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Protocols and guidelines in critical care: development and implementation.

Variation in clinical management has been associated with suboptimal outcomes and increased costs. Guidelines, protocols, and clinical pathways have evolved as a strategy to standardize care, principally by limiting variation, thereby reducing complications, decreasing length of stay and improving outcomes. However, the nature of critical care makes it difficult to conduct blinded, randomized, and controlled clinical trials, the specific type of science required for evidenced-based medicine and guideline development. Areas in which ICU-based guidelines have been successful include, among others, sedation and neuromuscular blockade use, ventilator management, antibiotic selection, and vascular surgical interventions.

Algorithms↗

[Data protection and data access (II): Physician's responsibility for confidentiality, federal statistics law and data collection by authorization with reference to implementing occupational medicine epidemiologic studies in Germany].

The additional legal rulings governing access to personal data for epidemiological research are the medical professional secrecy regulators and the federal statistics law. These permit access to personal data only if the individual has given his or her informed constant. Beyond this, both laws contain clauses governing the transfer of anonymous data for research and science. Thus anonymized data may be transferred on request to authorized persons or institutions, such as a physician or the regional statistics office. Finally, a custodian model is presented which provides further possibilities for research in occupational medicine and epidemiology within this very restrictive legal framework.

Cause of Death↗

Food and nutrition policies: what's being done in Turkey.

OBJECTIVE: The aim of the present paper is to describe the development of the National Plan of Action for Food and Nutrition (NPAFN) for Turkey. DESIGN: Access to a safe and healthy variety of food, a fundamental human right, was stressed by the International Conference on Nutrition and by the World Food Summit. In the International Conference on Nutrition in December 1992, one major commitment was the preparation of NPAFN. The NPAFN for Turkey was designed according to this commitment. SETTING: Turkey. RESULTS: To this end, under the coordination of the State Planning Organization, a Working Committee Report for National Food and Nutrition Strategy of Turkey was prepared and published, with the participation of different sectors. The goal of the prepared National Food and Nutrition Strategy for Turkey is to protect and promote health through and healthy nutrition and reduce the burden of diseases, while contributing to socio-economic development and a sustainable food security. CONCLUSION: In Turkey the NPAFN was developed and implementation has initiated. Nearly for all the actions, related projects are being developed.

Consumer Product Safety↗

Introducing clinical laboratory science: CLS students help shape the future.

OBJECTIVES: The profession of clinical laboratory science (CLS) is in dire need of increased exposure to young people. By introducing the clinical laboratory sciences to students at a critical point in their science education and by making it relevant to their lives, more choices are made available to them when considering future career options. With this in mind, the CLS faculty at Texas Tech University Health Sciences Center (TTUHSC) redesigned a recruitment program and developed it into one making use of CLS student knowledge, enthusiasm, and professionalism. CLS students were given the assignment of designing an entire curriculum for a ten day presentation of clinical laboratory science topics to middle and secondary school students. Following the presentations, participants in the program were asked to provide feedback regarding CLS student performance and overall opinion of their interest in clinical laboratory science. The objectives of this study were twofold: 1) to determine if educational methodologies could be appropriately applied by CLS students to present CLS disciplines to middle and high school students; and 2) to determine if the student presentation was successful in initiating interest in the CLS profession based on outcome measures. DESIGN: As a component of the CLS laboratory management course, CLS students were instructed in education methodologies including objective writing, teaching-unit preparation, and evaluation tool design. In the following semester, these students were divided into groups and assigned a specific CLS discipline that would then be presented to middle and secondary school students in a two week, 30 hour educational program. This program was offered by the TTUHSC CLS program in cooperation with the Institute for the Development and Enrichment of Advanced Learners (IDEAL) at Texas Tech University. The curriculum prepared by the CLS students (with faculty supervision) provided the framework for the present study. SETTING: Didactic instruction of the CLS students regarding objective writing, curriculum design, and preparation of evaluations was included as a component of a CLS laboratory management course. The educational program presented by IDEAL in conjunction with the TTUHSC CLS program within the School of Allied Health Sciences occurred in the CLS student laboratories located in Lubbock, Texas. PARTICIPANTS: TTUHSC senior CLS students in a 2 + 2 baccalaureate level CLS program acted as instructors in the educational program which was presented to middle and secondary school students from around the region. CLS program faculty served as supervisors of this program. MAIN OUTCOME MEASURES: Questionnaires with Likert-scaled responses were used to evaluate outcomes. These questionnaires regarded 1) faculty assessment of CLS student performance relative to instruction in education methods; 2) participant feedback on the effectiveness and competence of the CLS student instructors and overall appeal of the presented subject material; and 3) peer evaluations of attitude, contribution, and effort of the group members. RESULTS: CLS faculty strongly agreed that the CLS students demonstrated a high level of competence when writing objectives, planning age-appropriate curriculum and activities, and demonstrating a positive image of the profession. Regarding satisfaction of the IDEAL student participant, questionnaire responses demonstrated a high rate (84% or greater for middle school participants and 85% for high school students). The program design has been so successful that it has been implemented for several other programs offered by TTU and IDEAL. CONCLUSION: The education methods used in presenting the IDEAL program mirror those found in clinical and academic settings and is an effective technique to introduce CLS students to the varied aspects of educational methodology. The presentation by the CLS students also demonstrated that introduction of clinical laboratory science disciplines early in the education of middle and secondary school students leads to an interest in the CLS profession and to the desire to learn more about it.

