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PubMed2026

Integration of ear and hearing care services in low- and middle-income health systems: a systematic review and qualitative synthesis.

Hearing loss is a global public health burden and mostly affects those living in low- and middle-income countries (LMICs). One approach to address ongoing challenges is the World Health Organization's recommendation for the integration of ear and hearing care (EHC) services into healthcare packages. However, little is known about EHC integration approaches, particularly in LMICs additionally, these approaches have not been investigated through a health systems lens. This qualitative review aimed to describe the various approaches to the EHC service integration in LMICs and to identify enabling and constraining factors. We reviewed 17 studies, with a focus on LMICs, using adaptations of the Valentijn integration and World Health Organization EHC frameworks, following the PRISMA guidelines. Our investigation showed that most integration approaches were at micro or individual level. Enabling factors for integration of EHC services were training, mentorship, collaboration, technology, inclusion of EHC in healthcare packages and investment in EHC services. Barriers were challenges with training, facilities and equipment, policy implementation and resourcing of EHC services. We further described factors influencing healthcare seeking behaviour and the use of integrated EHC services, such as access and ability to pay, referral systems and communication and awareness. This study describes the complex nature of EHC integration and ways to support integration. Key considerations are the level of integration, training to address workforce issues and factors influencing service utilisation as we work towards health system strengthening.

Humans↗

PubMed2005

The World Health Organization/International Union Against Tuberculosis and Lung Disease Global Project on Surveillance for Anti-Tuberculosis Drug Resistance: a model for other infectious diseases.

Tuberculosis remains a global epidemic, with one-third of the population infected and 9 million active cases. Mono- and multidrug resistance in 6 World Health Organization (WHO) regions have been assessed in 40% of the global cases diagnosed by positive results of sputum testing. The 2004 report of the WHO Global Project on Anti-Tuberculosis Drug Resistance Surveillance confirms earlier findings that drug-resistant tuberculosis is ubiquitous and that multidrug-resistant tuberculosis has increased alarmingly. Control of tuberculosis, which is undermined by the human immunodeficiency virus (HIV) epidemic, is seriously jeopardized by multidrug resistant strains, for which treatment is complex, more costly, and less successful. Challenges for high-burden countries include implementation of the DOTS strategy and management of identified multidrug resistance with DOTS-Plus. Strengthening of the laboratory network in conjunction with improvement of surveillance, elucidation of the impact of HIV on transmission of tuberculosis and on amplification of resistance at individual and population levels, and implementation of private sector policies on drug resistance are imperative. New diagnostic tools and drugs are needed to expedite early detection and cure of multiresistant strains.

Drug Resistance, Bacterial↗

PubMed2006

Image-guidance for surgical procedures.

Contemporary imaging modalities can now provide the surgeon with high quality three- and four-dimensional images depicting not only normal anatomy and pathology, but also vascularity and function. A key component of image-guided surgery (IGS) is the ability to register multi-modal pre-operative images to each other and to the patient. The other important component of IGS is the ability to track instruments in real time during the procedure and to display them as part of a realistic model of the operative volume. Stereoscopic, virtual- and augmented-reality techniques have been implemented to enhance the visualization and guidance process. For the most part, IGS relies on the assumption that the pre-operatively acquired images used to guide the surgery accurately represent the morphology of the tissue during the procedure. This assumption may not necessarily be valid, and so intra-operative real-time imaging using interventional MRI, ultrasound, video and electrophysiological recordings are often employed to ameliorate this situation. Although IGS is now in extensive routine clinical use in neurosurgery and is gaining ground in other surgical disciplines, there remain many drawbacks that must be overcome before it can be employed in more general minimally-invasive procedures. This review overviews the roots of IGS in neurosurgery, provides examples of its use outside the brain, discusses the infrastructure required for successful implementation of IGS approaches and outlines the challenges that must be overcome for IGS to advance further.

Algorithms↗

PubMed2002

Hospice care for the incarcerated in the United States: an introduction.

Prison populations throughout the Unites States are growing; the 1990s saw an average 6.5% per year increase. Average inmate age is increasing, as are both the number and rate of inmate deaths. Aging inmates experience health concerns typical of the general, free, aging population. Inmates have higher incidence of health complications associated with various circumstances, risk behaviors, and associated medical conditions. These circumstances include prison violence, incarceration-related constraints on exercise, and diet. Inmates are more likely to have a history of alcohol abuse, substance abuse or addiction and sex industry work. Risk-behavior conditions include human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), hepatitis B and C, liver disease, tuberculosis, endocarditis, and cardiomyopathy. Hospice is increasingly the preferred response to the health and care needs of terminally ill inmates. Implementing hospice behind bars has some unique challenges in addition to those inherent in hospice work. This series will provide an in-depth look at four hospice programs for inmates in the United States.

