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Results for “Complex intervention”

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PubMed1988

[Ambulatory psychiatric care in the Canton of Basel: comparison of the performance of the Psychiatric University Polyclinic and the practicing psychiatrist].

A sample of 500 patients of the university psychiatric outpatient department was used for analysis of the services rendered by this public institution and to compare them with those of the psychiatrists in private practice. The services of the latter were studied with a questionnaire mailed to them. We could demonstrate that the outpatient department has important function in social psychiatry. There are also important tasks to fulfill at the central general hospital, while uncomplicated psychotherapies play a minor role among the duties of this service. In spite of a certain readiness the psychiatrists in private practice are hardly able to fulfill these first two tasks. Their ability for emergency interventions and management of demanding cases with complex social problems is limited. We could state that their main fields of activity are long term analytical psychotherapies. In addition they can take over a limited number of expertise assessments and some crises interventions.

Ambulatory Care↗

PubMed2001

Radiation protection in interventional radiology.

There is growing concern regarding the radiation dose delivered during interventional procedures, particularly in view of the increasing frequency and complexity of these techniques. This paper reviews the radiation dose levels currently encountered in interventional procedures, the consequent risks to operators and patients and the dose reduction that may be achieved by employing a rigorous approach to radiation protection.

Fluoroscopy↗

PubMed2003

The potential contributions of chronic inflammation to lung carcinogenesis.

A number of lines of evidence suggests that chronic inflammation contributes to the process of carcinogenesis. In this article, this theme is explored with particular emphasis on the involvement of inflammation in the development of lung cancer. A number of molecular pathways activated in chronic inflammation may contribute to lung carcinogenesis. The challenge is to conceptualize a cohesive picture of this complex biology that allows for effective pharmaceutical intervention. Initial therapeutic efforts involve strategies to block single pathways, such as with cyclooxygenase (COX) activity. However, the more that is learned about the consequences of COX activity, the more evident are the relationships of this enzyme to other classes of regulatory molecules such as the potent nuclear factor-kB. In light of this emerging picture, more global intervention strategies, such as with drug combinations, may be essential for success. Further basic study is essential to sort out possible molecular relationships and to permit elucidation of the most critical regulatory circuits. Given the complexity of these molecular interactions, well-designed clinical trials that specifically evaluate the precise effects of particular antiinflammatory drugs on lung carcinogenesis will also be critical to sort out the complexity and to validate successful approaches to arresting lung carcinogenesis.

Anti-Inflammatory Agents↗

PubMedDate not supplied

Use of family management styles in family intervention research.

Family management styles (FMSs) explain some of the complexities embedded in a family with a child who has chronic illness. The FMS typologies provide descriptions of family adjustment and management of care. These 5 distinct patterns may be valuable in tailoring and evaluating family interventions in research.

Adaptation, Psychological↗

PubMed2000

Development of the Nursing Minimum Data Set for the Netherlands (NMDSN): identification of categories and items.

Development of the Nursing Minimum Data Set for the Netherlands (NMDSN): identification of categories and items Rationale Currently, there is no systematic collection of nursing care data in the Netherlands, while pressure is growing from the profession, policy-makers and society to justify the contribution of nursing and its costs. A nursing minimum data set can provide data to demonstrate nursing's contribution to health care as it can be used to describe the diversity of different patient populations and the variability of nursing activities, and to calculate the associated nursing workload. Objective To identify categories and items for inclusion in the Nursing Minimum Data Set for the Netherlands. Design A multimethod, exploratory approach was used. This included interviews, document analysis, consensus rounds, seeking validation in the literature, and drawing up lists of most frequently occurring patient problems, interventions and outcomes of care. Eight hospitals, with a total of 16 wards, participated in the study. Results Relevant categories and items emerged after analysis and grouping of the material and included: five hospital-related items, six patient demographics items, seven medical condition items, 10 nursing process items, 24 patient problems, 32 nursing interventions, four outcomes of nursing care, and three complexity of care items. Almost every item could be located in the existing documentation systems, the lists of patient problems, outcomes and interventions, or in the literature. Conclusion A set of categories and items of nursing data has been identified. The content validity of this set is partly supported by its consistency with the literature, findings from practice and the judgement of potential users. Nursing outcomes need further development. The data set will be tested in practice to find out whether the categories and items are useful, and whether they can be minimized.