Clinical Laboratory Techniques↗

Learning from communities: overcoming difficulties in dissemination of prevention and promotion efforts.

The model of prevention science advocated by the Institute of Medicine (P. J. Mrazek & R. J. Haggerty, 1994) has not lead to widespread adoption of prevention and promotion programs for four reasons. The model of dissemination of programs to communities fails to consider community and organizational capacity to implement programs, ignores the need for congruence in values between programs and host sites, displays a pro-innovation bias that undervalues indigenous practices, and assumes a simplistic model of how community organizations adopt innovations. To address these faults, researchers should locate, study, and help disseminate successful indigenous programs that fit community capacity and values. In addition, they should build on theoretical models of how locally developed programs work to make existing programs and polices more effective.

Community Mental Health Services↗

Reshaping clinical nursing education: an academic-service partnership.

This article describes the conceptualization and implementation of an academic-service partnership for a baccalaureate nursing program. The partnership began its fifth year in the fall of 2002; 107 students have entered the partnership since its inception. The partnership goals were to develop and implement clinical training experiences that teach students key skills for community-based practice settings, and to develop and evaluate an innovative and collaborative model for community-based clinical education. Students in the partnership have a unique opportunity for learning the art and science of nursing in a complex, integrated health care system with a strong emphasis on quality of environment, providers, and care delivery. A longitudinal program evaluation is underway, based on an American Association of Colleges of Nursing publication, the vision and goals of the School of Nursing, and the construct of organizational socialization.

Clinical Competence↗

Nutrition and diet for healthy lifestyles in Europe: the 'Eurodiet' Project.

The aims of this project are to formulate a strategy and action plan for developing and implementing European dietary guidelines. The project is supported by DGV/F/3 and was initiated in October 1998. The work plan has entailed the formation of Working Parties composed of prominent experts from the member states to prepare consensus documents on the state of the art in Europe and the added value of European population-based guidelines. These groups are addressing 4 inter-linked components of the project: (1) evaluation of the role of diet and lifestyles in health & disease patterns in Europe; (2) the feasibility of developing an EU-wide framework for food-based dietary guidelines; (3) public health nutrition strategies for implementing FBDGs and for enhancing physically active lifestyles in Europe and (4) an evaluation of policy, trade, economic and technological aspects to improving nutritional status and lifestyles in the EU. Stakeholders from the spectrum of interests involved are invited to assess and debate the science and policy implications of these documents, which will be presented at a European Conference in May 2000. Recommendations in the form of a practical, evidence based policy document will be presented to the European Commission, the Council of Ministers and the European Parliament.

Diet↗

The Online Bioinformatics Resources Collection at the University of Pittsburgh Health Sciences Library System--a one-stop gateway to online bioinformatics databases and software tools.

