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PubMed1991

The epidemiology of HTLV-I infection.

It has been 10 years since the discovery of the human T-cell lymphotropic virus type I (HTLV-I), the first human retrovirus. During the past decade, significant progress has been made in understanding the transmission of the virus and defining its geographic distribution. It has been shown conclusively that HTLV-I is a causal factor in the induction of both adult T-cell leukemia/lymphoma and HTLV-I-associated myelopathy. However, the pathogenesis of each of these conditions is not clear, and in the light of the evidence of immune dysfunction seen among carriers of the infection, it is likely that other associated diseases will be identified. The challenge in the next decade will be to develop and implement therapeutic interventions among carriers to prevent such diseases as well as to curtail transmission within endemic populations.

HTLV-I Infections↗

PubMedDate not supplied

[National Research Program on the prevention of cardiovascular diseases: plan of study].

The main objectives of the Swiss National Research Program on primary prevention of cardiovascular diseases are: 1) the reduction of known cardiovascular risk factors among the local populations of two intervention Communities compared to two "regular care" communities and 2) the provision of tested cost-effective methods for nation-wide use in the future control of CVD. The main focus during both the screening and the three years intervention phase will be on the total mobilization of community resources to induce behavior change (active participation of the population as well as the local health and social services system both in planning and implementation). A program such as this has to meet the challenge of developing a design that combines the needs for rigorous evaluation with a maximal amount of flexibility regarding the results of local initiative and involvement.

Cardiovascular Diseases↗

PubMed2002

Does health technology assessment benefit health services and politics? The experiences of an established HTA institution: the Danish Centre for Evaluation and HTA.

Health technology assessment (HTA) was introduced in Denmark 20 years ago. However, it only came into fashion a few years ago. This happened when politicians and health service decision-makers realized that due to the increasing pressure on resources prioritization was an inescapable fact. HTA was supposed to support this effort by providing a broad spectrum of information designed for decision-making. Events speeded up from that point on: a national HTA strategy, a national HTA institution, satellite institutions, and many HTA projects were set up - at national, regional, and local levels. The diversity and decentralization of decision-making combined with a broad and interdisciplinary approach to methodology guided the development of Danish HTA. Experiences with HTA were gained from successful applications and disappointing encounters with uncontrollable political processes. Politicians seem in general to be content with the development. An evaluation of the impact of HTA has not yet been undertaken, and a good deal of work lies ahead. The implementation of HTA results will be one of the greatest challenges of the years ahead.

Journal Article↗

PubMedDate not supplied

A comparison of midazolam, diazepam, and placebo as oral anesthetic premedicants in younger children.

STUDY OBJECTIVES: To validate the superiority of higher-dose oral midazolam as an anesthetic premedicant in children 6 years of age and younger, to determine whether less expensive diazepam is a viable alternative oral premedicant in this age-group, and to assess the preoperative oxygenation effects of both benzodiazepines. DESIGN: A prospective, randomized, double-blind study. SETTING: Outpatient surgery department and operating room (OR) of a freestanding children's hospital. PATIENTS: Seventy-five ASA physical status I and II outpatients 1 to 6 years of age. INTERVENTIONS: Patients were randomized to receive either midazolam 0.6 mg/kg, diazepam 0.3 mg/kg, or a placebo orally in a timely manner prior to surgery. MEASUREMENTS AND MAIN RESULTS: Each child's subsequent reaction to separation from his or her parents in the presurgical holding area was scored on a three-point behavioral scale. Once in the OR, an initial room air oxygen saturation by pulse oximeter (SpO2) was obtained. Each child's initial acceptance of the anesthetic induction mask was then scored on a four-point scale. No significant differences in parental separation scores, initial room air SpO2, or postanesthesia care unit admission time were observed among the three study groups. However, both midazolam and diazepam were observed to be superior to the placebo in facilitating the initial acceptance of the anesthetic induction mask. CONCLUSIONS: Even without premedication, a majority of children did not react negatively to an impending anesthetic. Therefore, neither midazolam nor diazepam appears to be necessary in most children younger than 6 years of age. Rather than implementing the routine use of an oral preoperative sedative, the challenge appears to be the selective identification of those children at risk for preanesthetic difficulties and psychological trauma.

Administration, Oral↗

PubMed2005

Essential newborn care training activities: 8 years of experience in Eastern European, Caucasian and Central Asian countries.