Age Factors↗

PubMed2003

Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy.

In contrast to the first decade of the AIDS epidemic, the past decade has seen an increasing separation between AIDS care and palliative care services. While this may be due in part to the perception that AIDS is no longer a uniformly fatal illness, AIDS in fact remains an important cause of morbidity and mortality for young adult populations in the United States, particularly among certain racial-ethnic minorities. Death rates have remained steady since the dramatic decreases noted in the mid-1990s, and causes of death now increasingly include co-morbidities such as hepatitis B, C, end-organ failure, and various malignancies. Moreover, as AIDS has been transformed into a more manageable, chronic disease in the era of 'highly active antiretroviral therapy' (HAART), the opportunities for palliative care interventions have only increased. Patients with AIDS continue to experience a high burden of pain and other chronic symptoms, over a longer period of time, with a disease course marked by more cumulative exacerbations and remissions than when AIDS was a stereotypic, rapidly fatal illness. Advance care planning and discussions of goals of care are more complex and involve more uncertainty than was the case when prognosis was clear-cut and treatment options were more limited. For all of these reasons, it is important for the distance which has developed between HIV and palliative care providers to be bridged. Contrary to popular perceptions, palliative medicine continues to have much to offer in the HAART era for the care of patients and families with HIV/AIDS, for whom treatment outcomes will only benefit from greater integration of disease-specific and palliative interventions. The challenge for care providers is now to implement successful strategies for integrating AIDS and palliative care services in all relevant clinical environments.

Acquired Immunodeficiency Syndrome↗

PubMed2000

Goals and strategies for teaching death and dying in medical schools.

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should be identified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meet the needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Education on Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools. They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medical schools could miss their mark in fostering the student's ability to care for the dying.

Journal Article↗

PubMed2006

Implementation of a pre-dialysis clinical pathway for patients with chronic kidney disease.

OBJECTIVE: The objective of this study was to design and implement an efficient pathway to ensure a smooth transition of patients with advanced chronic kidney disease to dialysis. SETTING: In our dialysis service, as elsewhere, we recognized that there was an unacceptably high rate of inadequately prepared patients commencing dialysis. Knowledge of clinical practice and research-based guidelines has not in itself changed clinical practice and patient management. MAIN MEASURE: : To address these problems, multidisciplinary process redesign teams reviewed pre-existing arrangements by assessing current practice. The review identified critical points where problems could occur: failure to notify patients to dialysis service, late referral for vascular surgery, and inadequate pre-dialysis education. As a result of this process, we have formulated a modified and coordinated pre-dialysis programme. RESULTS: In association with process redesign, the proportion of patients registered 'late' decreased from 29% in July-September 2000 (pre-implementation) to 6% in January-March 2004 (P < 0.01) with the corresponding median time from registration to commencement of dialysis increasing from <1 month to 14 months (P < 0.01). Patients not registered with the service decreased from 57 to 0% (P < 0.001). Eighty-three per cent of patients commenced dialysis with a permanent vascular access in January-March 2004, compared with 24% in July-September 2000 (P < 0.001). CONCLUSIONS: Through process redesign, more of our patients are known to us before commencement of dialysis, a greater proportion of which are provided with pre-dialysis education and permanent vascular access. Our results highlight that implementation remains the final and most difficult challenge of the guideline process.

Ambulatory Care Facilities↗

PubMed2000

Deletion of follicle-stimulating hormone (FSH) receptor residues encoded by exon one decreases FSH binding and signaling in the rat.

The rat FSH receptor (rFSHR) shares considerable homology with the rat LH receptor (rLHR), yet binds human FSH (hFSH) with high fidelity, suggesting that the binding determinant encoded by the rFSHR gene shares no homology with the analogous rLHR primary sequence, thereby affording specificity of ligand binding. Two such regions of primary sequence have been previously identified and studied by peptide challenge tests and immunoneutralization studies. We therefore implemented site-directed mutagenesis to delete the regions S9-N30 and D300-F315 of the mature rFSHR sequence. The mutant receptor (DeltarFSHR) cDNAs were expressed in insect cells. The large deletion DeltarFSHRS9-N30 and a smaller deletion, DeltarFSHRS9-S18, did not bind (125)I-hFSH. However, DeltarFSHRK19-R29 and DeltarFSHRD300-F315 bound (125)I-hFSH with an affinity indistinguishable from wild-type rFSHR. The deletion mutants DeltarFSHR S9-N30 or DeltarFSHRS9-S18 were not detectable on the cell surface by flow cytometry unless cells were sheared. Although (125)I-hFSH binding to DeltarFSHRK19-R29 was normal, this form of the receptor was defective for signal transduction whereas DeltarFSHRD300-F315 was not. Furthermore, neither region seems to be a specificity determinant, since their removal did not result in high-affinity binding of hCG to DeltarFSHR.

