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RNA synthetic biology.

RNA molecules play important and diverse regulatory roles in the cell by virtue of their interaction with other nucleic acids, proteins and small molecules. Inspired by this natural versatility, researchers have engineered RNA molecules with new biological functions. In the last two years efforts in synthetic biology have produced novel, synthetic RNA components capable of regulating gene expression in vivo largely in bacteria and yeast, setting the stage for scalable and programmable cellular behavior. Immediate challenges for this emerging field include determining how computational and directed-evolution techniques can be implemented to increase the complexity of engineered RNA systems, as well as determining how such systems can be broadly extended to mammalian systems. Further challenges include designing RNA molecules to be sensors of intracellular and environmental stimuli, probes to explore the behavior of biological networks and components of engineered cellular control systems.

Computational Biology↗

Malaria in Sucre State, Venezuela.

The author reviews the malaria research program in Sucre State, Venezuela, taking an ecosystem approach. The goal was to determine which methods could have been introduced at the onset that would have made the study more ecological and interdisciplinary. Neither an ecosystem approach nor integrated disease control were in place at the time of the study. This study began to introduce an ecosystem approach when two contrasting ecosystems in Sucre State were selected for study and vector control methods were implemented based on research results. The need to have a health policy in place with an eco-health approach is crucial to the success of research and control. The review suggests that sustainability is low when not all the stakeholders are involved in the design and implementation of the research and control strategy development. The lack of community involvement makes sustainability doubtful. The author concludes that there were two interdependent challenges for malaria control: development of an ecosystem approach for malaria research and control, and the implementation of an integrated disease control strategy, with malaria as one of the important health issues.

Animals↗

Facing the challenge of a changing system: training child welfare workers in a privatized environment.

The state of Kansas' implementation of a privatized child welfare system is arguably an ambitious shift in child welfare service delivery. In an attempt to drastically improve services to vulnerable families, privatization resulted in intended and unintended consequences for the child welfare workforce. Some of these consequences, including the influx of inexperienced new workers, high worker turnover, and managing relationships with multiple partners, are issues that affect training needs of child welfare professionals. The following paper offers one approach to addressing these needs as well as identifying the challenges involved in training in a privatized environment.

Child↗

A prehabilitation program for physically frail community-living older persons.

OBJECTIVES: To describe the development and implementation of a preventive, home-based physical therapy program (PREHAB) and to provide evidence for the safety and interrater reliability of the PREHAB protocol. DESIGN: Demonstration study. SETTING: General community. PARTICIPANTS: Ninety-four physically frail, community-living persons, aged 75 years or older, who were randomized to the PREHAB program in a clinical trial. INTERVENTIONS: The PREHAB program built on the physical therapy component of 2 previous home-based protocols. A total of 223 assessment items were linked to 28 possible interventions, including progressive balance and conditioning exercises, by using detailed algorithms and decisions rules that were automated on notebook computers. MAIN OUTCOMES MEASURES: The percentages of participants who were eligible for and who completed each intervention, the extent of progress noted in the balance and conditioning exercises, adherence to the training program, and adverse events. RESULTS: Participants who completed the PREHAB program and those who ended it prematurely received an average of 9.7 and 7.2 interventions during an average of 14.9 and 9.5 home visits, respectively. With few exceptions, the completion rate and interrater reliability for the specific interventions were high. Despite high self-reported adherence to the training program, the majority of participants did not advance beyond the initial Thera-Band level for the upper- and lower-extremity conditioning exercises, and only about a third advanced to the highest 2 levels of the balance exercises. Adverse events were no more common in the PREHAB group than in the educational control group. CONCLUSION: Our results support the feasibility and safety of the PREHAB program, but also show the special challenges and pitfalls of such a strategy when it is implemented among persons of advanced age and physical frailty.

Aged↗

Sample preparation: quo vadis?

The sample preparation step in an analytical process typically consists of an extraction procedure that results in the isolation and enrichment of components of interest from a sample matrix. Extraction can vary in degree of selectivity, speed, and convenience and depends not only on the approach and conditions used but on the geometric configurations of the extraction phase. Increased interest in sample preparation research has been generated by the introduction of nontraditional extraction technologies. These technologies address the need for reduction of solvent use, automation, and miniaturization and ultimately lead to on-site in situ and in vivo implementation. These extraction approaches are frequently easier to operate but provide optimization challenges. More fundamental knowledge is required by an analytical chemist not only about equilibrium conditions but, more importantly, about the kinetics of mass transfer in the extraction systems. Optimization of this extraction process enhances overall analysis. Proper design of the extraction devices and procedures facilitates convenient on-site implementation, integration with sampling, and separation/quantification, automation, or both. The key to rational choice, optimization, and design is an understanding of the fundamental principles governing mass transfer of analytes in multiphase systems. The objective of this perspective is to summarize the fundamental aspects of sample preparation and anticipate future developments and research needs.