There is still an alarming gap in neonatal healthcare and outcome between Western and Eastern European countries and the former USSR countries in particular. Most of the causes of neonatal mortality and morbidity can be prevented or managed by simple cost-effective interventions aimed at improving quality of healthcare, health system organisation and family and community participation. Training of health professionals and health policy-makers in the field of essential neonatal care and breastfeeding promotion is one of the cornerstones of the World Health Organization (WHO) initiatives Making Pregnancy Safer (MPS) and Promoting Effective Perinatal Care (PEPC) - the latter specifically tailored to the European Region - aimed at ensuring safe pregnancy and childbirth through ensuring the availability, access and use of quality skilled care. After 8 years of experience of training in essential neonatal care, positive changes in planning for and delivering neonatal care are taking place, even in challenging contexts, and this model of intervention should be further implemented in the region.

Asia, Central↗

PubMed2006

Bone micro-damage assessment using non-linear resonant ultrasound spectroscopy (NRUS) techniques: a feasibility study.

Non-linear resonant ultrasound spectroscopy (NRUS) is a technique exploiting the significant non-linear behavior of damaged materials, related to the presence of damage. This study shows for the first time the feasibility of this technique for damage assessment in bone. Two samples of bovine cortical bone were subjected to a progressive damage experiment. Damage accumulation was progressively induced in the samples by mechanical testing. For independent assessment of damage, X-ray CT imaging was performed at each damage step, but only helped in the detection of the prominent cracks. Synchrotron micro-CT imaging and histology using epifluorescence microscopy were performed in one of the two samples at the last damage step and allowed detection of micro-cracks for this step. As the quantity of damage accumulation increased, NRUS revealed a corresponding increase in the non-linear response. The measured change in non-linear response is much more sensitive than the change in elastic modulus. The results suggest that NRUS could be a potential tool for micro-damage assessment in bone. Further work has to be carried out for a better understanding of the physical nature of damaged bone, and for the ultimate goal of in vivo implementation of the technique where bone access will be a challenging problem.

Algorithms↗

PubMed2003

Digital imaging overview.

Digital imaging consists of digital acquisition modalities, image, and information management systems. All modalities are available to be purchased as digital acquisition devices. Image management has been the domain for PACSs. PACSs are complex systems designed to transmit, store, and display medical images. They use and rely on many types of different information and display technologies. The initial focus for PACSs has been on solving the engineering issues associated with the transfer of large image data sets and the suitability of softcopy displays for diagnosis particular to the human visual system. For operating within a centralized radiology department, these are largely solved. However, for enterprise wide dissemination and distribution, there are still challenges in the form of expedient transfer syntaxes and image quality, but these are also being effectively addressed. Information management is the domain of the RIS. One of the goals of radiology management should encompass the development of a robust practice environment that emphasizes workflow enhancements with seamless integration of decision support tools. The concept of "person-machine" systems emphasizes taking full advantage of both human and machine capabilities with a capacity to grow and change function. As the computer capabilities increase, more jobs can be relinquished to the machine. The physician can then focus on tasks that require more complex judgment and comprehension. The goal of this human-machine hybrid is to have more power than either of its components alone. This multifaceted role will most likely be embedded in the background having agents query and retrieve context specific information to be presented to the user. As augmenters of human talent, computers can turn data into information and information into knowledge. Medical imaging is a beneficiary of the information technology developments driven by the consumer and business sectors. Although these applications of information technologies are not a solution to every problem, it certainly can bring the radiology department much closer to the desired ideal operational model. Even though there are many challenges to overcome, the benefits derived from a successful RIS/PACS implementation can be instrumental toward achieving a level of excellence in clinical service, teaching, and research that is unrivaled. Strategies for change management and quality improvement should begin by considering the entire chain of events from image acquisition through display to communication of a report.

Computer Communication Networks↗

PubMed1993

Ensuring excellence: reconceptualizing quality assurance, risk management, and utilization review.

A new conceptualization of the related activities QA, RM, and UR may allow an organization to ensure appropriate, proficient, and satisfactory care and to ameliorate the consequences of bad outcomes. Three processes incorporated into the conceptualization are essential to ensuring excellence, as are specific attributes of the care process. The difference in initiation of activities (reactive versus proactive) is part of the model; relationships among the essential activities and processes and between reactive and proactive activities are suggested; and viewing data sources or collection as separate from the processes and activities is suggested. Areas for development and research within the conceptualization that are inadequately understood include data sources and analysis methods useful for the processes needed, evaluation of the consequences of different reactive activities, and the usefulness of TQI activities for setting goals or standards and for changing behavior. Implementing such an approach to ensuring excellence would be a challenge. It is hoped that this formulation will assist in communication among those working to ensure excellence; promote analysis of whether current organizational structures for ensuring excellence and for cost containment are creating redundance, competition, or gaps in needed activities; broaden the perception of the possible and/or appropriate scope of some activities, such as the inclusion of proactive preventive care and the provision of special high-risk programs; and assist in the identification of areas of needed research and development.

