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PubMed1990

A versatile implementation of the Gauss-Newton minimization algorithm using MATLAB for Macintosh microcomputers.

The present report describes a weighted nonlinear least-squares minimization routine for fitting a wide variety of functions nonlinear in the parameters. The minimization routine is implemented in MacMATLAB, the Macintosh microcomputer version of MATLAB, an interactive program for scientific numeric calculations. Our algorithm makes use of a subroutine that estimates the required derivatives numerically, avoiding the need to differentiate the function under study analytically. We have also implemented two specific subroutines to integrate ordinary differential equations numerically. Therefore, in principle, any kind of nonlinear function can be fitted to a given set of data. The program only requires that the user writes the appropriate equation in a specific subroutine, thus relieving one from knowing and using any 'low-level' code. Other features of the program are: (a) the possibility of using weight to correct for nonuniformity of variance by flexible specification of the error structure; (b) the possibility of checking the parameter values and the residual variance at each iteration; and (c) by the use of the graphic capabilities of MacMATLAB, the possibility of following the improvement of the fitting graphically. One example of nonlinear functions and one example of linear differential equation together with their respective 'function file' and illustrative data are presented to demonstrate the flexibility of our approach and the power of the method used.

Algorithms↗

PubMed1990

Implementing and evaluating a system of generic infection precautions: body substance isolation.

Body substance isolation (BSI) is a system of infection precautions intended to reduce nosocomial transmission of infectious agents among patients and to reduce the risk of transmission of hepatitis B virus, human immunodeficiency virus, and other infectious agents to health care personnel. Harborview Medical Center in Seattle, Wash., was the first facility in the United States to implement the BSI system. Between 1984 and 1988 a systematic evaluation of the implementation process was conducted and the effects of BSI on appropriate glove use by hospital personnel and on the incidence of nosocomial colonization and infection by sentinel organisms was measured. Results of the evaluation showed (1) significant increments in knowledge of infection control procedures and practices as measured by comparing written examination responses before and after training sessions, (2) significant increases in appropriate glove use as determined by direct observation of hospital employees for 18 months, and (3) significant reductions in nosocomial colonization and infection caused by sentinel microorganisms during the period from 1984 to 1988.

Body Fluids↗

PubMed1995

Implementing a tuberculosis control program.

Between January 1989 and December 1990, 26 patients acquired multidrug-resistant tuberculosis at our institution. Their exposures occurred when they were admitted to a ward where a patient with acid fast bacillus smear-positive pulmonary tuberculosis was also admitted. In 20 cases, the infectious patients were not isolated until the sputum smears were positive. When the outbreak was recognized in the spring of 1990, the infection control department undertook a risk assessment and instituted measures that would become the tuberculosis control program. Since then, administrative and environmental controls have been implemented, education programs are ongoing, personal protective equipment is in use, and a more aggressive employee health testing program is underway. The steps we took and the barriers we had to overcome to implement our plan are included in this article.

Acquired Immunodeficiency Syndrome↗

PubMed1988

The implementation of a diarrheal disease control program in Honduras: is it 'selective primary health care' or 'integrated primary health care'?

International public health scientists have debated the distinction of selective and integrated primary health care since the development of new selective primary health care interventions such as the Expanded Programme on Immunizations and the Diarrhoeal Disease Control Programme of the World Health Organization were developed. This paper argues that the codification offered by the identification of two incompatible paradigms is not a productive one for describing the implementation of national-level primary health care programs. This paper will explore these concerns by reviewing case materials of the implementation of a diarrheal diseases control program in Honduras.

Diarrhea↗

PubMed1994

Primary health care in Zimbabwe: can it survive? An exploration of the political and historical developments affecting the implementation of PHC.

Using a multi-level perspective, this paper examines the structural constraints and conflicting perspectives affecting the implementation of Primary Health Care (PHC) in Zimbabwe. The analysis of these factors and processes is made by viewing the situation from the different perspectives, perceptions and actions of the state, the health workers and the population. It is argued that the continuing structural inequalities, the bureaucratic and centralization tendencies, the historical development and colonial transplantation of biomedical practice, and the de facto lack of support by government, constrain the implementation of PHC.

Community Health Workers↗

PubMed1995

Organizing and implementing a hospital-wide first-responder automated external defibrillation program: strengthening the in-hospital chain of survival.