Animals↗

PubMed2004

Core competencies in integrative medicine for medical school curricula: a proposal.

The authors present a set of curriculum guidelines in integrative medicine for medical schools developed during 2002 and 2003 by the Education Working Group of the Consortium of Academic Health Centers for Integrative Medicine (CAHCIM) and endorsed by the CAHCIM Steering Committee in May 2003. CAHCIM is a consortium of 23 academic health centers working together to help transform health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human beings, the intrinsic nature of healing, and the rich diversity of therapeutic systems. Integrative medicine can be defined as an approach to the practice of medicine that makes use of the best-available evidence taking into account the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of both conventional and complementary/alternative approaches. The competencies described in this article delineate the values, knowledge, attitudes, and skills that CAHCIM believes are fundamental to the field of integrative medicine. Many of these competencies reaffirm humanistic values inherent to the practice of all medical specialties, while others are more specifically relevant to the delivery of the integrative approach to medical care, including the most commonly used complementary/alternative medicine modalities, and the legal, ethical, regulatory, and political influences on the practice of integrative medicine. The authors also discuss the specific challenges likely to face medical educators in implementing and evaluating these competencies, and provide specific examples of implementation and evaluation strategies that have been found to be successful at a variety of CAHCIM schools.

Clinical Competence↗

PubMedDate not supplied

Geriatric assessment and management protocols: issues for home infusion therapy providers.

The accurate assessment of patients' health, functional abilities, and sociobehavioral status is essential for providing quality, cost-effective infusion services to home-based elders. Baseline and ongoing assessment identifies serious current, emerging, and potential problems, and facilitates interventions to prevent significant comorbidities and premature mortality. Three types of assessment (screening, intermediate or evaluation, and comprehensive) have been used successfully with geriatric populations across a variety of settings to improve patient outcomes. Further, Medicare now requires the completion of an OASIS assessment for the reimbursement of home health services to all seniors. Geriatric assessment has been found to improve care quality and cost effectiveness, but protocol development and evaluation can be challenging. Home infusion therapy providers, encouraged to implement and evaluate evidence-based assessment and management protocols, question the usefulness of these protocols, especially for short-term geriatric patients. Research, education, and policy strategies can be used to overcome the many barriers to developing quality, cost-effective assessment and management protocols for elderly home infusion therapy recipients.

Aged↗

PubMed2025

Automated chromatin profiling with spa-ChIP-seq uncovers the impacts of condition variations.

Chromatin immunoprecipitation followed by sequencing (ChIP-seq) is widely used to study the genomic localization of DNA-associated proteins. However, conventional protocols include multiple manual steps that can introduce inconsistency and limit scalability, thereby restricting the inclusion of appropriate replicates and controls. Although the introduction of liquid handling platforms has improved reproducibility, most existing efforts have automated only a subset of the workflow, and extending automation to efficiently map non-histone proteins, such as chromatin regulators, remains challenging. Here, we present a fully automated implementation of our previously developed single-pot ChIP-seq protocol (Texari et al. 2021), named spa-ChIP-seq, which enables scalable processing of 8 to 96 ChIP-seq samples from crosslinked cells to sequencing-ready library in approximately three days with an estimated cost of $70 per sample. Benchmarking spa-ChIP-seq against manual ChIP-seq performed in parallel demonstrates comparable signal-to-noise ratio between the two workflows. Using spa-ChIP-seq, we systematically evaluate multiple parameters including shearing and crosslinking conditions, buffer compositions, and the ratio of antibody to cell-number. We find, for the first time to our knowledge, that weaker genomic localization signals are sensitive to changing the antibody to cell-number ratio, whereas the stronger signals remain unaffected. This finding underscores the importance of maintaining consistent antibody-to-cell-number ratio for comparative studies, such as treatment responses or chromatin-QTL mapping. The spa-ChIP-seq protocol is publicly available, including deck setups, operational parameters, and scripts. We envision that this robust, cost-efficient protocol will facilitate high-throughput, reproducible ChIP-seq analyses, supporting large-scale studies of antibody validation, compound screening, population genomics, and diagnostic frameworks.

