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PubMed2002

Cardiovascular fitness and type 2 diabetes.

Exercise has long been recognized as a cornerstone in diabetes care. Even so, modern science is just beginning to understand the physiologic impact cardiovascular fitness has on long-term diabetes management, and the prevention or delay, of type 2 diabetes. Recent advances in research are defining the metabolic pathways involved in insulin signaling and in reducing insulin resistance. Tools and guidelines exist for the health care provider to use when prescribing cardiovascular activities to individuals with type 2 diabetes. The true challenge now lies in assisting individuals in implementing and maintaining safe, therapeutic levels of physical activity.

Cardiovascular System↗

PubMed2005

Hospital management of diabetes.

The evidence continues to strengthen our understanding that improved glycemic control with the use of insulin therapy may significantly improve morbidity and mortality in hospitalized patients with hyperglycemia, with or without a previous diagnosis of diabetes. However, many questions remain concerning the impact and relative contributions of blood glucose and insulin per se. Nevertheless, the publication of numerous and consistent studies have made it clear that the topic of glycemic management in the hospital requires a larger priority among clinicians caring for these patients. The recently published guidelines by the American Association of Clinical Endocrinologists are the first formal recommendations on this topic,but national guidelines for blood glucose levels cannot take into account all of the different challenges facing different hospitals. This suggests that each institution will require individualization of protocols even though the ultimate metabolic goals are identical. Furthermore, it is not realistic to expect those unfamiliar with diabetes therapy to appreciate all of the nuances and vagaries of insulin treatment. Like any medical treatment, a significant amount of time will need to be invested by the providers involved with the.care of these patients before a mastery of the therapy can be achieved. Nevertheless, because the rewards to our patients can be significant, we need to strive to improve the systems where we work. Individual clinicians with vast experience in diabetes care cannot be successful for the inpatient with diabetes unless the hospital has systems in place to effectively and efficiently facilitate the management of the metabolic needs of this population. The main challenge now is the safe and effective implementation of these guidelines in both small and large hospitals given the limited level of re-sources available in today's medical environment. Therefore, our single most important recommendation is to ensure that all clinicians involved in the management of these patients are in agreement about general philosophies of diabetes management. We would recommend that there are "champions" for each discipline: endocrinology, cardiology, anesthesiology, surgery, nursing,and pharmacy, all of which have developed hospital-specific guidelines for glycemic management. These recommendations can be slowly adapted, one unit at a time, until the entire hospital has transitioned to a more "diabetes-friendly" environment. The ultimate goal of well-controlled glycemia with minimal hypoglycemia should be possible for most hospitals, and we hope this review will assist clinicians in achieving this objective. We await additional outcome research with carefully controlled studies to confirm the value of these recommendations at different levels of glycemic control. We believe that we can already state with confidence that the preliminary evidence shows that, like outpatient diabetes management,metabolic control matters during acute illness.

Algorithms↗

PubMed2005

Primary healthcare information system--the cornerstone for the next generation healthcare sector in Republic of Croatia.

At no time in the history of medicine has the growth in knowledge and technologies been so profound [Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine (IOM), 2001. ISBN 0-309-07280-8]. However, healthcare delivery systems today are not able to keep up with the pace. Studies have shown that it takes an average of about 17 years for new knowledge generated by randomized trials to be incorporated into practice [B. Andrew, S. Boren, Managing clinical knowledge for health care improvement, in: Yearbook of Medical Informatics, National Library of Medicine, Bethesda, MD, 2000, pp. 65-70]. It is safe to say that today healthcare systems "have the data, but not information". In order to provide highest quality patient care, Republic of Croatia has started the process of introducing enterprise information systems to support business processes in the healthcare domain. Two major requirements are in focus: to provide efficient healthcare related data management in support of decision-making processes; and to support continuous process of healthcare resources spending optimization. The first initiated project refers to Primary Healthcare Information System (PHCIS) that provides domain of primary care with state-of-the-art enterprise information system that connects General Practitioners, Pediatricians and Gynecologists offices with the Croatian Institute for Health Insurance and Public Health Institute. In the years to come, PHCIS will serve as the main integration platform for connecting all other stakeholders and levels of healthcare (e.g. hospitals, pharmacies, laboratories) into single enterprise healthcare network. This article gives an overview of PHCIS, explains challenges that were faced in designing and implementing the system, and elaborates PHCIS role as the cornerstone for the next generation healthcare provisioning in Republic of Croatia.

