Academic Medical Centers↗
PubMed2001

Therapeutic interventions for enhancing collateral development by administration of growth factors: basic principles, early results and potential hazards.

The importance of spontaneously developing collateral vessels to supplement perfusion of tissue rendered ischemic by vascular obstruction was recognized many years ago. However, it was not until potent angiogenesis factors were identified, purified, and produced in sufficient quantities, that the field began its rapid development. In the early 1990s it was first shown that basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) proteins could actually stimulate collateral flow. However, additional studies also demonstrated that the duration of exposure of the vessels to angiogenesis factors was critical, and that the administration of proteins, with their relatively brief half-lives, may pose important practical limitations. The demonstration that gene therapy can improve collateral function presents one of the solutions to the conundrum, since gene therapy can be considered a sophisticated form of a sustained delivery system. The results of several clinical trials have been reported. All involve administration of single angiogenesis agents, and most are Phase I trials. The two studies rising to Phase II status demonstrated no treatment effect on the primary end-point. It may therefore be relevant to consider that the molecular mechanisms responsible for angiogenesis are extraordinarily complex, and an optimal angiogenesis intervention may require a 'multiple factor' strategy. It is important to note that no serious side-effects ascribable to an angiogenesis agent were recognized in these trials. However, angiogenesis agents are potent molecules with multiple activities. It is therefore possible that they might occasionally cause side-effects, some serious. Among these, based on their biologic activities, are neovascularization of non-targeted tissues, expansion and induction of instability of atherogenic plaque, and growth of tumors. In summary, there is ample experimental evidence justifying an optimistic outlook relating to our eventually being successful in enhancing collateral flow to ischemic tissue in a clinical setting. However, we are not there yet, and identification of the optimal angiogenesis strategy is still unclear. Additional experimental work, in parallel with large, carefully controlled clinical trials are needed to continue the exciting advances of the last decade, and to achieve the goal of providing patients with alternative potent therapies to improve collateral flow, and thereby to alleviate their symptoms and perhaps to prolong their lives.

Animals↗
PubMed2005

Beginning the process of teamwork: design, implementation and evaluation of an inter-professional education intervention for first year undergraduate students.

An evidence-based interprofessional educational (IPE) intervention involving first year undergraduate students studying medicine, nursing, physiotherapy and occupational therapy was piloted at the University of Liverpool. Campbell's phased approach and Complexity Theory guided development of the intervention and its evaluation. The intervention included a staff-training programme, e-learning materials and interprofessional team working skills workshops. A multi method study design was used to evaluate outcomes and the processes by which the outcomes had transpired. The first year cohort of students (n=442) was invited to attend the pilots. Fifty-four per cent (n=237) opted to attend. Findings showed that the intervention promoted theoretical learning about team working. It enabled the students to learn with and from each other (p<0.001), it significantly raised awareness about collaborative practice (p<0.05), and its link to improving the effectiveness of care delivery (p<0.01). The qualitative data showed that it served to increase students' confidence in their own professional identity and helped them to value difference making them better prepared for clinical placement. The findings support the need to start IPE early in students' training before professional doctrines have been built into their learning. As a result of the findings, the intervention has become compulsory for students to attend and the project has evolved to include trained service users/carers as co-facilitators of the workshops. It is also working on strengthening e-learning by integrating the generic materials into the curricula of all courses. Alongside this, strategies are being explored for interprofessional learning in practice.

Adult↗
PubMed2004

Responding to serious and complex mental health problems in youth: the role of an interagency forum.

OBJECTIVE: To review the origins, processes, clientele and outcomes of a child and youth interagency forum, a collaborative response to children and youth with severe and complex presentations. METHODS: After a description of the Forum origins, membership and processes, both qualitative and quantitative information is provided on the Forum clientele. The Forum's effectiveness is considered in terms of changes in services provided to this group, as well as changes in agency and interagency work practices. RESULTS: Forum clients were predominantly boys aged 12 years, with an overrepresentation of indigenous and intellectually disabled children. Few lived with biological parents, and on average had experienced five schools, 11 or more residential placements and were involved with six agencies. Disruptive behaviour symptoms were common, as were suicidal thoughts or actions (43%), history of physical (50%) or sexual abuse (21%), alcohol (29%) and drug use (14%). On average Forum clients were taking three psychotropic medications. Forum client impairment ranged from major impairment to gross impairment across several domains. CONCLUSIONS: While this is not a formal outcome study, evidence suggesting Forum usefulness included qualitative feedback from agencies, altered clinical and interagency practices, and decreased client impairment. Practical interventions for clients with chronic, complex multidomain impairments are discussed in the context of current Australian child and adolescent mental health services.