Attitude of Health Personnel↗

PubMed1994

Prevention of suicide: aspirations and evidence.

The Health of the Nation white paper set a target for 15% reduction in overall suicide rates by the year 2000. If the targets are to be achieved interventions must be identified which are of proved effectiveness. This paper examines the evidence on the available interventions and points of access to the population at risk. No single intervention has been shown in a well conducted randomised controlled trial to reduce suicide. The greatest potential seems to arise from limiting the availability of methods. In particular it is likely that the introduction of the catalytic convertor will lead to reduced lethality of care exhausts and reductions in suicide using this method. General practitioner education programmes, the effectiveness of lithium and maintenance antidepressants, and limits on the quantity of medicines available over the counter or on prescription should all be evaluated. Particular high risk groups include people recently discharged from psychiatric hospitals and those with a history of parasuicide. Many social processes affect suicide rates and these rather than specific interventions may help or hinder the ability to realise the Health of the Nation targets. Well conducted trials are essential to distinguish complex social processes from the effects of specific interventions for suicide prevention. This review of the available evidence offers little support for the aspiration that the posited targets can be achieved on the basis of current knowledge and current policy.

Family Practice↗

PubMed2002

Comparative trial of a short workshop designed to enhance appropriate use of screening tests by family physicians.

BACKGROUND: Educational interventions that support the implementation of complex clinical practice guidelines (CPGs) require substantial time commitments from participants. We conducted a comparative study to evaluate if a 90-minute workshop would increase compliance with the recommendations of the Canadian Task Force on Preventive Health Care as well as decrease the ordering of tests not the subject of specific recommendations. METHODS: Eighty-seven family physicians from Quebec participated in the study. Group assignment was initially randomized, but, owing to logistic problems, randomization was not maintained. After unannounced visits, 2 standardized patients coded the physicians' performance of 23 items recommended for inclusion in the periodic health examination (10 for men and 13 for women) and 8 items recommended for exclusion (4 for both men and women). The "exposed" physicians were visited within 4 to 6 months after the workshop. The "nonexposed" physicians were visited within 4 to 6 months after consent was obtained but before they attended the workshop. We used linear regression analysis to determine if exposure to the workshop resulted in improved performance. RESULTS: Exposure to the workshop was not associated with a difference in the adjusted mean score for items recommended for inclusion (12.07 for exposed physicians v. 12.35 for those not exposed; maximal and ideal score 23; r = -0.28; 95% confidence interval [CI] = -1.63 to 1.08). However, workshop exposure was associated with lower adjusted mean scores for items recommended for exclusion (1.55 v. 3.17; maximal score 8, ideal score 0; r = -1.63; 95% CI = -2.50 to -0.75) and for other tests (3.59 v. 6.53; r = -2.95; 95% CI = -5.10 to -0.79). INTERPRETATION: A short workshop can decrease the ordering of unnecessary screening tests by family physicians. Given its low cost and its potential for general application, such an intervention can support the implementation of prevention CPGs.

Education, Medical, Continuing↗

PubMed1999

Osteopenia in young adult survivors of childhood cancer.