Croatia↗

PubMedDate not supplied

Aggressive cholesterol management: role of the lipid nurse specialist.

There are millions of people with coronary heart disease and tens of millions more who are at risk. Research reveals that aggressive cholesterol management, especially in patients with known coronary heart disease, reduces the incidence of clinical cardiac events and improves survival rates. A review of the literature reveals disturbing evidence that patients with dyslipidemia are not being treated according to the National Cholesterol Education Program guidelines. The need for lipid nurse specialists is real and growing; the challenge of managing care for patients with dyslipidemia is tremendous. Because the role of the lipid nurse specialist is relatively new, it is described in detail in this article. Nurses who desire to fight heart disease aggressively will find this area of nursing practice interesting, challenging, and rewarding. Nurses who facilitate the implementation of the National Cholesterol Education Program guidelines to the large numbers of patients with dyslipidemia offer a valuable public health service.

Cholesterol↗

PubMed2003

Public access defibrillation in Helsinki--costs and potential benefits from a community-based pilot study.

In cardiac arrest the interval between the collapse and defibrillation may be shortened by teaching lay people to use defibrillators. We conducted a 3-year prospective, community-based study on public access defibrillation (PAD) in an urban emergency medical services system. All public sites with a cardiac arrest incidence of at least one per year were equipped with automated external defibrillators. Twenty cardiac arrest patients were enrolled, seven in PAD and 13 in control group. Defibrillation was accomplished significantly earlier (P=0.01) in the PAD group. The direct costs were 110,270 Eur and only 13.5-16% of this figure would be related to the cost of defibrillators during their 8 years lifespan. This study showed that a community based model of PAD shortens the time to CPR and defibrillation significantly in an urban environment but various challenges have to be solved before wider implementation of PAD. In future projects the nature of the costs especially should be considered.

Aged↗

PubMed2001

Prioritizing resource allocation for clinical enhancement: a participative methodology.

The allocation of hospital funding for new and expanded clinical programs can be a difficult but most important task to deal with during the development of the operating plan (budget). Like many other hospitals, York Central Hospital has struggled with this task each year. In order to address this challenge, the hospital has successfully designed and implemented a prioritization process that includes a standardized program proposal and peer evaluation. The process is grounded in the hospital's vision and strategic directions and built on a culture of evidence-based practice.

Economics, Hospital↗

PubMed2003

Effective analgesic modalities for ambulatory patients.

The introduction of government-mandated standards for pain management has focused our attention on postoperative pain. With the recent JACHO standards' for ambulatory surgery, it is imperative that all health care workers who care for these patients are familiar with appropriate pain management. Developments in our understanding of the pathophysiology of acute pain have further enhanced our ability to improve pain management for postoperative ambulatory patients. This has led to the concept of preventive analgesia (inhibition of physiological and pathological secondary inflammatory pain). Extensive work has shown that this is best achieved using a multimodel approach usually consisting of an NSAID, opioid, and local anesthetic. NMDA antagonists (ketamine, dextromethorphan) and alpha-2 agnoists (clonodine) show potential supplements to further enhance pain management, especially if given preemptively. Nonpharmacological intervention such as cold therapy or acupuncture may also be considered. The armanentarium for effective pain management has improved substantially over the past few years. The challenge is for health care workers to implement these therapies to obtain optimum pain management in ambulatory surgical patients.

Ambulatory Surgical Procedures↗

PubMed1999

AMA Clinical Quality Improvement Forum ties it all together: from guidelines to measurement to analysis and back to guidelines.