To bridge the gap between the rising information needs of biological and medical researchers and the rapidly growing number of online bioinformatics resources, we have created the Online Bioinformatics Resources Collection (OBRC) at the Health Sciences Library System (HSLS) at the University of Pittsburgh. The OBRC, containing 1542 major online bioinformatics databases and software tools, was constructed using the HSLS content management system built on the Zope Web application server. To enhance the output of search results, we further implemented the Vivísimo Clustering Engine, which automatically organizes the search results into categories created dynamically based on the textual information of the retrieved records. As the largest online collection of its kind and the only one with advanced search results clustering, OBRC is aimed at becoming a one-stop guided information gateway to the major bioinformatics databases and software tools on the Web. OBRC is available at the University of Pittsburgh's HSLS Web site (http://www.hsls.pitt.edu/guides/genetics/obrc).

Computational Biology↗

Lessons learned in applying the U.S. EPA proposed cancer guidelines to specific compounds.

An expert panel was convened to evaluate the U.S. Environmental Protection Agency's "Proposed Guidelines for Carcinogen Risk Assessment" through their application to data sets for chloroform (CHCl3) and dichloroacetic acid (DCA). The panel also commented on perceived strengths and limitations encountered in applying the guidelines to these specific compounds. This latter aspect of the panel's activities is the focus of this perspective. The panel was very enthusiastic about the evolution of these proposed guidelines, which represent a major step forward from earlier EPA guidance on cancer-risk assessment. These new guidelines provide the latitude to consider diverse scientific data and allow considerable flexibility in dose-response assessments, depending on the chemical's mode of action. They serve as a very useful template for incorporating state-of-the-art science into carcinogen risk assessments. In addition, the new guidelines promote harmonization of methodologies for cancer- and noncancer-risk assessments. While new guidance on the qualitative decisions ensuing from the determination of mode of action is relatively straightforward, the description of the quantitative implementation of various risk-assessment options requires additional development. Specific areas needing clarification include: (1) the decision criteria for judging the adequacy of the weight of evidence for any particular mode of action; (2) the role of mode of action in guiding development of toxicokinetic, biologically based or case-specific models; (3) the manner in which mode of action and other technical considerations provide guidance on margin-of-exposure calculations; (4) the relative roles of the risk manager versus the risk assessor in evaluating the margin of exposure; and (5 ) the influence of mode of action in harmonizing cancer and noncancer risk assessment methodologies. These points are elaborated as recommendations for improvements to any revisions. In general, the incorporation of examples of quantitative assessments for specific chemicals would strengthen the guidelines. Clearly, any revisions should retain the emphasis present in these draft guidelines on flexibility in the use of scientific information with individual compounds, while simultaneously improving the description of the processes by which these mode-of-action data are organized and interpreted.

Animals↗

Use of a group objective structured clinical examination with first-year medical students.

PURPOSE: To evaluate the implementation of a quarterly group objective structured clinical examination (GOSCE) to assess the patient-evaluation abilities of a medical school class. METHOD: The study subjects were 94 first-year students participating in the Principles of Clinical Medicine course at the Oregon Health Sciences University School of Medicine in 1992-93. To create the GOSCE, the authors modified the format of the quarterly objective structured clinical examination by making each standardized-patient station the site of an interaction between a standardized patient and a group of four or five students. The GOSCE's reliability, content and face validity, and expense were evaluated. Student feedback was obtained using a structured questionnaire. RESULTS: Performances varied both among the five stations of the GOSCE and among the 23 student groups: the mean percentage of items performed correctly per station was 83%, with a range of 73-97%. The reliability of the GOSCE's stations was low, with intraclass correlations during the three consecutive quarters of .29, .05, and .12. Despite no prior experience with this type of testing, the students' mean rating of the GOSCE's appropriateness was 3.8 (on a Likert scale of 1, poor, to 5, excellent), compared with 2.5 for the appropriateness of the written examination also used for quarterly assessment. The expense of the GOSCE was much less than the costs reported for the OSCE format. CONCLUSION: The use of the quarterly GOSCE favorably influenced the students, faculty, and curriculum. The GOSCE format made possible the assessment of a large number of students' abilities, without the time and expense needed to evaluate students individually.

Attitude↗

Critical issues in the development of culturally relevant substance abuse treatments for specific minority groups.

