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PubMed1992

The community bioethics committee: a unique pathway out of bioethical dilemmas.

We believe that most bioethics committees as well as individual ethics consultants have major shortcomings in that they are unlikely to be open to serving the widest number of citizens who may need their services when facing bioethical dilemmas. The HDCC serves as a community resource, is open to all citizens, is free standing, and provides a wide variety of perspectives which can assist patients, their families, and healthcare providers to explore a range of values and options. The HDCC serves as a model for communities that seek to establish a bioethics resource. Further, the HDCC model permits the further exploration of ways in which important healthcare issues can be faced. AHD believes, in keeping with its mission, that the creation of the HDCC can increase the public's awareness of and involvement in healthcare issues. As B. Jennings reminds us, The mission of community health decisions projects is to stimulate a well-informed conversation where many voices are heard and all reasonable perspectives given due consideration. They not only inform, but also enable responsible civic participation and thoughtful health care decisionmaking. The HDCC model can serve to bring discussions on bioethical dilemmas out of secrecy into safer, yet more open, community fora.

Arizona↗
PubMed1990

International behavioral responses to a health hazard: AIDS.

This paper expands on Jonathan Mann's third wave of the AIDS pandemic: the epidemic of economic, social, political, and cultural reaction and response to the HIV infection and to AIDS. This worldwide epidemic is a major economic challenge, especially in Third World countries, which can ill afford additional health care costs. AIDS is also a harbinger of political and cultural conflicts between and among nations, states, institutions, and people everywhere. It may ultimately transform law as radically as it has health care practices. In terms of management, it is possible to approach AIDS much as we do natural and technological hazards. The biology and epidemiology of AIDS require a coordinated attack, involving research on vaccines and drugs, modification of human behavior and education of populations to arrest the disease. All of these require money, of which the United States was the major contributor before the Reagan years. Funding to the United Nations and WHO has since languished, jeopardizing the AIDS efforts of those two organizations.

Acquired Immunodeficiency Syndrome↗
PubMed1998

An epidemiological and economic simulation model to evaluate the spread and control of infectious bovine rhinotracheitis in The Netherlands.

Bovine herpesvirus type I (BHV1), causing infectious bovine rhinotracheitis (IBR), was introduced in the Netherlands in 1971. In 1993, about 42% of the dairy cows had antibodies against BHV1. In the future, stricter requirements are anticipated regarding the health status of exported breeding cows and material. To support policymakers in their decisions on IBR eradication, a simulation model was developed in which the epidemiological and economic consequences of various control strategies were evaluated. This paper describes the model and provides an overview of some important outcomes. In the model, dairy herds were classified into different disease states based on (1) the reproduction ratio of the disease (R, defined as the number of secondary cases caused by one infectious animal) (2) the within-herd prevalence, within each value of R and (3) the expected number of infectious animals in an infectious herd within each prevalence range. The dynamic transition probability of a herd going from one state to another per week depends on direct contacts between animals, and other contacts such as transmission through fomites, indirect transmission through other species, airborne transmission and minor disease-specific routes such as venereal or iatrogenic transmission. Five control strategies, including both a voluntary vaccination program and a compulsory vaccination program for all dairy herds were evaluated. A voluntary vaccination program with 50% participation is not expected to lead to eradication of IBR. It appears that compulsory vaccination would be necessary to reach an IBR-free status.

Animals↗
PubMed2006

Quality and quantity of antenatal HIV counselling in a PMTCT programme in Mombasa, Kenya.

A recent report from a PMTCT implementation study in Mombasa, Kenya, points at an important gap between the efficacy in clinical trial circumstances and the effectiveness of PMTCT programmes when implemented in real life. Hence, the quality and quantity of antenatal HIV counselling in a routine setting were appraised. The counsellors' social and communicative skills, duration and topics covered during pre- and post-test counselling sessions were assessed by means of the VCT assessment tools published by UNAIDS. A total of 14 group educational sessions, 66 pre-test counselling sessions and 50 post-test counselling sessions were observed and assessed. In general, the frequency and duration of the counselling was low. Crucial topics such as window period and partner involvement and follow-up support were covered haphazardly. The counsellor's social and communicative skills were given high marks, yet information was rarely repeated or summarized. The limited time dedicated to women receiving antenatal VCT contrasts with the heavy and comprehensive load of health information and advice they are supposed to receive. Ample pre- and post-test counselling including follow-up should be pursued for optimal effectiveness of PMTCT. We propose a number of health system interventions preceded and guided by ongoing audit.

Counseling↗
PubMed1998

Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); interpretation of "federal public benefit"--HHS. Notice with comment period.

