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Minimum spanning trees for gene expression data clustering.

This paper describes a new framework for microarray gene-expression data clustering. The foundation of this framework is a minimum spanning tree (MST) representation of a set of multi-dimensional gene expression data. A key property of this representation is that each cluster of the expression data corresponds to one subtree of the MST, which rigorously converts a multi-dimensional clustering problem to a tree partitioning problem. We have demonstrated that though the inter-data relationship is greatly simplified in the MST representation, no essential information is lost for the purpose of clustering. Two key advantages in representing a set of multi-dimensional data as an MST are: (1) the simple structure of a tree facilitates efficient implementations of rigorous clustering algorithms, which otherwise are highly computationally challenging; and (2) as an MST-based clustering does not depend on detailed geometric shape of a cluster, it can overcome many of the problems faced by classical clustering algorithms. Based on the MST representation, we have developed a number of rigorous and efficient clustering algorithms, including two with guaranteed global optimality. We have implemented these algorithms as a computer software EXCAVATOR. To demonstrate its effectiveness, we have tested it on two data sets, i.e., expression data from yeast Saccharomyces cerevisiae, and Arabidopsis expression data in response to chitin elicitation.

Algorithms↗

Problem Based Learning, curriculum development and change process at Faculty of Medicine, Makerere University, Uganda.

INTRODUCTION: The faculty of Medicine, (FOM) Makerere University Kampala was started in 1924 and has been running a traditional curriculum for 79 years. A few years back it embarked on changing its curriculum from traditional to Problem Based Learning (PBL) and Community Based Education and Service (COBES) as well as early clinical exposure. This curriculum has been implemented since the academic year 2003/2004. The study was done to describe the steps taken to change and implement the curriculum at the Faculty of Medicine, Makerere University Kampala. OBJECTIVE: To describe the steps taken to change and implement the new curriculum at the Faculty of Medicine. METHODS: The stages taken during the process were described and analysed. RESULTS: The following stages were recognized characterization of Uganda's health status, analysis of government policy, analysis of old curriculum, needs assessment, adoption of new model (SPICES), workshop/retreats for faculty sensitization, incremental development of programs by faculty, implementation of new curriculum. CONCLUSION: The FOM has successfully embarked on curriculum change. This has not been without challenges. However, challenges have been taken on and handled as they arose and this has led to the implementation of new curriculum. Problem based learning can be adopted even in a low resourced country like Uganda.

Adult↗

Bovine mastitis: an evolving disease.

Mastitis remains a major challenge to the worldwide dairy industry despite the widespread implementation of mastitis control strategies. The last forty years have seen a dramatic decrease in clinical mastitis incidence but this has been accompanied by a change in the relative and absolute importance of different pathogens. Escherichia coli and Streptococcus uberis are now the two most common causes of bovine mastitis and are an increasing problem in low somatic cell count herds. This paper reviews the changes in incidence and pattern of mastitis in the UK over the last four decades and discusses some of the possible explanations for these changes. It focuses in particular on apparent changes in the behaviour of E. coli and its ability to cause persistent intramammary infection; which may be as a result of bacterial adaptation or the unmasking of previously unrecognized patterns of pathogenesis. The prospects for novel approaches to mastitis control are discussed, as are the current and future challenges facing the industry.

Animal Husbandry↗

A framework of strategies for client-centred practice.

BACKGROUND: Implementing strategies to overcome barriers to client-centred practice is a challenge encountered by many occupational therapists in their daily practice. The Client-centred Strategies Framework is proposed as a tool to assist occupational therapists to consider barriers and implement strategies from a variety of perspectives. DESCRIPTION: The framework consists of five categories: personal reflection, client-centred processes, practice settings, community organizing, and coalition advocacy and political action. Within each category are a number of actions that can be taken to facilitate client-centred practice. This paper describes the framework with elaboration of each of the five categories. A case example is used to illustrate how a therapist can use the framework to address client-centred practice issues. PRACTICE IMPLICATIONS: This framework will assist therapists and students to problem-solve ways to enhance the use of client-centred processes within their own practice environments.

Communication↗

[Implementation of laparoscopic rectal cancer surgery].