BACKGROUND: Improved survival of children with malignant diseases is in part due to the application of intensive, multimodality therapies, including radiotherapy, surgery, glucocorticoids, and cytotoxic agents. Such interventions have the potential to induce complex hormonal, metabolic and nutritional effects that may interfere with skeletal mass acquisition during childhood and adolescence: it is possible that such childhood cancer survivors may therefore reach adulthood with diminished peak bone mass and be at increased risk for clinically significant osteoporosis later in their life. PROCEDURE: A bone mineral density (BMD) was measured in 26 unselected former cancer patients attending the Pediatric Long-Term Clinic at M.D. Anderson Cancer Center. BMD was measured at the lumbar spine and the hip using dual X-ray absorptiometry (Hologic QDR-4500W). In addition, the patients' complete medical records were reviewed with particular attention to disease type, age modalities of treatment, and hormonal residual deficiencies. RESULTS: The median age of patients at the time of cancer diagnosis was 8 years (range, 0.3 to 16 years). Median age at BMD determination was 23 years (range, 18 to 41 years), and the median interval since cancer diagnosis and BMD was 18 years (range, 5 to 29). Overall, their BMD was decreased relative to peak bone mass at all sites: osteopenia was especially pronounced in patients with a history of cranial irradiation who had developed evidence of pituitary insufficiency during childhood or adolescence. Overall, the median BMD T-score was -1.41 at the lumbar spine, -1.04 at the femoral neck, and -1.06 for total hip. For patients with prior cranial irradiation, T-score at the lumbar spine was -2.18 (range, -4.06 to -0.98), at the femoral neck -1.92 (range, -4.11 to +1.10), and for total hip -1.67 (range, -4.79 to +0.56); BMD for irradiated patients was significantly lower than BMD of patients without cranial irradiation. We could not discern an independent impact of other disease characteristics or treatment modalities in this small group of patients. CONCLUSIONS: Osteopenia is a prominent finding in young adults who are survivors of childhood cancers; it is likely that antineoplastic treatments during childhood and adolescence impede peak bone mass acquisition. We suggest that systematic attention to this potential complication is needed in order to identify what subgroups of children may require regular surveillance and what interventions are required for its prevention or treatment.

Adolescent↗

PubMed2003

CNS involvement in overactive bladder: pathophysiology and opportunities for pharmacological intervention.

The pathophysiology of overactive bladder (OAB) syndrome is complex, and involves both peripheral and CNS factors. Several CNS disorders are associated with OAB, e.g. stroke, spinal cord injury, Parkinson's disease and multiple sclerosis, and in each disorder the pathophysiology of OAB can be multifactorial. Irrespective of cause or pathophysiology of OAB, antimuscarinic drugs are the first line of pharmacological treatment. However, adverse effects and limited efficacy makes alternative therapeutic principles desirable. Most alternative drugs used for the treatment of OAB have a peripheral site of action, mainly affecting efferent or afferent neurotransmission or the detrusor muscle itself. New targets for pharmacological intervention may be found in the CNS. Several CNS transmitters/transmitter systems are known to be involved in micturition control, but few drugs with a defined CNS site of action (e.g. baclofen, imipramine and duloxetine) have been used for the treatment of voiding disorders. GABA, glutamate, opioid, serotonin, noradrenaline (norepinephrine), and dopamine receptors and mechanisms are known to influence micturition, and drugs influencing these systems could potentially be developed for the treatment of OAB. Preclinical studies in different animal models have shown that modulation of normal micturition and detrusor overactivity by drugs acting within the spinal cord or supraspinally is possible. Promising results have been obtained in such models, e.g. with drugs interfering with GABA mechanisms, serotonin 5-HT1A receptors, mu-opioid receptors and alpha-adrenoreceptors. However, considering the limited predictability of existing animal models for efficacy in humans, positive proof of concept studies in humans are mandatory. Such studies are scarce and further investigations are needed.

Animals↗

PubMed1991

Propranolol overdose--a dramatic response to calcium chloride.

OBJECTIVE: To present a case of severe propranolol overdose which responded dramatically to the administration of calcium chloride. CLINICAL FEATURES: A 22-year-old female Caucasian who was unemployed arrived by ambulance to a hospital emergency department after propranolol overdose. She was convulsing and in electromechanical dissociation. An electrocardiogram showed sinus rhythm with broad QRS complexes. She had no relevant medical history. INTERVENTION: Resuscitation with basic and then advanced life support and administration of oxygen, adrenaline, atropine, fluids and bicarbonate gave no response. Calcium chloride, however, repeatedly produced a dramatic restoration of blood pressure and a narrowing of the QRS complexes. She made a good recovery with no sequelae. CONCLUSION: Calcium chloride may have a role to play in propranolol overdose.

Adult↗

PubMed2002

Thirteenth annual pezcoller symposium: focusing analytical tools on complexity in cancer.