This notice with comment period interprets the term "Federal public benefit" as used in Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), Pub. L. 104-193, and identifies the HHS programs that provide such benefits under this interpretation. According to section 401 if PRWORA, aliens who are not "qualified aliens" are not eligible for any "Federal public benefit," unless the "Federal public benefit" falls within a specified exception. A "Federal public benefit" includes "any grant, contract, loan, professional license, or commercial license" provided to an individual, and also "any retirement, welfare, health, disability, public or assisted housing, postsecondary education, food assistance, unemployment benefit, or any other similar benefit for which payments or assistance are provided to an individual, household, or family eligibility unit." Under section 432, providers of a non-exempt "Federal public benefit" must verify that a person applying for the benefit is a qualified alien and is eligible to receive the benefit. The HHS programs that provide "Federal public benefits" and are not otherwise excluded from the definition by the exceptions provided in section 401(b) are: Adoption Assistance Administration on Developmental Disabilities (ADD)-State Developmental Disabilities Councils (direct services only) ADD-Special Projects (direct services only) ADD-University Affiliated Programs (clinical disability assessment services only) Adult Programs/Payments to Territories Agency for Health Care Policy and Research Dissertation Grants Child Care and Development Fund Clinical Training Grant for Faculty Development in Alcohol & Drug Abuse Foster Care Health Profession Education and Training Assistance Independent Living Program Job Opportunities for Low Income Individuals (JOLI) Low Income Home Energy Assistance Program (LIHEAP) Medicare Medicaid (except assistance for an emergency medical condition) Mental Health Clinical Training Grants Native Hawaiian Loan Program Refugee Cash Assistance Refugee Medical Assistance Refugee Preventive Health Services Program Refugee Social Services Formula Program Refugee Social Services Discretionary Program Refugee Targeted Assistance Formula Program Refugee Targeted Assistance Discretionary Program Refugee Unaccompanied Minors Program Refugee Voluntary Agency Matching Grant Program Repatriation Program Residential Energy Assistance Challenge Option (REACH) Social Services Block Grant (SSBG) State Child Health Insurance Program (CHIP) Temporary Assistance for Needy Families (TANF) While all of these programs provide "Federal public benefits" this does not mean that all benefits or services provided under these programs are "Federal public benefits." As discussed in sections II and III below, some benefits or services under these programs may not be provided to an "individual, household, or family eligibility unit" and, therefore, do not constitute "Federal public benefits" as defined by PRWORA.

Eligibility Determination↗
PubMed1987

The case against compulsory casefinding in controlling AIDS--testing, screening and reporting.

The spread of acquired immune deficiency syndrome (AIDS) demands a comprehensive and effective public health response. Because no treatment or vaccine is currently available, traditional infection control measures are being considered. Proposals include compulsory testing and screening of selected high risk populations. The fairness and accuracy of compulsory screening programs depend upon the reliability of medical technology and the balancing of public health and individual confidentiality interests. This Article proposes criteria for evaluating compulsory testing and screening programs. It concludes that voluntary identification, education, and counselling of infected persons is the most effective means of encouraging the behavioral changes that are necessary to halt the spread of AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1998

Follow-up of rapists treated in a forensic psychiatric hospital.

Current research examining the effectiveness of sex offender treatment is encouraging. Despite this optimism, research focusing on men who sexually assault adult women is less optimistic. This study examines the preliminary results of 74 rapists admitted into the Phoenix program, a voluntary sex offender treatment program in a forensic psychiatric hospital. Patients were categorized according to whether they completed treatment or not. Treated rapists (n = 36) reoffended at a substantially lower rate than untreated rapists who were assessed but not treated (n = 38). Statistically significant differences in reoffense rates were found for violent, nonsexual offenses as well as nonviolent, nonsexual offenses. Although nearly twice as many treatment noncompleters reoffended sexually, the difference between the two groups was not statistically significant. Mean follow-up time was well over four years for both groups. The implications of these findings are discussed.

Adult↗
PubMed1996

Economic impact of treatment of HIV-positive pregnant women and their newborns with zidovudine. Implications for HIV screening.