INTRODUCTION: The integration of laparoscopic surgery for rectal cancer in clinical practice is one of the challenges faced by surgical societies. The aim of the present study was to analyze the results obtained during the implementation phase of this technique. PATIENTS AND METHOD: From January 2003 to June 2005, 40 patients with rectal carcinoma underwent laparoscopic surgery in our center. Clinical and pathological variables were prospectively collected for statistical analyses. RESULTS: A total of 27 men and 13 women underwent surgery: 11 high (HAR) and 20 low anterior resections (LAR) and 9 abdominoperineal resections (APR) were performed. Operative time was 240.4 +/- 200 min and was greater in the LAR group (259.7 vs 201.5 min; p=.02). The intraoperative complication rate was 22.5% (9% HAR vs 25% LAR; p=NS). The mean length of hospital stay was 8.7 +/- 4.8 days. The rate of postoperative complications was 32.5%. The conversion rate was 15% (6 patients), and was greater in the LAR group (25% vs 0% HAR vs 11.1% APR; p=0.02). The most common intraoperative complication and the most frequent cause of conversion consisted of stapling problems (4 patients). Surgery was considered curative in 34 patients (85%). One case of positive radial margins was encountered (3.3%). The mean distal and radial margins were 3.6 +/- 2.7 cm and 1.1 +/- 0.9 cm respectively. CONCLUSIONS: The overall results during the implementation stage of laparoscopic surgery for rectal surgery were satisfactory. Conversion rates were highest in LAR, which proved to be the most demanding procedure.

Aged↗

How to evaluate and implement new technologies in an era of managed care and cost containment.

New technologies often enable clinical laboratorians to overcome the challenges we face. These technologies sometimes become available with amazing punctuality, addressing recent problems and keeping the physician-customer satisfied for another day. Traditionally, developments such as a new cancer marker have been implemented into routine use with little circumspection because the benefits diagnostically and financially were perceived to far outweigh the risk that the new test or technology was not as effective as described. The notion of subsequently removing older tests inferior to the new one has hardly been considered. The challenges confronting clinical laboratorians today, however, are affecting that typical pattern dramatically. Four of the most pervasive challenges are comprehensively examined in the 1995 Clinical Chemistry Forum. One of these key areas--the proper implementation of modern technology in the form of new tests or new approaches to producing clinical laboratory results--is the main topic of this review.

Chemistry, Clinical↗

Accounting and reimbursement schemes for inpatient care in France.

The new French case-mix system of hospital payment was adopted in 2004 for public hospitals and in March 2005 for private-for-profit hospitals. Implementing this reform requires a period of transition but the challenges ahead can already be predicted. Prices will have to change before this mode of reimbursement can have any real impact. This requires producing more detailed hospital cost data and using fine measuring tools such as the cost accounting method developed for use in this context. This article describes and analyses the main tools and methods selected to implement the new French prospective payment system.

Accounting↗

Knowledge and skill acquisition for critical care nursing practice.

In many critical care units, extended orientation or education programs have been offered to prepare the registered nurse to work in this specialty area. Current shortages of nurses and less experienced nurses applying for critical care positions have augmented the need for educational programs. In the Edmonton region, a partnership between two public institutions led to the development and implementation of an innovative educational program. In this article, we describe challenges and strategies to prepare critical care nurses to integrate knowledge, and meet the standards and expectations of both partners. In particular, methods are described to achieve theoretical and clinical outcomes. This article contributes to the discussion and implementation to offer knowledge and skill acquisition for a novice critical care nurse.

Clinical Competence↗

[Evidence-based guidelines in nephrology].

INTRODUCTION: The preparation of evidence-based guidelines by the Nephrology Societies is fundamental to improve long-term outcomes of patients with chronic kidney diseases. However, this is a complex process and requires the interaction of clinicians and experts in epidemiology methods, and researchers and research enterprises. METHODS: In this review, we present the potential structure of a body for the coordination and development of evidence-based guidelines in a nephrology society and we address the major problems that can arise in this process describing strategies that could be used to overcome them. RESULTS: The development of evidence-based nephrology guidelines requires a structure; this should consist of a coordinating center and a number of working groups. The working groups is to identify specific research questions and to develop and synthetize the evidence in answer to the questions proposed. This shall be done in collaboration with the coordinating center. Draft guidelines produced by this process should be peer reviewed, disseminated and implemented. CONCLUSIONS: The development of evidence-based nephrology guidelines is a challenge for individual nephrology societies. These guidelines are different from typical research publications in that their success does not lie in the final publication, but in the actual dissemination and implementation, which is in the improvement of patient outcomes and its measurement.

Evidence-Based Medicine↗

Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital.

Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.

Aged↗

Are we implementing community health promotion in nursing?

Promoting the health of communities has been the rallying cry (now renewed) from the nation's top public health officials. Public health nurses have always stressed community health promotion, not only in their work but also in the educating of future public health nurses. Facilitating the shift from focusing primarily upon secondary and tertiary prevention, individual, and disease-oriented processes is a constant challenge, given the current health care and reimbursement systems. The objectives of this paper are: to give a brief historical review of the nation's health objectives, other recent pertinent documents, and early public health nursing's emphases regarding community health promotion; to give a selected overview of recent community health promotion programs implemented by community and public health nurses in nursing education and practice; and to focus on present challenges to nursing in implementing community health promotion.

Community Health Planning↗

Impact of duty hour limits on resident training in otolaryngology.