The physiopathology of cancer cells is the result of very complex signaling networks that represent in many cases distortions of the orderly networks regulating the physiology of normal cells. These networks are the consequence of the expression of, or the lack of expression of, genes, mutated or not, which represent the genomic profile of different types of or of individual cancers. The complex signaling pathways, the cross-talks among them, and the redundancies existing for several of them mediate not only the transmission of signals from the cell environment to the nucleus but also that from the nucleus to the other cellular components whose function is involved in cell proliferation, apoptosis, or differentiation. Modern approaches to cancer therapy and also prevention are aimed at identifying new molecular targets, pivotal to the life of the cancer cell, which would provide for specific sites of intervention. In the face of the enormous complexity of the phenomena on which the life of cancer cells is based, it is both difficult to identify unique specific target for intervention and important to develop analytical tools and approaches capable to identify them for further exploitation. This was the main subject of the Symposium. Consideration was given to: (a) tumor genotypic analysis through expression array evaluation and definition of cancer transcriptomes in studies aimed at identifying determinants of specific characteristics of cancer cells; (b) approaches based on the knowledge gained in this analysis that would lead to the visualization of new targets exploitable for antitumor action; and (c) multifactorial analysis of the complex interactions regulating cancer cells and methods to comprehend the complexity of molecular models and validate their functional relevance.

Animals↗

PubMed2006

Case management to improve major depression in primary health care: a systematic review.

BACKGROUND: Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care. METHOD: A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either 'standard' or 'complex' case management. RESULTS: Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6-12 months of -0.40 (95% CI -0.60 to -0.20). Patients in the intervention groups were more likely to achieve remission after 6-12 months [relative risk (RR) 1.39, 95% CI 1.30-1.48]. The relative risk for clinical response was 1.82 (95% CI 1.68-2.05). Patients in intervention groups had better medication adherence than the control group (RR 1.5, 95% CI 1.28-1.86). We found heterogeneous results when assessing effects of different types of intervention. CONCLUSIONS: We conclude that case management improves management of major depression in primary health-care settings.

Case Management↗

PubMed2006

Data and safety monitoring in social behavioral intervention trials: the REACH II experience.

BACKGROUND: Psychosocial and behavioral interventions trials targeting a broad range of complex social and behavioral problems such as smoking, obesity and family caregiving have proliferated in the past 30 years. At the same time the use of Data and Safety Monitoring Boards (DSMBs) to monitor the progress and quality of intervention trials and the safety of study participants has increased substantially. Most of the existing literature and guidelines for safety monitoring and reporting of adverse events focuses on medical interventions. Consequently, there is little guidance for investigators conducting social and behavior trials. PURPOSE: This paper summarizes how issues associated with safety monitoring and adverse event reporting were handled in the Resources for Enhancing Alzheimer's Caregiver Health (REACH II) program, a multi-site randomized clinical trial, funded by the National Institutes on Aging (NIA) and the National Institutes of Nursing Research (NINR), that tested the efficacy of a multicomponent social/behavioral intervention for caregivers of persons with Alzheimer's disease. METHODS: A task force was formed to define adverse events for the trial and protocols for reporting and resolving events that occurred. The task force conducted a review of existing polices and protocols for data and safety monitoring and adverse event reporting and identified potential risks particular to the study population. An informal survey regarding data and safety monitoring procedures with investigators on psychosocial intervention trials was also conducted. RESULTS: Two categories of events were defined for both caregivers and patients; adverse events and safety alerts. A distinction was also made between events detected at baseline assessment and those detected post-randomization. Standardized protocols were also developed for the reporting and resolution of events that occurred and training of study personnel. Results from the informal survey indicated wide variability in practices for data safety and monitoring across psychosocial intervention trials. CONCLUSIONS: Overall, the REACH II experience demonstrates that existing guidelines regarding safety monitoring and adverse event reporting pose unique challenges for social/behavioral intervention trials. Challenges encountered in the REACH II program included defining and classifying adverse events, defining "resolution" of adverse events and attributing causes for events that occurred. These challenges are highlighted and recommendations for addressing them in future studies are discussed.

Alzheimer Disease↗

PubMed2003

[Indications for refractive procedures in adult patients with strabismus and results of the subsequent therapeutic procedures].