First-responder automated external defibrillation (AED) in the hospital is consistent with the American Heart Association's (AHA) early defibrillation standard or care. With trained personnel and automated external defibrillators immediately available, early defibrillation should have a greater impact on survival than early cardiopulmonary resuscitation (CPR). Therefore, in our hospitals we modified basic life support to include automated external defibrillation (BLS-AED) for all personnel who are expected to respond to a cardiac arrest, with rapid defibrillation taking priority over CPR. We describe how we organized and implemented this hospital-wide first-responder BLS-AED program. Planning the process includes gaining support from key leaders who are responsible for resuscitation practice, and identifying the target audience of the training program. Hospital unit needs for AED or conventional defibrillation and equipment must be identified, the training program developed, and existing policies and procedures modified. Several barriers to implementation may exist. Education about the efficacy and safety of AED and experience once the BLS-AED program is in place can overcome attitudes and bias. Concerns about the cost of equipment and training must be addressed. Program evaluation may include patient issues such as measuring the time to the first defibrillation and patient outcome; as well as training and retention issues.

Adult↗

PubMed1993

Use of Veff and iso-NTCP in the implementation of dose escalation protocols.

PURPOSE: This report investigates the use of a normal tissue complication probability (NTCP) model, 3-D dose distributions, and a dose volume histogram reduction scheme in the design and implementation of dose escalation protocols for irradiation of sites that are primarily limited by the dose to a normal tissue which exhibits a strong volume effect (e.g., lung, liver). METHODS AND MATERIALS: Plots containing iso-NTCP contours are generated as a function of dose and partial volume using a parameterization of a NTCP description. Single step dose volume histograms are generated from 3-D dose distributions using the effective-volume (Veff) reduction scheme. In this scheme, the value of Veff for each dose volume histogram is independent of dose units (Gy, %). Thus, relative dose distributions (%) may be used to segregate patients by Veff into bins containing different ranges of Veff values before the assignment of prescription doses (Gy). The doses for each bin of Veff values can then be independently escalated between estimated complication levels (iso-NTCP contours). RESULTS AND CONCLUSION: Given that for the site under study, an investigator believes that the NTCP parameterization and the Veff methodology at least describe the general trend of clinical expectations, the concepts discussed allow the use of patient specific 3-D dose/volume information in the design and implementation of dose escalation studies. The result is a scheme with which useful prospective tolerance data may be systematically obtained for testing the different NTCP parameterizations and models.

Humans↗

PubMed1995

Clinical implementation of a commercial multileaf collimator: dosimetry, networking, simulation, and quality assurance.

PURPOSE: Clinical implementation of multileaf collimation (MLC) includes commissioning (including leaf calibration), dosimetric measurements (penumbra, transmission, calculation parameters), shaping methods, networking for file transfer, verification simulation, and development of a quality assurance (QA) program. Differences of MLC and alloy shaping in terms of penumbra and stair-step effects must be analyzed. METHODS AND MATERIALS: Leaf positions are calibrated to light field. The resultant decrement line, penumbras, leaf transmission data, and isodoses in various planes were measured with film. Penumbra was measured for straight edges and corners, in various media. Ion chambers were used to measure effects of MLC on output, scatter, and depth dose. We maintain midleaf intersection criteria. MLC fields are set 7 mm beyond planning target volumes. After shaping by vendor software or by our three-dimensional planning system, files are transferred to the MLC workstation by means of sharing software, interface cards, and cabling. A MLC emulator was constructed for simulation. Our QA program includes file checks, monthly checks (leaf position accuracy and interlock tests), and annual review. RESULTS: We found the MLC leaf position (light field) corresponds to decrement lines ranging from 50 to 59%. Transmission through MLC (1.5-2.5%) is less than alloy (3.5%). Multileaf penumbra is slightly wider than for alloy. Relative penumbra did not increase in the lung, and composite field dosimetry exhibited negligible differences compared with alloy. Verification simulations provide diagnostic image quality hard copies of the MLC fields. Monitor unit parameters used for alloy held for MLC. DISCUSSION: Clinical implementation for MLC as a block replacement was conducted on a site-by-site basis. Time studies indicate significant (25%) in-room time reductions. Through imaging and dosimetric analysis, the accuracy of field delivery has increased with MLC. The most significant impact of MLC is the ability to increase the number of daily treatment fields, thereby reducing normal tissue dosing, which is vital for dose escalation.

Calibration↗

PubMed1995

Physiologically based pharmacokinetic models: mathematical fundamentals and simulation implementations.

This review paper gives an overview of the building blocks of physiologically based pharmacokinetic (PBPK) models and their implementation using computer facilities. The approach focuses on the development of a PBPK model with the most important and appropriate limiting steps for the conditions and exposure scenarios under study. In this approach, the assumptions made in constructing the set of equations, as well as the fitting of variables to specific experimental results, need to be accounted for when making extrapolation to other conditions. A well-constructed PBPK model should account for all possible ranges of extrapolation from the development stages so that appropriate experimental studies and assumptions can be designed to handle the intended applications. Two common assumptions are revisited: the flow-limited assumption and the metabolic clearance using Michaelis-Menten kinetics assumption. Computer hardware and software requirements for implementing PBPK models are briefly reviewed.