BACKGROUND: In Chicago October 15, 1998, the American Medical Association (AMA) Department of Clinical Quality Improvement introduced a broadened scope for its Practice Parameters Forum, now retitled the Clinical Quality Improvement Forum. The Forum will now focus on integrating all the components of what the AMA has identified as the quality continuum-clinical practice guidelines, performance measurement, and process and outcomes analysis. KEYNOTE ADDRESS: The address "The Quality Continuum" heralded the ushering in of a third stage known as "clinical integration," which will become medicine's "industrial revolution." Unexplained clinical variation remains the major roadblock to lowering costs, improving quality, and establishing accountability. But several tools, from guidelines to case management, will help us work through our industrial revolution and integrate clinically. PANEL I: GUIDELINES AND EVIDENCE-BASED REPORTS: The international Cochrane Collaboration, through its Collaborative Review Groups and systematic reviews, and the Agency for Health Care Policy and Research, through its Evidence-Based Practice Centers and other programs, are providing the evidence for other groups to use in developing their own guidelines, performance measures, and other tools. But measuring the effectiveness of implementing clinical preventive services remains a difficult challenge. PANEL II: CLINICAL PROCESS MEASUREMENT: Presentations on the relationship between guidelines and performance measures, translating guidelines into review criteria/process measures, reasons for non-compliance with guideline recommendations, patient-reported process measurement, and specific process measurement experiences together reflected federal, national medical specialty society, state medical society/peer review organization, and university/health plan perspectives. PANEL III: CLINICAL OUTCOMES MEASUREMENT: If outcomes can be associated with specific processes of care, clinical practice guidelines can be refined. However, outcomes are dependent on factors outside physicians' behavior and control, such as patient compliance, comorbidities, and other risk factors, and consequently consideration of these variables is essential to appropriately interpreting the data.

American Medical Association↗

PubMed2003

The challenge of constructing large phylogenetic trees.

The amount of sequence data available to reconstruct the evolutionary history of genes and species has increased 20-fold in the past decade. Consequently the size of phylogenetic analyses has grown as well, and phylogenetic methods, algorithms and their implementations have struggled to keep pace. Computational and other challenges raised by this burgeoning database emerge at several stages of analysis, from the optimal assembly of large data matrices from sequence databases, to the efficient construction of trees from these large matrices and the piece-wise assembly of 'supertrees' from those trees in turn. A final challenge is posed by the difficulty of visualizing and making inferences from trees that might soon routinely contain thousands of species.

Algorithms↗

PubMed2006

Translational research on early language development: current challenges and future directions.

There is a pressing need for the early and accurate identification of young children at risk for language and other developmental disabilities and the provision of timely, age-appropriate intervention, as mandated by Part C of the Individuals with Disabilities Education Act. Research has shown that early intervention is effective for many language impaired children in different etiological groups, and can reduce the functional impact of persistent disorders on children and their families. Yet, the accurate identification of infants and toddlers at risk for language impairment remains elusive, especially for late-talking children without obvious genetic or neurological conditions. In this paper, the need for translational research on basic processes in early language development in typical and atypical populations and the contextual factors that affect them are discussed, along with current challenges and future directions for its successful implementation. Implications of this research for clinical evidence-based practice are also considered.

Age Factors↗

PubMed2006

Posttraumatic stress disorder: a missed link between psychiatric and cardiovascular morbidity?

Posttraumatic stress disorder (PTSD) symptoms may develop as a result of an acute, life-threatening traumatic event. Such acute events are quite common in patients with cardiovascular illnesses (ie, a myocardial infarction, acute exacerbations of heart failure or edema). Indeed, PTSD symptoms have been described in a substantial minority of patients who had such events (10% to 25%), and have been shown to be associated with medical morbidity and with non-adherence to medications. This review summarizes available information about these symptoms in patients with cardiovascular illnesses. It also describes the importance of recognizing PTSD as a distinct psychiatric disorder (that can be addressed by specific treatments) and as an important compounding factor in studies of psychopathology in cardiovascular patients. In particular, an argument is made that the understanding of depressive disorders in patients with cardiovascular illnesses should incorporate conceptual and treatment information from the emotional trauma literature if indeed depressive and anxiety disorders are to be successfully treated in these patients. The authors conclude with a description of the challenges and promise of an effort to implement a clinical program to screen for PTSD symptoms in patients with cardiovascular illnesses, and with recommendations for future efforts.