Journal Article↗

PubMed1999

Automated extraction and variability analysis of sulcal neuroanatomy.

Systematic mapping of the variability in cortical sulcal anatomy is an area of increasing interest which presents numerous methodological challenges. To address these issues, we have implemented sulcal extraction and assisted labeling (SEAL) to automatically extract the two-dimensional (2-D) surface ribbons that represent the median axis of cerebral sulci and to neuroanatomically label these entities. To encode the extracted three-dimensional (3-D) cortical sulcal schematic topography (CSST) we define a relational graph structure composed of two main features: vertices (representing sulci) and arcs (representing the relationships between sulci). Vertices contain a parametric representation of the surface ribbon buried within the sulcus. Points on this surface are expressed in stereotaxic coordinates (i.e., with respect to a standardized brain coordinate system). For each of these vertices, we store length, depth, and orientation as well as anatomical attributes (e.g., hemisphere, lobe, sulcus type, etc.). Each arc stores the 3-D location of the junction between sulci as well as a list of its connecting sulci. Sulcal labeling is performed semiautomatically by selecting a sulcal entity in the CSST and selecting from a menu of candidate sulcus names. In order to help the user in the labeling task, the menu is restricted to the most likely candidates by using priors for the expected sulcal spatial distribution. These priors, i.e., sulcal probabilistic maps, were created from the spatial distribution of 34 sulci traced manually on 36 different subjects. Given these spatial probability maps, the user is provided with the likelihood that the selected entity belongs to a particular sulcus. The cortical structure representation obtained by SEAL is suitable to extract statistical information about both the spatial and the structural composition of the cerebral cortical topography. This methodology allows for the iterative construction of a successively more complete statistical models of the cerebral topography containing spatial distributions of the most important structures, their morphometrics, and their structural components.

Algorithms↗

PubMed2004

Mosquito nets and the poor: can social marketing redress inequities in access?

Treated mosquito nets are a practical malaria control tool. However, implementation of efficient delivery mechanisms remains a challenge. We investigated whether social marketing of treated mosquito nets results in decreased equity in rural Tanzania, through household surveys before the start of a social marketing programme and 3 years later. About 12,000 household heads were asked about ownership of nets and other assets including a tin roof, radio, or bicycle. A socio-economic status score was developed for each household. Net ownership was calculated for households in each quintile of this score, from poorest to least poor. In 1997, about 20% of the poorest households and over 60% of the least poor households owned a mosquito net. Three years later, more than half of the poorest households owned a net, as did over 90% of the least poor: the ratio of net ownership among the poorest to least poor increased from 0.3 in 1997 to 0.6 in 2000. Social marketing in the presence of an active private sector for nets was associated with increased equity.

Animals↗

PubMed2004

Unproven diagnostic procedures in IgE-mediated allergic diseases.

A considerable body of literature on therapeutic aspects of complementary and alternative medicine has been published in recent years, but little is known on diagnostic procedures. This short review lists complementary and alternative diagnostic procedures for the diagnosis of allergic diseases and presents an assessment of their usefulness for the daily practice. The review of the literature revealed that neither the determination of specific immunoglobulin G-antibodies in serum, the hair-analysis, the cytotoxic test, kinesiology, iridology, or electrodermal testing represent useful tests for the daily practice. To date, no complementary or alternative diagnostic procedure can be recommended as a meaningful element in the diagnostic work-up of allergic diseases. This is especially true for food allergy: properly performed oral food challenges still represent the gold standard for implementing specific diets in food allergic individuals. Ineffective diagnostic approaches may be costly for the consumer and delay appropriate therapy.

Animals↗

PubMed2005

Diagnostic pitfalls in food allergy in children.