Health Services Research↗

PubMed2001

Changing face of medical curricula.

The changing role of medicine in society and the growing expectations patients have of their doctors means that the content and delivery of medical curricula also have to change. The focus of health care has shifted from episodic care of individuals in hospitals to promotion of health in the community, and from paternalism and anecdotal care to negotiated management based on evidence of effectiveness and safety. Medical training is becoming more student centred, with an emphasis on active learning rather than on the passive acquisition of knowledge, and on the assessment of clinical competence rather than on the ability to retain and recall unrelated facts. Rigid educational programmes are giving way to more adaptable and flexible ones, in which student feedback and patient participation have increasingly important roles. The implementation of sustained innovation in medical education continues to present challenges, especially in terms of providing institutional and individual incentives. However, a continuously evolving, high quality medical education system is needed to assure the continued delivery of high quality medicine.

Curriculum↗

PubMed2002

Access to antiretroviral drugs in Brazil.

Since 1996, the Brazilian Ministry of Health has guaranteed free and universal access to antiretroviral treatment for people living with HIV/AIDS. Implementation of this policy has had political, financial, and logistical challenges. I have investigated the history and context of antiretroviral policy in Brazil, the logistics of the drugs' distribution, and the government's strategies for acquisition of the drugs. Many antiretrovirals used in Brazil are produced domestically; the remainder, including some of the most expensive drugs, are purchased from abroad. Although the Brazilian policy of antiretroviral distribution has had notable success, it remains threatened by the high cost of acquisition of drugs, which has led to disputes with international pharmaceutical companies over prices and patents. Whether or not the Brazilian model of guaranteeing access to antiretroviral treatment for people living with HIV/AIDS can be applied in other countries or regions, much can be learnt from the country's experience.

Anti-HIV Agents↗

PubMedDate not supplied

Risk factors of mortality among the home-based disabled patients in central Taiwan.

The objective of this study was to investigate the factors that affected mortality 1 year after an intensive service program among the disabled. Three hundred and twenty-two disabled subjects were selected from communities in central Taiwan. Sixty-six percent of the participants had cerebral vascular accident (CVA) followed by hypertension (28%) and diabetes mellitus (20%). After 1 year, 117 (36.3%) had died. The activities of daily living (ADL) scores of the participants who had died were significantly lower than those in the survival group. Of those who had pressure sores, 60% were in the 'death group' compared with about 40% in the survival group. Overall, mortality rate was 36.3% after the intensive service program. Based on multiple logistic regression, the factors that affected mortality were as follows: age over 65 years compared with less than 64 years (adjust odds ratio (AOR)=1.897), severe ADL dependence (AOR=0.502), incidence of CVA (AOR=0.448), and pressure sores (AOR=1.978). The authors recommend that the factors affecting mortality be evaluated urgently and that medical services and community support systems cooperate to provide disabled patients with adequate health care. In addition, the implementation of the intensive service program provides an opportunity and challenge for nurses to examine their working practices.

Journal Article↗

PubMed1999

Juvenile violence.

No one missing piece can solve the puzzle of juvenile violence. Although numerous risk factors have been identified, the implementation of successful preventive and treatment programs remains the greatest challenge. With children increasingly turning to gangs as substitutes for their families and using weapons to solve their problems, there is little alternative but to meet this challenge. The consequence of failing to do so is summarized by King's prophetic statement, "The choice today is no longer between violence and nonviolence. It's either nonviolence or nonexistence."

Adolescent↗

PubMed2002

The virtual colonoscopy study: a large multicenter clinical trial designed to compare two diagnostic screening procedures.

This paper reviews the design of a large multicenter clinical trial currently being conducted to test the equivalence of two screening procedures for colorectal polyps. The primary outcome is the sensitivity and specificity of the new and standard procedures for detecting subjects with and without polyps of a size > or =6 mm, respectively. An important secondary outcome is the accuracy of these procedures in detecting individual polyps. A total of 619 participants underwent virtual colonoscopy, the new procedure, followed by conventional colonoscopy, the standard procedure. Strategies for the design and implementation of the study are shared as well as the challenges encountered.

Bias↗

PubMedDate not supplied

Recent advances in mathematical modeling of developmental abnormalities using mechanistic information.