Contemporary substance abuse treatment providers are now recognizing the growing diversity within American society. This recognition includes a growing appreciation of racial/ethnic diversity, although few models exist to aid in conceptualizing this diversity as related to substance abuse treatment. This situation prompts the need to better understand the influences of cultural variables in the design and delivery of culturally-responsive and effective substance abuse treatments. Culturally-responsive treatments are those that are sensitive to the specific treatment needs of members of special populations. This article presents specific issues and provides directions for the design, development, and implementation of more effective substance abuse treatments for clients from special populations. These important issues include: (1). the development of provider cultural competence, (2). the need to incorporate cultural variables into treatment, (3). issues in program adaptation, and (4). issues in the transfer of science to practice. Strategic models are presented to aid in conceptualizing these issues, and to further understand relationships between important cultural variables. Finally, further scientific research is encouraged that will contribute an empirical database that will test and further develop these strategic models, in the interest of enhancing the efficacy and effectiveness of substance abuse treatments as delivered to racial/ethnic minority clients, and to clients from other special populations.

Cross-Cultural Comparison↗

An algebraic geometry approach to protein structure determination from NMR data.

Our paper describes the first provably-efficient algorithm for determining protein structures de novo, solely from experimental data. We show how the global nature of a certain kind of NMR data provides quantifiable complexity-theoretic benefits, allowing us to classify our algorithm as running in polynomial time. While our algorithm uses NMR data as input, it is the first polynomial-time algorithm to compute high-resolution structures de novo using any experimentally-recorded data, from either NMR spectroscopy or X-Ray crystallography. Improved algorithms for protein structure determination are needed, because currently, the process is expensive and time-consuming. For example, an area of intense research in NMR methodology is automated assignment of nuclear Overhauser effect (NOE) restraints, in which structure determination sits in a tight inner-loop (cycle) of assignment/refinement. These algorithms are very time-consuming, and typically require a large cluster. Thus, algorithms for protein structure determination that are known to run in polynomial time and provide guarantees on solution accuracy are likely to have great impact in the long-term. Methods stemming from a technique called "distance geometry embedding" do come with provable guarantees, but the NP-hardness of these problem formulations implies that in the worst case these techniques cannot run in polynomial time. We are able to avoid the NP-hardness by (a) some mild assumptions about the protein being studied, (b) the use of residual dipolar couplings (RDCs) instead of a dense network of NOEs, and (c) novel algorithms and proofs that exploit the biophysical geometry of (a) and (b), drawing on a variety of computer science, computational geometry, and computational algebra techniques. In our algorithm, RDC data, which gives global restraints on the orientation of internuclear bond vectors, is used in conjunction with very sparse NOE data to obtain a polynomial-time algorithm for protein structure determination. An implementation of our algorithm has been applied to 6 different real biological NMR data sets recorded for 3 proteins. Our algorithm is combinatorially precise, polynomial-time, and uses much less NMR data to produce results that are as good or better than previous approaches in terms of accuracy of the computed structure as well as running time. In practice approaches such as restrained molecular dynamics and simulated annealing, which lack both combinatorial precision and guarantees on running time and solution quality, are commonly used. Our results show that by using a different "slice" of the data, an algorithm that is polynomial time and that has guarantees about solution quality can be obtained. We believe that our techniques can be extended and generalized for other structure-determination problems such as computing side-chain conformations and the structure of nucleic acids from experimental data.

Algorithms↗

Understanding caring through arts and humanities: a medical/nursing humanities approach to promoting alternative experiences of thinking and learning.

It is often claimed that nursing is both an art and a science, yet nursing education has been reluctant to accord arts and literature a prominent place within nursing curricula. While the discipline of medical humanities has been developing for around two decades, there has been no comparable movement within nursing. This paper describes the development, implementation and initial hermeneutic evaluation of a new course, 'Understanding Caring Through Arts and Humanities' which we believe to be unique in being a fully accredited unit which is offered within a BA (Honours) Health Studies Degree for nurses and other health care professionals.

Attitude of Health Personnel↗

Combining results of microarray experiments: a rank aggregation approach.