Journal Article↗

Budget development and implementation for the APN in independent practice.

Advanced practice nurses have a unique opportunity to meet the health needs in our communities. Although laden with barriers and challenges, independent practice is a viable option for advanced practice nurses. This article reviews the critical steps to developing and implementing a budget and operational plan for a successful independent nursing practice.

Budgets↗

Polio eradication--global initiative; strategy challenged in Kerala, India.

The 'polio eradication initiative' launched by the World Health Assembly in 1988, although successfully implemented in several countries, could not achieve the goal of global eradication by the year 2000. It has components on strengthening routine immunization system, observance of National Immunization Days (NIDs) and strengthening of surveillance for Acute Flaccid Paralysis (AFP). Recently, this strategy was challenged in Kerala, India. Kerala has excellent health indicators compared with other Indian states. In 1999, Intensified Pulse Polio Immunization (IPPI) was introduced with four NIDs throughout India. More than 2000 doctors working under the Kerala Government challenged the strategy, demanding its redesign. Zero prevalence of polio for 2 years, near-complete coverage of children by the routine system, probable business interests of vaccine manufactures and suppliers, dubious interests of officials, and weakening of the routine system by concentrating more on NIDs were all cited as reasons for discontinuing current strategy. The authorities, citing the success stories of polio eradication by the global initiative in several countries, discard the allegations as baseless. They alleged that the medical officers who were on strike demanding higher pay and better conditions were using the 'polio issue' to win their strike. The incidence of two polio cases in Malappuram in northern Kerala during September 2000 has further complicated the issue. As the controversy continues it is felt that the 'eradication initiative' will have to be revisited.

Child, Preschool↗

Evidence-based health practice: knowing and using what works for older adults.

Community-based health care agencies are facing demands for improved outcomes, cost-effective programming, and higher customer satisfaction. Implementing evidence-based health interventions and programs can help to address these challenges. This article provides an overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. The article concludes with a list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs.

Aged↗

Implementing Mutational Epidemiology on a Global Scale: Lessons from Mutographs.

The Mutographs Cancer Grand Challenge team aimed to discover unknown causes of cancer through mutational epidemiology, an alliance of cancer epidemiology and somatic genomics. By generating whole-genome sequences from thousands of cancers and normal tissues from more than 30 countries on five continents, it discovered unsuspected mutagenic exposures affecting millions of people, raised the possibility that some carcinogens act by altering forces of selection in tissue microenvironments rather than by mutagenesis, and demonstrated changes to the direction of somatic evolution in normal cells of the human body in response to exogenous exposures and noncancer diseases. See related article by Bressan et al., p. 16 See related article by Bhattacharjee et al., p. 28 See related article by Goodwin et al., p. 34.

Humans↗

Implementing an empowerment-based diabetes self-management education program.

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants' questions and concerns. Culturally tailored written educational materials were also provided.

Diabetes Mellitus↗

New group formation and mergers. The qualification and implementation process.

Group practice formation and mergers can open a new--and sometimes very challenging--opportunity for the uninitiated, writes Robert Bohlmann, FACMGA. This article reviews the necessary steps for a successful merger or formation of a new group based on the collective experience of MGMA's Management Consulting team.

Group Practice↗

[End phase challenges of poliomyelitis eradication programme realization].

The progress of poliomyelitis eradication programme realization, the implementation schedule and strategies for the future, are summarised based on publications of the World Health Organisation. During the following two years wild poliovirus strains should be globally eradicated. This means that potentially in 2010 the global eradication of wild polioviruses will be certified. To eradicate poliomyelitis, cessation of the oral polio vaccine (OPV) is necessary, since the vaccine strains produce cases of vaccine-associated paralytic poliomyelitis (VAPP) and cases of poliomyelitis caused by circulating vaccine-derived poliovirus (cVDPV). However, the WHO plan to stop immunization with OPV and the immunization with inactivated polio vaccine (IPV) shortly after, is alarming in the present situation. The article describes the measures undertaken to prevent or minimise the risk of reintroduction of wild poliovirus strains, which is potentially associated with WHO plan of action.