The authors estimated the contribution of the refraction intervention and a possible evolution in the position of eyes in 102 adult individuals considering a refraction intervention. The indications for this intervention were a disorder in eye position or amblyopia in those who were interested in this operation and were examined in the years 1996 to 2002. The basic refraction examination was always supplemented by a detailed orthoptic analysis. Based on this examination the intervention was not recommended in 14 examined subjects (14%). ARK represented the contraindication of the refraction intervention in 9 patients, since subsequent changes in the size of the deviation or operation adjustment of strabismus could result in diplopia. An excessive convergence with a high AC/A in hyperopia was also considered as an unsuitable indication, since a lasting cosmetic and functional significant convergent deviation into near distances could not be excluded. Five patients declined from the refraction intervention on the basis of this explanation. The paper is mainly dealing with an analysis of the development of position of the eyes and binocular functions in 46 adult patients, who decided to undergo a refraction intervention and further orthoptic care after a complex stroboscopic and refraction examination. The adjustment of refractive error was made by the LASIK methods (Laser in Situ Keratomileusis) on 69 eyes (80%) and CLE (Cleans Lens Extraction) on 17 eyes (20%). The orthoptic analyses before and the refraction intervention revealed that in all 29 even only partially accommodating esotropia, the deviation was diminished after the refraction intervention on the average by +11.2 degrees (in the rage of +2 degrees to +30 degrees) to 5.4 degrees (in the range of parallel position to +20 degrees) in the predominantly represented hyperopia, but also in 6 myopias. The improved position of the bulbs was not directly associated with the degree of hyperopia with the original deviation. The deviation after the refraction intervention in 23 patients (79%) with esotropia was not higher than degrees. The cosmetic position of the eyes was completely satisfactory and did not therefore represent even indication for the operation. The 9 patients (35%) with esotropia and hyperopia there were an improvement of binocular functions. It could be theoretically due to the newly developed emetropia making permanent optimal sensory information possible. In all 17 exotropias there were not any significant changes in the size of deviation and the binocular functions were not reestablished, if they were not retained before. The position of eyes was solved surgically in 12 patients, while exotropia predominated in two thirds of them. The weakening or strengthening interventions on horizontal straight muscles were selected according to character of strabismus in 11 patients. Recession of the lower oblique muscle was indicated one case only for the simultaneously present torticollis with exotropia. The residual deviation was not greater than 5 degrees immediately after the operation or during the following months. Binocular functions were not reestablished in any patients. A alternate suppression or suppression of perception on one eye were proved.

Adult↗

PubMed2002

[Radiation protection for patient and operator in interventional radiology].

While interventional radiological procedures are minimally invasive and beneficial to patients, some complex and lengthy fluoroscopically guided procedures may cause radiation-induced skin injuries. Interventional radiologists should be aware of threshold doses, actual dose rates of specific X-ray equipment, and practical techniques to control the patient's cumulative skin dose. The International Commission on Radiation Protection recommends that the maximum dose to the skin be recorded when it approaches 1 Gy (for procedures that may be repeated) or 3 Gy (for any procedure) and that patient follow-up be provided in the latter situation. To reduce operator exposure, it is essential to avoid direct exposure of the primary beam to the hands in procedures such as transhepatic biliary drainage. During vascular interventions, the majority of operator exposure is caused by scatter radiation from the patient. Almost every effort to reduce patient dose secondarily reduces scatter radiation to the operator as well. The overcouch X-ray tube system is associated with higher exposure to the hands and eyes, and should not be used for complicated procedures. Appropriate shields help in reducing scatter to the operator.

Humans↗

PubMedDate not supplied

Can a community development model be used for health programmes in an industrialized country?

Injury resulting from accident is a serious public health problem in Sweden, as it is in the rest of the world. Theoretically, almost all incidents can be prevented. However, in practice, injury-prevention is a complex problem. A community-level intervention programme for prevention of accidents was developed in the municipality of Sollentuna, Stockholm County. The primary strategy has been to involve the community through representatives as well as through local organizations and groups. Project organization has been built up in cooperation with the municipal primary health-care department, local authorities, voluntary organizations and citizen agencies. A common opinion is that it is the actual process in a community programme which is important, that alters the type of involvement from a 'top-down' to a 'bottom-up' approach. Can a local community take over responsibility for running such a programme which has been initiated by an external authority or organization? We think that, at least for Swedish circumstances, the community development approach is far too optimistic in its expectation that community members should and can stay actively involved in programme decisions. Based on our experience, it does not seem possible to maintain a broad self-sustained programme solely with input from community members.