Currently, the diagnostic work-up of suspected food allergy includes skin prick tests, the measurement of food specific immunoglobulin E (IgE), and the atopy patch test, and double-blind, placebo-controlled food challenges. However, all of these methods, even double-blind, placebo-controlled food challenges (DBPCFC), may sometimes be misleading. This overview describes several pitfalls for standard diagnostic methods such as problems with irritative skin reactions mimicking IgE-mediated symptoms, the problem of non-IgE-mediated reactions, pitfalls arising from the way foods are prepared or processed, effects of the route of exposure, the role of augmentation factors lowering the threshold value for clinical reactions, the noncomparability of specific IgE decision points, the influence of the timing of diagnostic measures. In addition, the problem of alternative diagnostic measures is discussed. In conclusion, there are several pitfalls in the diagnostic work-up of food allergy, which may be misleading for the physician. Properly performed controlled oral food challenges still represent the gold standard for implementing specific diets in food allergic individuals in order to avoid both unjustified diets, which may lead to severe impairments in growth and development, and to avoid unnecessary symptoms if an underlying food allergy is not correctly identified as a cause for the symptoms of the patient.

Child↗

PubMed2005

How well do clinic-based blood pressure measurements agree with the mercury standard?

BACKGROUND: Obtaining accurate blood pressure (BP) readings is a challenge faced by health professionals. Clinical trials implement strict protocols, whereas clinical practices and studies that assess quality of care utilize a less rigorous protocol for BP measurement. OBJECTIVE: To examine agreement between real-time clinic-based assessment of BP and the standard mercury assessment of BP. DESIGN: Prospective reliability study. PATIENTS: One hundred patients with an International Classification of Diseases-9th edition code for hypertension were enrolled. MEASURES: Two BP measurements were obtained with the Hawksley random-zero mercury sphygmomanometer and averaged. The clinic-based BP was extracted from the computerized medical records. RESULTS: Agreement between the mercury and clinic-based systolic blood pressure (SBP) was good, intraclass correlation coefficient (ICC)=0.91 (95% confidence interval (CI): 0.83 to 0.94); the agreement for the mercury and clinic-based diastolic blood pressure (DBP) was satisfactory, ICC=0.77 (95% CI: 0.62 to 0.86). Overall, clinic-based readings overestimated the mercury readings, with a mean overestimation of 8.3 mmHg for SBP and 7.1 mmHg for DBP. Based on the clinic-based measure, 21% of patients were misdiagnosed with uncontrolled hypertension. CONCLUSIONS: Health professionals should be aware of this potential difference when utilizing clinic-based BP values for making treatment decisions and/or assessing quality of care.

Academic Medical Centers↗

PubMed2005

A technique for on-board CT reconstruction using both kilovoltage and megavoltage beam projections for 3D treatment verification.

The technologies with kilovoltage (kV) and megavoltage (MV) imaging in the treatment room are now available for image-guided radiation therapy to improve patient setup and target localization accuracy. However, development of strategies to efficiently and effectively implement these technologies for patient treatment remains challenging. This study proposed an aggregated technique for on-board CT reconstruction using combination of kV and MV beam projections to improve the data acquisition efficiency and image quality. These projections were acquired in the treatment room at the patient treatment position with a new kV imaging device installed on the accelerator gantry, orthogonal to the existing MV portal imaging device. The projection images for a head phantom and a contrast phantom were acquired using both the On-Board Imager kV imaging device and the MV portal imager mounted orthogonally on the gantry of a Varian Clinac 21EX linear accelerator. MV projections were converted into kV information prior to the aggregated CT reconstruction. The multilevel scheme algebraic-reconstruction technique was used to reconstruct CT images involving either full, truncated, or a combination of both full and truncated projections. An adaptive reconstruction method was also applied, based on the limited numbers of kV projections and truncated MV projections, to enhance the anatomical information around the treatment volume and to minimize the radiation dose. The effects of the total number of projections, the combination of kV and MV projections, and the beam truncation of MV projections on the details of reconstructed kV/MV CT images were also investigated.

Humans↗

PubMed1999

Paired Mg and Mg(B) ionization chambers for the measurement of boron neutron capture dose in neutron beams.

The use of the boron neutron capture (BNC) reaction to provide a dose enhancement in fast neutron therapy is currently under investigation at the Gershenson Radiation Oncology Center of Harper Hospital in Detroit, MI. The implementation of this treatment modality presents unique challenges in dosimetry. In addition to the measurement of photon and neutron doses in the mixed field, a measure of the thermal neutron flux and the associated boron neutron capture dose throughout the treatment volume is desired. A pair of small-volume magnesium ionization chambers has been constructed with the aim of providing this information. One of the chambers, denoted the Mg(B) chamber, is lined with a boron-loaded foil. The ionization response of this chamber has been calibrated in terms of BNC dose per ppm loading of 10B. These paired chambers can be used to map the local BNC response in neutron beams. From this data and an estimation of the boron concentration in the tumor and normal tissue, the boron neutron capture enhancement may be evaluated.

Boron↗