Achievement↗
PubMed2000

Calcium, dairy products and osteoporosis.

Osteoporosis is a multifactorial disorder in which nutrition plays a role but does not account for the totality of the problem. 139 papers published since 1975 and describing studies of the relationship of calcium intake and bone health are briefly analyzed. Of 52 investigator-controlled calcium intervention studies, all but two showed better bone balance at high intakes, or greater bone gain during growth, or reduced bone loss in the elderly, or reduced fracture risk. This evidence firmly establishes that high calcium intakes promote bone health. Additionally, three-fourths of 86 observational studies were also positive, indicating that the causal link established in investigator-controlled trials can be found in free-living subjects as well. The principal reason for failure to find an association in observational studies is the weakness of the methods available for estimating long-term calcium intake. While most of the investigator-controlled studies used calcium supplements, six used dairy sources of calcium; all were positive. Most of the observational studies were based on dairy calcium also, since at the time the studies were done, higher calcium intakes meant higher dairy intakes. All studies evaluating the issue reported substantial augmentation of the osteoprotective effect of estrogen by high calcium intakes. Discussion is provided in regard to the multifactorial complexity of osteoporotic response to interventions and to the perturbing effect in controlled trials of the bone remodeling transient, as well as about how inferences can validly be drawn from the various study types represented in this compilation.

Bone and Bones↗
PubMed2003

Signal transduction mediated by the Ras/Raf/MEK/ERK pathway from cytokine receptors to transcription factors: potential targeting for therapeutic intervention.

The Ras/Raf/Mitogen-activated protein kinase/ERK kinase (MEK)/extracellular-signal-regulated kinase (ERK) cascade couples signals from cell surface receptors to transcription factors, which regulate gene expression. Depending upon the stimulus and cell type, this pathway can transmit signals, which result in the prevention or induction of apoptosis or cell cycle progression. Thus, it is an appropriate pathway to target for therapeutic intervention. This pathway becomes more complex daily, as there are multiple members of the kinase and transcription factor families, which can be activated or inactivated by protein phosphorylation. The diversity of signals transduced by this pathway is increased, as different family members heterodimerize to transmit different signals. Furthermore, additional signal transduction pathways interact with the Raf/MEK/ERK pathway to regulate positively or negatively its activity, or to alter the phosphorylation status of downstream targets. Abnormal activation of this pathway occurs in leukemia because of mutations at Ras as well as genes in other pathways (eg PI3K, PTEN, Akt), which serve to regulate its activity. Dysregulation of this pathway can result in autocrine transformation of hematopoietic cells since cytokine genes such as interleukin-3 and granulocyte/macrophage colony-stimulating factor contain the transacting binding sites for the transcription factors regulated by this pathway. Inhibitors of Ras, Raf, MEK and some downstream targets have been developed and many are currently in clinical trials. This review will summarize our current understanding of the Ras/Raf/MEK/ERK signal transduction pathway and the downstream transcription factors. The prospects of targeting this pathway for therapeutic intervention in leukemia and other cancers will be evaluated.

Drug Design↗
PubMedDate not supplied

Relieving the pressure in the radiology department.

Interventional radiological procedures can be complex, requiring patients, many of whom already have compromised arterial circulation, to lie immobile for significant periods. X-ray table mattresses are designed to avoid radiation attenuation, which could degrade image quality or increase patient dose. Consequently, most mattresses do not have pressure redistribution properties. Skin changes, noted after lengthy radiological procedures, would appear to indicate that this unrelieved pressure places vulnerable patients at risk of sustaining pressure damage that could potentially initiate pressure ulcer development. This article examines the biomedical basis of pressure ulcer development, and discusses the suitability of alternative support devices for radiological examinations in an apparently under-researched environment.

Beds↗
PubMed2005

Rating scale for psychogenic movement disorders: scale development and clinimetric testing.