Cardiovascular Diseases↗

PubMed2003

Cultural specificity and comparison in psychiatric epidemiology: walking the tightrope in American Indian research.

Increasingly, the mental health needs of populations are measured using large-sample surveys with standardized measures and methods. Such efforts, however, rarely include sufficient number of smaller, culturally defined populations to draw defensible conclusions about their needs. Furthermore, without some adaptation, the standardized methods and measures may yield invalid results in such populations. Using a recently completed psychiatric epidemiology and services study with American Indian populations as a case example, this paper outlines issues facing epidemiologists working in such culturally diverse contexts. The issues discussed include the following: (1) persuading the scientific community and potential sponsors that work with distinct or culturally defined populations is important; (2) framing research questions and activities to meet the needs of communities; (3) defining a population of inference; (4) balancing the needs for comparability and cultural specificity; (5) maximizing scientific validity in light of the challenges in sample acquisition; and (6) developing and implementing data collection methods that uphold scientific standards but are also realistic given the context. The authors draw on their experiences--most recently in the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP)--to illustrate these issues and suggest ways to address each. A goal of this paper is to challenge those invested in conducting culturally valid epidemiologic work in such populations to better articulate the nature of these efforts.

Cross-Cultural Comparison↗

PubMedDate not supplied

Recommendations for monitoring of polybrominated diphenyl ethers in the Canadian environment.

Polybrominated diphenyl ethers (PBDEs) have been reported in air, surface waters, suspended sediments, soil, sediment, fish, marine mammals, and bird eggs throughout Canada, from the St. Lawrence Estuary to the Strait of Georgia and the northernmost reaches of the Canadian Arctic. Canadian scientists have detected the presence of PBDEs in breast milk in every Canadian province. In fact, recent data on temporal trends strongly suggests that the concentrations of PBDEs are on the rise in the Canadian environment. These findings are similar to those reported in other nordic countries, and have prompted several countries to implement environmental monitoring programs. Among the key challenges currently facing Canada and other countries concerns how best to measure these chemicals in different matrices. In this paper, several analytical methods cited in the scientific literature for determining PBDE concentrations in different abiotic and biological matrices are reviewed. The critical criteria required for accurate determination of PBDEs in complex environmental matrices are discussed, including instrument sensitivity, reliability, potential interference's and the need for specialized instrumentation for the determination of compounds up to 975 Daltons. While a single analytical method that meets these and other criteria has not yet been perfected by scientists, GC/HRMS-based methods amenable to isotope dilution techniques warrant further refinement, and likely represent the best tools for future environmental monitoring programs.

Animals↗

PubMedDate not supplied

The challenge of assessing children's residential exposure to pesticides.

In implementing the Food Quality Protection Act (FQPA) the U.S. Environmental Protection Agency (USEPA) has adopted a policy that the exposure factors and models used to assess and predict exposure to pesticides should generally be conservative. Some elements of exposure assessments for FQPA are screening level--they are both uncertain and conservative. If more realistic assessments are to be conducted, then research is required to reduce uncertainty associated with the factors and models used in the exposure assessments. To develop the strategy for conducting this research, critical exposure pathways and factors were identified, and the quality and quantity of data associated with default assumptions for exposure factors were evaluated. Then, based on our current understanding of the pathways that are potentially most important and most uncertain, significant research requirements were identified and prioritized to improve the data available and assumptions used to assess children's aggregate exposure to pesticides. Based on the results of these efforts, four priority research areas were identified: (1) pesticide use patterns in microenvironments where children spend time, (2) temporal and spatial distribution of pesticides following application in a residential setting, (3) dermal and nondietary ingestion exposure assessment methods and exposure factors, (4) dietary exposure assessment methods and exposure factors for infants and young children. The National Exposure Research Laboratory (NERL) research strategy in support of FQPA is designed to address these priority research needs.