Computer Simulation↗

PubMedDate not supplied

Implementation of mixed bandwidth MRI pulse sequences using a single analog lowpass filter.

In many MR imaging situations, such as when imaging certain areas of the brain, substantial increases in the signal-to-noise and contrast-to-noise ratios can be achieved by extending the duration of the data sampling period, or equivalently stated, by reducing the bandwidth of the data acquisition. This technique is particularly applicable for the clinically useful long TR double spin-echo sequence for improving the signal-to-noise and contrast-to-noise ratios for the long TE second echo image. Such a sequence would employ a relatively short data sampling period (wide bandwidth) for the short TE first echo, and a relatively long data sampling period (narrow bandwidth) for the long TE second echo. Implementing such a sequence which uses two data acquisitions of different bandwidths within one sequence repetition can present certain technical problems. In this communication, we describe a method to implement such a mixed bandwidth pulse sequence on a standard commercial whole-body imager without the need for additional software or hardware. This sequence is now in routine clinical use at our institution.

Brain↗

PubMed1995

Implementation of violence prevention education in clinical settings.

Clinical settings provide excellent opportunities for educating adolescent patients about violence prevention. This paper reports on the experience of the Violence Prevention Project of Boston in implementing comprehensive violence prevention activities in different clinical settings. The project's evaluation revealed that staff training, specialized educational materials and staff commitment are required for both initial and sustained implementation of the education. Waiting room brochures and videos are inadequate to address the problem. Conversely, clinical settings can host a variety of educational experiences that generate significant response from patients, families and friends. Clinical settings can also be integrated into broader community-based efforts.

Adolescent↗

PubMed1991

Obstacles to implementing cancer clinical trials.

There are numerous obstacles to implementing and conducting clinical trials. Patient accrual and the costs of clinical trials are difficult problems for researchers. Additional obstacles to implementing clinical trials are patient-related, physician-related, and nurse-related barriers.

Clinical Trials as Topic↗

PubMedDate not supplied

The effects of implementing program consequences with a group of individuals who engaged in sensory maintained hand mouthing.

This study evaluated whether a multicomponent treatment package could be successfully implemented with individuals who engage in self-injurious hand mouthing maintained by sensory consequences in the context of both individual and small group settings. Three ambulatory individuals with profound mental retardation participated on an individual basis followed by treatment within a group setting. Generalization of the intervention results to the natural living environment was then analyzed. Using an ABAB experimental design, the effectiveness of brief response interruption followed by the introduction of a preferred leisure item to reduce hand mouthing during 15-min intervention sessions was analyzed. Results of these experiments showed that the intervention could be successfully implemented during individual and small group sessions and during group sessions conducted in the natural environment. The benefits and limitations of this intervention strategy and future research are discussed.

Adult↗

PubMed1995

An approach to the design and implementation of clinical trials of empirical antibiotic therapy in febrile and neutropenic cancer patients.

The results of many clinical trials on empirical therapy in febrile, neutropenic cancer patients cannot be readily transferred to the clinical practice, because the methodology is often flawed and definitions, study endpoints and eligibility criteria differ from trial to trial. This article critically reviews some issues related to the design and implementation of randomised clinical trials of empirical antibiotic therapy in cancer patients. Within the definition of phase III clinical trials, two approaches co-exist, based on the trial's specific aims: the "explanatory" approach and the "pragmatic" approach. The usual "explicit" aim of clinical trials of empirical therapy in febrile, neutropenic patients has been that of comparing the "efficacy" of two regimens. However, this term has been more often used with reference to the antibacterial activity of the regimen under study (explanatory aim) than to indicate the practical benefits it draws to the overall patient population treated for fever and neutropenia (pragmatic aim). These two meanings are often taken as perfectly interchangeable, while, conversely, they are completely distinct (though not independent) treatment effects. Most trials conducted in this patient population in recent years are explanatory trials, though not explicitly so, but their results have been widely applied to clinical practice, as they were pragmatic trials. In an explanatory trial the appropriate endpoint is success or failure (defined by clinical and laboratory data) among those patients affected with the specific infection for which the study drug is being given, while in pragmatic trials survival is probably the more appropriate outcome variable, since they are designed to assess the practical benefits that the overall population of febrile and neutropenic patients can obtain from the new empirical treatment. Unfortunately, survival is not a practical study endpoint for the difficulty in assessing the cause of death in this patient population and, especially, for the need for very large sample sizes, which might render the implementation problematic even for large, multicentre groups. Both types of trials need an intention to treat analysis, but this is especially crucial for pragmatic trials, which should not differentiate those cases in which success was obtained through multiple treatment modifications from those who did not require any treatment change. Obviously, this implies that no conclusion should be drawn about the antibacterial activity of the study drugs and that the number of treatment modifications should be taken into account in the interpretation of the results, especially for quality of life and cost evaluations. Information related to fever and signs of infection, age, underlying disease, neutropenia and concomitant administration of other antibiotics are crucial entry criteria that need to be clearly discussed and defined. Finally, the evaluation of toxicity is problematic in this patient population, due to the existence of a number of toxigenic factors, including the underlying disease, the type of infectious complication, the administration of chemotherapy and radiotherapy and the use of parental nutrition. All these effects tend to overlap, thus impairing the investigator's ability to detect specific drug-related side-effects.