Disease Outbreaks↗

Diabetes translation research: where are we and where do we want to be?

Translation research transforms currently available knowledge into useful measures for everyday clinical and public health practice. We review the progress in diabetes translation research and identify future challenges and opportunities in this field. Several promising interventions to optimize implementation of efficacious diabetes treatments are available. Many of these interventions, singly or in combination, need to be more formally tested in larger randomized or quasi-experimental practical trials using outcomes of special interest to patients (for example, patient satisfaction and quality of life) and policymakers (for example, cost and cost-effectiveness). The long-term outcomes (such as morbidity, mortality, quality of life, and costs) of strategies aimed at improving diabetes care must be assessed. Translation research also needs to incorporate ways of studying complex systems of care. The challenges and opportunities offered by translation research are tremendous.

Biomedical Research↗

The nurse shortage. A home care agency perspective.

Certified home care agencies are challenged to meet an increasing demand for services while faced with a predicted severe nursing shortage. Meeting this demand will depend on an agency's ability to recruit and retain a qualified nursing staff. Knowledge of the extent of the nursing shortage, along with information of administrators' perceptions of the problem and activities they have implemented to alleviate a shortage will provide information to meet this new challenge.

Centers for Medicare and Medicaid Services, U.S.↗

Prejudice, paradox, and possibility: nursing people from cultures other than one's own.

Nurses in New Zealand are being challenged to recognise and address racism in their practice. Yet, the implementation of cultural safety in nursing education has created tension within the profession and between nursing and the wider community. This article provides a brief overview of the findings of a hermeneutic study that explored the experience of nursing people from cultures other than one's own. The notions prejudice, paradox, and possibility are argued to describe this phenomenon. As nurses negotiate the conflicts essential for ongoing development of their practice, the play of prejudice, paradox, and possibility is evident at intrapersonal and interpersonal levels as well as in relation to professional and other discourses. Nurses are challenged to continue their efforts to understand and move beyond the prejudices that otherwise preclude the exploration of new possibilities.

Cultural Diversity↗

Challenges of outcomes research for nurse practitioners.

PURPOSE: To describe the numerous methodological challenges nurse practitioners (NPs) face in designing and conducting outcomes research and provide practical tips to implement an outcomes study within an institution. DATA SOURCES: Review of world wide scientific literature on outcomes research. CONCLUSIONS: Nurse practitioners must be aware of the challenges of conducting outcomes research. Challenges associated with variable definition, designing outcomes studies, use of data sets, and instrument development and selection must be understood prior to undertaking an outcome study. IMPLICATIONS FOR PRACTICE: Valuable studies have laid a foundation for evidence of quality care provision by NPs. Now is the time to measure patient outcomes of the NP care longitudinally over significant periods of time.

Humans↗

Telemedicine and the academic health center: the University of Michigan health system model.

The changing health care environment is generating a number of challenges for Academic Health Centers' (AHC) ability to pursue their traditional tripartite mission of medical care, education, and research. A number of strategies have been suggested to aid the AHC to respond, among them telemedicine. In this paper, telemedicine is examined for its potential to assist in meeting financial, cost, and quality challenges. In particular, the model developed at the University of Michigan Health System for implementing telemedicine within the AHC is presented together with lessons learned. This model, based largely on intramural rather than extramural funding, is offered as a basic strategy to be considered by AHCs facing these challenges.

Academic Medical Centers↗

Evaluating and managing attention deficit disorder in children who are deaf or hard of hearing.

Effective management of children who are deaf or hard of hearing and faced with the added challenge of Attention Deficit Disorder requires a comprehensive and coordinated spectrum of services. A complex array of underlying or associated factors can mimic, cause, or exaggerate the symptoms. Careful diagnosis is thus essential and is the prerequisite for developing effective intervention. In this article, we present a practical approach to the problem, based on experience with a model treatment program at a residential school for the deaf. Suggestions are provided regarding the diagnostic work-up of children presenting with attention problems. Management approaches are discussed for the classroom, home, and residential area as well as specialized therapeutic intervention and the use of medication. A model for implementing a treatment program in a school is presented, and future challenges are discussed.

Achievement↗