Administration, Cutaneous↗

PubMed2001

The potential contribution of decision aids to screening programmes.

Decision aids for health service users facing decisions about screening have been developed for controversial tests (such as that for prostate specific antigen as a screen for prostate cancer) and tests in which outcomes are value laden (as in some prenatal tests). The potential usefulness of decision aids in established screening programmes (such as those offering mammography to women over 50 in the United Kingdom) remains to be explored. In principle any decision about screening test acceptance may be sensitive to individual preferences and could be supported by an appropriate decision aid. Decision aids might also help reduce some of the problems currently associated with public misconceptions about screening. Objections to the promotion of individual choice regarding screening tests usually take the form of concern that this will lead to unacceptable losses in terms of population health gain and health system efficiency, or of fear that individuals will choose options that are wrong for them. The introduction of decision aids could alleviate both of these objections to some extent. Decision aids could encourage people to consider the social as well as the individual consequences of their choices and they should promote choices consistent with personal values. Although there are strong arguments in principle for introducing decision aids into established screening programmes, their potential needs to be confirmed in empirical evaluations and there may be many contentious decisions and practical challenges to be overcome in order to implement them.

Decision Making↗

PubMed2003

University and industry partnerships: lessons from collaborative research.

Collaborative research between educational institutions and health agencies is being increasingly used as a method of achieving joint outcomes and bringing together theory and practice. This paper reports on the experiences of collaboration that arose out of just such a project carried out in a residential aged care setting. The research team included university academics, two nurses in management positions in the aged care facility and a senior research assistant. In this paper, we explore some of the unexpected issues that emerged during implementation of the research project. The major challenges to successful collaboration arose not from within the collaborative research team, but from the responses of the broader staff who generally had little, if any, experience of research. Despite efforts to inform and involve staff, deep suspicions about the 'real' motives of the project proved difficult to shift. Trust and commitment are vital dimensions of successful collaborative research, yet gaining these from some staff proved elusive. Collaborative relationships between educational and practice settings need to be viewed as long-term endeavours driven by a common unifying goal to enhance client care. This has implications for costs and timelines which might be difficult to manage.

Activities of Daily Living↗

PubMedDate not supplied

[Facilities offered by community-oriented professional rehabilitation centres for mentally challenged persons in the Federal Republic of Germany].

OBJECTIVE: Vocational rehabilitation is an important component of community-oriented mental health care. How is the situation of supply with vocational rehabilitation facilities in Germany offering their services to mentally challenged persons? METHOD: Search of a Germany-wide rehabilitation database, supplemented by information from the Federal Working Groups on Vocational Rehabilitation. Cartographical classification of the identified facilities. Analysis of the results in a comparison of the situation in the 16 German States (Länder). RESULTS: The Länder of North Rhine Westphalia, Bavaria, Baden-Wuerttemberg and Lower Saxony offer the greatest number of vocational rehabilitation facilities to mentally challenged persons. In all East German and in some of the West German Länder vocational rehabilitation facilities are restricted to some areas and to certain vocational preconditions. Many of the facilities in these areas are structured as centres and situated in rural areas. Hence, they lack community-orientation. Only North-Rhine Westphalia offers country-wide community-oriented vocational rehabilitation facilities to mentally challenged persons, which are not restricted to certain vocational preconditions. DISCUSSION AND CONCLUSIONS: The supply with vocational rehabilitation facilities for mentally challenged persons has improved during recent years. Nevertheless, the situation in many of the German Länder needs to be improved, particularly in respect of the availability of rehabilitation facilities for younger mentally challenged persons without prior working experience. The implementation of decentralised community-oriented facilities should be favoured in centres, especially in larger sparsely populated areas.

Community Mental Health Centers↗

PubMed2005

Educational and health services innovation to improve care for rural Hispanic communities in the US.

BACKGROUND: Access to comprehensive and quality health care services is difficult for socioeconomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisciplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as Promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural health care initiatives targeting minority groups. This paper reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.

Adult↗