As technology for microarray analysis becomes widespread, it is becoming increasingly important to be able to compare and combine the results of experiments that explore the same scientific question. In this article, we present a rank-aggregation approach for combining results from several microarray studies. The motivation for this approach is twofold; first, the final results of microarray studies are typically expressed as lists of genes, rank-ordered by a measure of the strength of evidence that they are functionally involved in the disease process, and second, using the information on this rank-ordered metric means that we do not have to concern ourselves with data on the actual expression levels, which may not be comparable across experiments. Our approach draws on methods for combining top-k lists from the computer science literature on meta-search. The meta-search problem shares several important features with that of combining microarray experiments, including the fact that there are typically few lists with many elements and the elements may not be common to all lists. We implement two meta-search algorithms, which use a Markov chain framework to convert pairwise preferences between list elements into a stationary distribution that represents an aggregate ranking (Dwork et al, 2001). We explore the behavior of the algorithms in hypothetical examples and a simulated dataset and compare their performance with that of an algorithm based on the order-statistics model of Thurstone (Thurstone, 1927). We apply all three algorithms to aggregate the results of five microarray studies of prostate cancer.

Algorithms↗

The DPACS project at the University of Trieste.

The DPACS project (Data and Picture Archiving and Communication System) was undertaken at the University of Trieste by the Institute of Radiology and the DEEI (Dipartimento di Elettrotecnica, Elettronica ed Informatica), in collaboration with the CRSTBS (Centro Ricerche e Studi Tecnologie Biomediche Sanitarie) of the Area Science Park and the Azienda Ospedaliera of Trieste. The main objective of this project is to create an open system for the management of clinical data and images and for the integration of health care services. The first phase is oriented toward finding an implementation strategy for the creation of a prototype DPACS system, to serve as a starting point for the realization of a distributed structure for the extension of the service, firstly to the entire structure of the Cattinara Hospital and subsequently to all the Public Health units in Trieste. After local testing, the service will finally be expanded to a wider geographical level. The intensive computerization of the Institute of Radiology furnished the most favourable environment for the verification of the prototype, as the service provided by the existing RIS (Radiology Information System) and PACS (Picture and Archiving Communication System) has long been consolidated. One of the main goals of the project, in particular, is to replace the old, by now obsolete, PACS with the DPACS services.

Humans↗

Hospitals and the educational institution: an innovative partnership for nursing specialty education.

Rapid technological and economic change require that educational institutions respond efficiently and effectively to the needs of the health care industry. Nurses demand education that is accessible, affordable, and relevant, and demand recognition for educational achievement in terms of credentials and financial rewards. This article describes a partnership between British Columbia Institute of Technology (which is driven by and responds to industry) and The School of Health Science (which prepares nurses for specialty practice). The partnership permits a proactive relationship that utilizes the best qualities of both the health care and educational institutions. Although this alliance has been used extensively to prepare nurses for specialty areas, this partnership model could be implemented by a variety of institutions to meet educational needs in many health care professions.

British Columbia↗

A blended learning experience for teaching microbiology.

OBJECTIVES: To create a virtual laboratory system in which experimental science students could learn required skills and competencies while overcoming such challenges as time limitations, high cost of resources, and lack of feedback often encountered in a traditional laboratory setting. DESIGN: A blended learning experience that combines traditional practices and e-learning was implemented to teach microbiological methods to pharmacy students. Virtual laboratory modules were used to acquire nonmanual skills such as visual and mental skills for data reading, calculations, interpretation of the results, deployment of an analytical protocol, and reporting results. ASSESSMENT: Learning achievement was evaluated by questions about microbiology case-based problems. Students' perceptions were obtained by assessment questionnaire. CONCLUSION: By combining different learning scenarios, the acquisition of the necessary but otherwise unreachable competences was achieved. Students achieved similar grades in the modules whose initiation was in the virtual laboratory to the grades they achieved with the modules whose complete or partial initiation took place in the laboratory. The knowledge acquired was satisfactory and the participants valued the experience.

Education, Pharmacy↗

From the histophotometer to the confocal microscope: the evolution of analytical microscopy.

With new ideas and with the aid of modern technology, novel microscopical and micro-analytical methods are practically implemented, as a fruit of the co-operative effect of theoretical and experimental advances achieved in distinct fields. The results obtained in the development of new micro-analytical instruments and in their applications, increasingly help to solve many investigative problems in materials science and in biology. Among the oldest forms of analytical microscopy, some encountered histophotometers while, among the latest, some are working with confocal microscopes. Given by one that had the opportunity of attending to both of the developments, an overview encompassing these two instruments can hopefully serve to illustrate the progress of analytical microscopy, a discipline evolving during the second half of this century.

Microscopy↗