Accident Prevention↗

PubMed2004

alpha1 Integrin activation: a link between beta-amyloid deposition and neuronal death in aging hippocampal neurons.

A growing body of evidence obtained using in vitro model systems indicates that the deposition of fibrillar beta-amyloid (Abeta) results in neurite degeneration and cell death in central neurons. Little is known, however, about the molecular mechanisms underlying these neurotoxic effects. We have shown previously that fibrillar Abeta induced sustained activation of the mitogen-activated protein kinase (MAPK) followed by hyperphosphorylation of tau proteins in aging hippocampal neurons. Furthermore, the blockage of MAPK activation using specific inhibitors prevented neurite degeneration in these cells. These results suggested that the MAPK signal transduction pathway could play a key role in Abeta-induced neurite degeneration. We sought to identify upstream elements of the MAPK signaling cascade activated by Abeta deposition. We evaluated the participation of the integrins in this pathway by monitoring the activation of MAPK in the presence of specific integrin inhibitors. Our results indicate that pretreatment of mature hippocampal neurons with either echistatin or alpha(1) integrin-blocking antibodies prevented Abeta-induced MAPK activation. In addition, the blockage of alpha(1) activation prevented cell death induced by Abeta. Similar results were obtained when alpha(1) and beta(1) integrin blocking antibodies were used combined. Taken collectively, these results identify alpha(1) integrin and the alpha(1) plus beta(1) integrin complexes as potential targets for therapeutic intervention in the Abeta signaling pathway in aging neurons.

Aging↗

PubMed2003

New development of functional neurorehabilitation in neurosurgery.

OBJECTIVES: Today, increasingly more patients with severe brain and spinal cord lesions mainly secondary to accidents, violence, stroke, and tumours survive their injuries, in many cases, however, suffering from severe functional impairments of functioning as described by the WHO-ICF criteria. New developments of functional neurorehabilitation in neurosurgery could significantly improve the patients' quality of life (QoL) in terms of brain and body functioning and certain health-related components of well-being (such as social activities and leisure). METHODS: Functional rehabilitation is an original task of neurosurgery from the very outset. Advances in biotechnology regarding both basic research and clinical application have opened up a new and very promising field to restore or compensate impaired or definitively lost organic functions in addition to the conservative rehabilitation methods. RESULTS: Along with the scientific progress in biotechnology and functional MRI and PET, neurosurgeons have become increasingly interested and actively involved in rehabilitation science and neurosurgical re-engineering of the damaged brain and spinal cord. Some of them have developed new specially designed institutions for early (acute) and subacute neurorehabilitation. Attached to the acute services, neurosurgeons thus become responsible for neurorehabilitation and at the same time for the management of all kinds of complications, which significantly improves the early and late functional outcome. At the same time microelectronics, biotechnology, and genetic engineering are being introduced into the field of neurosurgical rehabilitation in a step-by-step manner. DISCUSSION: Progress in the fields of microelectronics, computer technology, and genetic engineering along with rehabilitation science is opening up a new field of unknown chances to partially restore lost body functions and to help improve the quality of life of disabled patients in the sense of ICF. Functional neurosurgery plays a major role in neurosurgical rehabilitation. e.g. functional electrostimulation, brain-stem implants, pain and epilepsy control, restoration of locomotion and grasp faculties, and the use of potent substances such as botulinum toxin (Btx). This demands the capacity of time work and the realization of the necessity to draw up a detailed plan for the restoration of impaired functions prior to enacting a neurosurgical intervention in the sense of a complex neurorehabilitation, and consequently to assume the responsibility for the patient's outcome. From the beginning of neurological surgery, the preservation and restoration of impaired brain and spinal-cord functions as an original task for neurosurgeons demand their involvement with issues of functional neurorehabilitation including neurosurgical re-engineering of the damaged brain and spinal cord. In this connection the close and trusting cooperation with the clinical neuropsychologist from the very outset is an indispensible factor.

Brain Injuries↗