HYPOTHESIS: Implementation of Accreditation Council for Graduate Medical Education (ACGME) duty hour standards has had limited effects on resident training in otolaryngology. STUDY DESIGN: Retrospective survey of residents and residency program directors (PDs). METHODS: Surveys were mailed to residents and PDs in otolaryngology asking about compliance with ACGME duty hour standards and perceptions of changes brought on by the new regulations. RESULTS: : Surveys were returned by 53.5% of PDs and 29.9% of residents. A majority of PDs described changes made to achieve compliance as "minor;" this consisted most commonly of altering call structure, although some programs hired new support staff or faculty. Mean estimated costs for changes were $14,211. Residents reported working a mean of 67.5 hours per week. Among PDs and residents, only 60% to 70% reported always being in compliance with the main components of the duty hour standards. Residents were largely divided in their opinions as to whether the duty hour limits had led to improvements in patient care, resident education, fatigue, or errors, although most felt that improvement in resident morale had occurred. PDs were more negative because almost half disagreed that improvement had occurred in any of these areas. CONCLUSIONS: Compliance with ACGME duty hour standards remains challenging in otolaryngology. Neither residents nor PDs agree that implementation of the duty hour standards has led to the intended improvements in patient care or resident education, although most agree that resident morale has improved. Further study of objective patient care and educational outcome measures is indicated to validate the need for this change in residency training.

Accreditation↗

Schistosomiasis: challenges for control, treatment and drug resistance.

PURPOSE OF REVIEW: Schistosomiasis is a parasitic disease that has recently attracted increased focus and funding for control. Despite shifts in global health policy towards the implementation of mass chemotherapeutic control programmes at the national scale in sub-Saharan Africa, however, many challenges still exist. RECENT FINDINGS: Publications reviewed for this article cover: the development of treatment strategies; the planning, implementation and impact of control programmes; the re-evaluation of the burden of schistosomiasis; improved tools for control; new drugs; the safety of treatment during pregnancy; and the development of resistance against praziquantel. SUMMARY: The morbidity due to schistosomiasis has been shown to be greater than was previously thought. The reduction in morbidity of schistosomiasis by control programmes has been demonstrated, while new tools include a validated dose pole for delivering the correct treatment, geographical information systems mapping for determining high-risk areas, and Lot Quality Assurance Sampling for determining treatment strategies at the local level. Sustainability and future funding are issues to be addressed. Despite some positive results, myrrh is apparently ineffective against schistosomiasis, but fortunately no resistance to praziquantel has developed. We predict the impact of schistosomiasis control will be a healthier generation of children within 5 years.

Adult↗

Automatic analysis of hand radiographs for the assessment of skeletal age: a subsymbolic approach.

The assessment of skeletal maturity is crucial for the analysis of growth disorders and plays an important role in paediatrics. For this reason, several methods have been developed for estimating skeletal maturity. Among them, the Tanner and Whitehouse method (TW2), which is based on the analysis of hand radiographs, is usually considered the most accurate and reliable. Nevertheless, TW2 is applied only in a small fraction of cases, due to its complexity and long examination times. Thus, the development of automated systems which reliably implement this method is highly desirable. However, major difficulties have been found in the development of computer-based systems for the assessment of skeletal maturity. In particular the extraction of the bones of interest has proved to be extremely challenging. In this paper, we propose a system architecture for the implementation of the TW2 method, which is based on artificial neural networks. For each bone considered, the maturation stage is determined by means of a two-step process which first locates the position of the bone in the radiograph and then analyzes the bone shape. Experimental results obtained with our implementation of the carpal version of TW2 are in good agreement with those provided by trained observers.

Adolescent↗

Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry.

OBJECTIVE: The implementation of evidence-based practice poses a significant challenge in the intensive care unit. In this quality improvement intervention we assessed the effect of an institutional protocol and computerized decision support for red cell transfusion in the critically ill. DESIGN: We compared processes of care and outcomes during the two 3-month periods before and after the introduction of a multidisciplinary quality improvement intervention. SETTING: Multidisciplinary intensive care units--medical, surgical, and mixed--in a tertiary academic center. PATIENTS: Consecutive critically ill patients with anemia (hemoglobin of <10 g/dL). INTERVENTION: Using the computerized provider order entry, we developed an evidence-based decision algorithm for red cell transfusion in adult intensive care units. MEASUREMENTS AND MAIN RESULTS: We collected information on demographics, diagnosis, severity of illness, transfusion complications, and laboratory values. The main outcome measures were number of transfusions, proportion of patients who were transfused outside evidence-based indications, transfusion complications, and adjusted hospital mortality. The mean number of red cell transfusions per intensive care unit admission decreased from 1.08 +/- 2.3 units before to 0.86 +/- 2.3 units after the protocol (p<.001). We observed a marked decrease in the percentage of patients receiving inappropriate transfusions (17.7% vs. 4.5%, p< .001). The rate of transfusion complications was also lower in the period after the protocol (6.1% vs. 2.7%, p = .015). In the multivariate analysis, protocol introduction was associated with decreased likelihood of red cell transfusion (odds ratio, 0.43; 95% confidence interval, 0.30 to 0.62). Adjusted hospital mortality did not differ before and after protocol implementation (odds ratio, 1.12; 95% confidence interval, 0.69 to 1.8). CONCLUSIONS: The implementation of an institutional protocol and decision support through a computerized provider order entry effectively decreased inappropriate red cell transfusions.