We developed and tested the clinimetric properties of a scale for psychogenic movement disorders (PMDs). PMDs are disabling but lack any generally accepted treatment strategies. To develop treatments, means of assessing disease severity must be provided. No scale to assess PMDs existed. The PMD scale developed here rates 10 phenomena (rest tremor, action tremor, dystonia, chorea, bradykinesia, myoclonus, tics, athetosis, ballism, cerebellar incoordination), 2 functions (gait, speech), and 14 body regions. To study interrater agreement, three movement disorder neurologists independently rated 88 videotapes of PMD patients. Data analysis was performed using a kappa coefficient of agreement, Kendall's coefficient of concordance, Spearman correlations, and intraclass correlation coefficients. Validity and scale responsiveness were tested as well. All phenomena and speech and gait dysfunction occurred in the patient sample. A wide range of affected body regions, severity, and incapacitation was captured. Ratings showed excellent interrater reliability for presence or absence of each phenomenon (kappa range, 0.63 to 0.86). Kendall's concordance coefficients for phenomenology, function, and total PMD scores were 0.92, 0.93, and 0.91. Spearman correlations between raters ranged from 0.86 to 0.90. The scale was responsive to changes that occurred as a result of a neuropsychiatric intervention. The PMD scale adequately captures the complex movements of PMDs and can be used to assess PMDs and test the efficacy of intervention strategies.

Adolescent↗
PubMed1990

Stimulus complexity and autistic children's responsivity: assessing and training a pivotal behavior.

Interdisciplinary research suggests that autistic children's limitations in responding to environmental stimuli may be directly related to the number of components contained in the stimuli; as the number of components increases, such children hypothetically would exhibit greater difficulties in responding. The central purpose of this experiment was to assess whether such children indeed exhibit greater difficulties in responding as the number of components contained in an environmental stimulus was increased from one to four. If the children's responsivity was a function of stimulus complexity, a second focus of this experiment was to assess the feasibility of teaching them to respond to a complex environmental stimulus containing up to four components and to determine whether the effects of the intervention would generalize to other situations involving complex structured and social stimuli. Data gathered using a multiple baseline design across behaviors and children indicate that all of the children exhibited fewer correct responses to a stimulus as the number of stimulus components was increased from one to four. The results further showed that the training program used in this investigation was effective in producing some generalized increases in the children's responses to complex structured and social stimuli. Conceptualizing autistic children's responses to complex multicomponent stimuli as a pivotal target behavior that can be operationally defined may have important implications for understanding and altering the children's responsivity and development.

Adolescent↗
PubMedDate not supplied

Palliative medicine in a United States cancer center: a prospective study.

PURPOSE: (a) To report the medical complexity of cancer and noncancer patients receiving palliative medicine (PM) consultation at a tertiary medical center and (b) to describe the consult recommendations madefor this group. PATIENTS AND METHODS: Prospective data collection was performed on all consultations (cancer, n = 175; noncancer, n = 35) done by first author (JDC) as a PM fellow at the Cleveland Clinic Foundation between July 1998 and April 1999. A computer database was used to query for demographics, complexity of medical problems, current medications, mortality, symptoms, nursing problems, and consult recommendations. RESULTS: A median of three (range, 0-12) acute medical problems and three (range, 0-16) chronic medical problems were identified for each patient. Patients were taking a median of six medications (range, 0-20). They had a median of five symptoms (range, 0-13) with pain (73 percent) being most common, followed by weakness (40 percent) and shortness of breath (40 percent). Cancer patients were twice as likely to have more than five symptoms (48 percent versus 23 percent) (chi-square = 0.006). The most common nursing problems were ambulation or fall risk (15 percent) and skin integrity (11 percent). A median of five (range, 1-11) management recommendations were made as part of each consultation. These included medication changes in 81 percent, nonmedication changes in 53 percent, andfollow-up services in 100 percent. The median survivalfrom the time of consultation for the known dead was 29 days with 65 percent living more than 14 days. CONCLUSION: Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.

Adult↗
PubMed1985

[Treatment of gastric and duodenal ulcers during endoscopy].

The author reviews the results of the local treatment of 142 patients for peptic ulcer of the stomach (24 patients) and duodenum (67 patients). In 51 cases, symptomatic ulcers were diagnosed. Use was made of a complex of surgical and therapeutic endoscopic interventions. The local treatment of gastroduodenal ulcers made it possible to attain positive results with a complete ulcer cicatrization and disappearance of the clinical symptom-complex in 105 (83.3%) out of the 142 patients. The effect was transient in 24 (16.3%) patients. The ulcer did not heal in 13 (9.1%) patients. The follow up studies for 2 to 5 years revealed no relapses in 79.5% of patients. No complications were recorded. Indications and contraindications as to the therapeutic endoscopy were determined with regard to the clinical and esophagogastroduodenoscopy data and histological examination of biopsy material.

Adolescent↗