During the last several years, significant changes in the risk assessment process for developmental toxicity of environmental contaminants have begun to emerge. The first of these changes is the development and beginning use of statistically based dose-response models [the benchmark dose (BMD) approach] that better utilize data derived from existing testing approaches. Accompanying this change is the greater emphasis placed on understanding and using mechanistic information to yield more accurate, reliable, and less uncertain risk assessments. The next stage in the evolution of risk assessment will be the use of biologically based dose-response (BBDR) models that begin to build into the statistically based models factors related to the underlying kinetic, biochemical, and/or physiologic processes perturbed by a toxicant. Such models are now emerging from several research laboratories. The introduction of quantitative models and the incorporation of biologic information into them has pointed to the need for even more sophisticated modifications for which we offer the term embryologically based dose-response (EBDR) models. Because these models would be based upon the understanding of normal morphogenesis, they represent a quantum leap in our thinking, but their complexity presents daunting challenges both to the developmental biologist and the developmental toxicologist. Implementation of these models will require extensive communication between developmental toxicologists, molecular embryologists, and biomathematicians. The remarkable progress in the understanding of mammalian embryonic development at the molecular level that has occurred over the last decade combined with advances in computing power and computational models should eventually enable these as yet hypothetical models to be brought into use.

Abnormalities, Drug-Induced↗

PubMedDate not supplied

Designing an infection control program.

Designing and implementing an infection control program for home care poses many challenges. Some of these challenges stem from a long-standing lack of research and on-site expertise in the home care setting. Recent changes in health care and the proliferation of external regulations regarding home care practice further complicate the development of an effective and efficient infection control program.

Home Care Services↗

PubMed2001

Modern chemotherapeutic options for malaria.

Unlike HIV disease or tuberculosis, both of which are also major threats to public health throughout the tropics, uncomplicated malaria of whatever species can be cheaply and rapidly cured, usually in outpatients. However, in common with both HIV and tuberculosis, control of malaria is threatened by inadequate resources and by drug resistance. Africa carries the greatest burden of malaria mortality and morbidity; by no coincidence, Africa is also the most resource-limited. The drugs for severe disease (quinine and the artemisinins) are largely unaffected by resistance so far, but the "first-line" drugs, mainly used by outpatients (eg, chloroquine and sulfadoxine-pyrimethamine), are a major cause for concern. Although effective drugs are available they are mostly too expensive for routine use. This article reviews the main drugs for malaria and outlines the therapeutic use of these drugs for uncomplicated and severe disease. The article then examines the challenges faced in the processes of changing policy, and the implementation of that policy shift.

Africa↗

PubMedDate not supplied

Pilot-scale adenovirus seed production through concurrent virus release and concentration by hollow fiber filtration.

Recovery of recombinant adenoviruses from infected mammalian cell cultures often requires multiple unit operations such as cell lysis for virus release, microfiltration for clarification, and ultrafiltration for concentration. While development of these multiple unit operations is relatively straightforward, implementation under aseptic conditions in a closed system can be challenging for the production of virus seed at industrial scales. In this study, we have developed a simple, single-step, scaleable process to effectively recover adenoviruses from infected PER.C6 cell cultures for the production of concentrated adenovirus seeds under aseptic conditions. Specifically, hollow fiber tangential flow filtration technology was applied to maximize cell lysis of infected cultures for virus release while simultaneously concentrating the virus to an appropriate level of volume reduction. Hollow fiber filters with small lumen diameter of 0.5 mm were chosen to maximize the wall shear for a highly effective cell lysis and virus release. Cell lysis and virus release were shown to correlate with the exposure time in the hollow fiber cartridge: the shear zone. In most cases, a virus recovery yield of more than 80% and a 15- to 20-fold concentration (or up to 95% volume reduction) was achieved in less than 2 h of processing time. The virus seeds prepared using this process at lab scale and at 300-L scale without clarification have been successfully tested for sterility and potency and used for subsequent infection with consistent virus productivity. This process should enable rapid production of adenovirus seeds with minimal unit operations and high efficiency recovery for adenovirus production at 1000-L scale.

Adenoviridae↗

PubMedDate not supplied

Ethics in sentinel node biopsy in breast cancer: an open question.

The sentinel node concept agrees with the modern principles of surgical oncology in breast cancer, which are related to lymphatic dissection, accurate axillary study, and less traumatic surgery. After publication of many series, it has proven its capacity to correctly stage axilla and select patients who need axillary dissection. The Brazilian Society of Senology established the current norms for its practice. However, the transportation of new surgical techniques from research to practice always occurs with some ethical dilemmas related to its introduction in clinical practice. The aim of this study was to analyze the ethical challenges of the sentinel node technique and problems with its implementation.

Breast Neoplasms↗