Anti-Bacterial Agents↗

PubMed2006

How to successfully implement E-learning for both students and teachers.

RATIONALE AND OBJECTIVES: Electronic learning (e-learning) may provide a means to enhance learning efficacy. However, introduction of e-learning often fails. We describe a strategy of how an e-learning curriculum was successfully implemented. MATERIALS AND METHODS: The curriculum was designed based on published evidence. It consists of self-directed learning, an online discussion forum, and discussion rounds. The e-content in nuclear medicine and radiotherapy was produced by the k-MED team of medical authors, web designers, and psychologists. The online courses were delivered via a dedicated learning management system. The e-content for diagnostic radiology and physics was provided as PDF/HTML script by the respective teachers who objected to participate in the k-MED project. The exam was taken online. Online evaluation of the curriculum by the students was taken at the end of the course. RESULTS: The new curriculum proved very effective. The time for the preparation for the clinical part of the radiology course could be reduced from 4 to 2 weeks. The students particularly enjoyed the self-directed learning. Although the material provided by k-MED received 90%-99% positive scores, the HTML and PDF scripts scored worse (13%-67% positive ratings). The positive results of the evaluation convinced the teachers responsible for physics and diagnostic radiology to participate in k-MED. CONCLUSIONS: As our example shows, new e-learning curricula can successfully be introduced. The strategy of implementation should be based on the existing evidence from the literature. The new curriculum helped to increase the efficacy of teaching and save time as the duration of the respective part of the course could be reduced by half.

Computer-Assisted Instruction↗

PubMed2005

Implementing and evaluating Social Behaviour and Network Therapy in drug treatment practice in the UK: a feasibility study.

This paper reports on the implementation and preliminary evaluation of Social Behaviour and Network Therapy (SBNT) within drug treatment services. SBNT was initially developed and evaluated as part of a trial for alcohol treatment in the UK (UKATT). For the study reported in this paper SBNT was adapted for application with drug users. Therapists (N=20) from community drug services in Birmingham, UK, were trained to deliver the intervention. Training methods were supported by a treatment manual and included a two-day workshop followed by video supervision and monitoring. Following training therapists were asked to implement the treatment within the services in which they worked. Twelve of the therapists that were trained delivered SBNT to 24 clients within the study period of 8 months. Baseline and 3-month follow-up measures were administered using both quantitative and qualitative methods. This paper reports the quantitative results including drug use, levels of dependence, drug users' social network variables and family environment. Results suggest that it was feasible to train a number of therapists to deliver SBNT, and preliminary outcome results are encouraging. Further evaluation is needed in order to continue developing this promising social intervention.

Adult↗

PubMed2005

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program.

PURPOSE: To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations. METHODS: A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement. RESULTS: Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication. CONCLUSIONS: Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.

Antibiotic Prophylaxis↗

PubMed2006

Implementation of a continuous quality improvement program for percutaneous coronary intervention and cardiac surgery at a large community hospital.

BACKGROUND: Continuous quality improvement (CQI) is widely used in other industries and has been promoted as a method for quality control in medicine. The national databases developed by the American College of Cardiology and the Society of Thoracic Surgeons have greatly facilitated data collection for CQI. Hospitals can encounter barriers to CQI, however, which include creating the proper organizational infrastructure and engaging physicians and hospital administrators in the process. These barriers are particularly evident in large community hospitals. METHODS: We describe the organizational infrastructure for CQI, including committee structure, methods of repeated data collection and feedback, and maintenance of data integrity and confidentiality. We report demographic data and clinical outcomes for patients undergoing percutaneous coronary intervention and coronary artery bypass surgery before and after implementation of our CQI program. RESULTS: Since 1995, we have maintained a CQI process driven by repeated collection of valid, confidential, operator-specific data. We have observed sustained physician and administration participation and buy-in. During the follow-up period, patient complexity increased and observed outcomes improved, although the improvement was clearly multifactorial. CONCLUSIONS: We describe the organization of a CQI program at a large complex community hospital. Our CQI program was successfully implemented, has been sustained, and is associated in observed improvement in patient outcomes. The program described here may be a useful model for other similar hospitals that are attempting to create a program to address quality improvement.

Aged↗