Algorithms↗

Beyond screening for domestic violence: a systems model approach in a managed care setting.

BACKGROUND: Implementation of screening guidelines for domestic violence has been challenging. The multifaceted "systems model" may provide an effective means to improve domestic violence screening, identification, and intervention in the healthcare setting. METHODS: We developed: (1) a systems model approach using tools for effective referral, evaluation, and reporting of domestic violence; (2) materials for distribution to female patients; (3) training for social service and mental health clinicians to provide domestic violence evaluation; and (4) strong links to the community. SETTING: A nonprofit, managed care facility in Richmond, California. PARTICIPANTS: Staff and members of the managed care plan. MAIN OUTCOME MEASURES: (1) Increased screening for domestic violence by clinicians; (2) increased awareness of the healthcare facility as a resource for domestic violence assistance; and (3) increased member satisfaction with the health plan's efforts to address domestic violence. RESULTS: The number of clinician referrals and patient self-referrals to an on-site domestic violence evaluator increased more than twofold. A pre-intervention and post-intervention phone survey of members seen for routine checkup showed an increase in member recall of being asked about domestic violence. After intervention, statistically significant increases were seen in members' perception that the health plan was concerned about the health effects of domestic violence (p<0.0001) and about members' satisfaction with the health plan's efforts to address this issue (p<0.0001). CONCLUSIONS: A systems model approach improved domestic violence services in a managed care health setting within 1 year and affected clinicians' behavior as well as health plan members' experience. This successful implementation makes it possible to address critical research questions about the impact of a healthcare intervention for victims of domestic violence in a managed healthcare setting.

Adolescent↗

Leptospirosis in "Eco-Challenge" athletes, Malaysian Borneo, 2000.

Adventure travel is becoming more popular, increasing the likelihood of contact with unusual pathogens. We investigated an outbreak of leptospirosis in "Eco-Challenge" multisport race athletes to determine illness etiology and implement public health measures. Of 304 athletes, we contacted 189 (62%) from the United States and 26 other countries. Eighty (42%) athletes met our case definition. Twenty-nine (36%) case-patients were hospitalized; none died. Logistic regression showed swimming in the Segama River (relative risk [RR]=2.0; 95% confidence interval [CI]=1.3 to 3.1) to be an independent risk factor. Twenty-six (68%) of 38 case-patients tested positive for leptospiral antibodies. Taking doxycycline before or during the race was protective (RR=0.4, 95% CI=0.2 to 1.2) for the 20 athletes who reported using it. Increased adventure travel may lead to more frequent exposure to leptospires, and preexposure chemoprophylaxis for leptospirosis (200 mg oral doxycycline/week) may decrease illness risk. Efforts are needed to inform adventure travel participants of unique infections such as leptospirosis.

Adult↗

The implementation of a harm minimisation model for the identification and treatment of over-the-counter drug misuse and abuse in community pharmacies in Northern Ireland.

OBJECTIVE: This study tested an intervention model which sought to minimise over-the-counter (OTC) drug misuse and abuse in community pharmacies. METHOD: Pharmacists in six community pharmacies in the Greater Belfast area volunteered to participate in the study. The intervention model consisted of client identification and recruitment, treatment and referrals, and finally follow-up data collection and outcome measurements. All pharmacists participated in semi-structured interviews to explore their views and experiences of the study. RESULTS: Pharmacists identified 196 cases of suspected abuse/misuse. Pharmacists approached 70 of the identified clients during the six-month study; some clients agreed to stop using the product of abuse/misuse, used an alternative, or had been switched to a maintenance prescription under general practitioner (GP) supervision. No client proceeded to completion of the follow-up phase (e.g. health-related quality of life). Analysis of the interviews revealed that pharmacists had encountered some difficulties in approaching potential clients, but had used skills gained in the study in other aspects of their practice. CONCLUSIONS: Some difficulties were encountered in implementing the harm minimisation model, but these may be alleviated by further training and greater collaborative working. PRACTICE IMPLICATIONS: Notwithstanding the challenges faced in the study, this approach to harm minimisation should be considered for wider implementation in community pharmacy.

Adult↗