OBJECTIVES: To estimate the economic impact of (1) treating pregnant women who are human immunodeficiency virus (HIV)-positive with zidovudine and (2) voluntary screening programs for pregnant women for HIV infection and offering treatment with zidovudine to those found to be HIV-positive. MAIN OUTCOME MEASURES: Number of cases of pediatric HIV infection and costs of screening, zidovudine treatment, and pediatric HIV infection treatment. DESIGN: Health care costs associated with treatment of HIV-positive pregnant women and their newborns are estimated as the costs of zidovudine and its administration and the reduction in costs of treating pediatric HIV infection. The lifetime costs of pediatric HIV infection are derived from the published literature. Estimates of the reduction in maternal-to-fetal transmission rates are taken from the AIDS [acquired immunodeficiency syndrome] Clinical Trials Group (ACTG) Protocol 076. Costs of a voluntary screening program include costs of screening tests and counseling. Sensitivity and threshold analyses are performed to determine the impact of changes in input parameter values including zidovudine treatment costs, efficacy of treatment, costs of pediatric HIV infection, prevalence of HIV infection in pregnant women, screening test sensitivity and specificity, and pregnancy termination rates on the results. RESULTS: Assuming transmission rates are reduced from 25.5% to 8.3% as found in the ACTG 076 trial, treatment costs of $104,502 for 100 HIV-positive pregnant women and their newborns are offset by the reduction of $1,701,333 associated with fewer cases of pediatric HIV infection for a net savings of $1,596,831. The sensitivity and threshold analyses show that overall cost savings from treatment of HIV-positive pregnant women and their newborns are achieved for a wide range of possible maternal treatment costs, efficacy rates, and lifetime pediatric HIV treatment costs. In the base-case analysis for the voluntary screening program, overall cost savings are seen when HIV prevalence rate among pregnant women is greater than 4.6 per 1000. However, this threshold prevalence rate is sensitive to changes In parameter value-especially pediatric HIV treatment costs, counselling costs, efficacy of treatment, and years of additional HIV treatment for the pregnant women. CONCLUSIONS: Offering zidovudine treatment to pregnant women known to be HIV-positive will decrease the number of cases of pediatric HIV infection and reduce health care costs. Voluntary screening programs for pregnant women will further decrease the number of cases of pediatric HIV infection. The effect of a screening program on health care costs varies according to HIV prevalence and the costs associated with the screening program.

AIDS Serodiagnosis↗
PubMed2004

Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series.

STUDY DESIGN: A case series. OBJECTIVES: The purpose of this case series was to assess the effect of high-intensity neuromuscular electrical stimulation (NMES) on quadriceps strength and voluntary activation following total knee arthroplasty (TKA). BACKGROUND: Following TKA, patients exhibit long-term weakness of the quadriceps and diminished functional capacity compared to age-matched healthy controls. The pain and swelling that results from surgery may contribute to quadriceps weakness. The use of high-intensity NMES has previously been shown to be effective in quickly restoring quadriceps strength in patients with weakness after surgery. METHODS AND MEASURES: All patients were treated for 6 weeks, 2 to 3 visits per week, in outpatient rehabilitation. Five patients (NMES group) participated in a voluntary exercise program for both knees and NMES for the weaker knee. Three patients (exercise group) participated in a voluntary exercise program for both knees without NMES. For each treatment session, 10 isometric electrically elicited muscle contractions were administered at maximally tolerated doses to the initially weaker leg of the NMES group. Quadriceps strength and muscle activation were repeatedly assessed up to 6 months after surgery using burst superimposition techniques. RESULTS: At 6 months, the weak NMES-treated legs of 4 of 5 patients in the NMES group had surpassed the strength of the contralateral leg. In contrast, none of the weak legs in the exercise group were stronger than the contralateral leg at 6 months. Changes in quadriceps muscle activation mirrored the changes exhibited in strength. CONCLUSION: When NMES was added to a voluntary exercise program, deficits in quadriceps muscle strength and activation resolved quickly after TKA.

Aged↗
PubMed1997

Prenatal HIV screening in pregnant women: a medical-legal review.

Identifying pregnant women's human immunodeficiency virus (HIV) infection status provides them with the opportunity to seek appropriate treatment and to take measures to prevent vertical and horizontal transmission. Prenatal screening program options include targeting at-risk women, testing on a voluntary basis, or mandating prenatal HIV screening. When examining these options, the number of cases identified, programmatic costs, long-term health care costs, and legal implications must all be considered. Research indicates that targeting at-risk women misses a significant percentage of seropositive women, although programmatic costs may be lower. It is difficult to ascertain the difference between voluntary and mandatory programs with respect to the number of cases identified and treated. As a result, long-term savings are difficult to calculate. Mandatory programs would have the greatest direct costs and place the greatest burden on the woman's constitutional rights. By making HIV counseling and testing a routine component of prenatal care, voluntary programs could achieve the benefits of prenatal HIV screening without violating the woman's civil liberties.

AIDS Serodiagnosis↗
PubMed2004

Cortical neuromagnetic fields preceding voluntary jaw movements.

Slow cortical potentials (readiness potentials, RPs) reflecting the central programming of voluntary jaw movements were reported to appear preceding the movements. However, the current source producing the RP has not yet been localized. This study aimed to determine the cortical regions involved in the central programming of bilaterally symmetrical voluntary jaw movements, by locating the current source of the neuromagnetic counterpart of the RP (readiness field, RF). The RFs were found in the fronto-lateral region bilaterally, starting around 860 and 600 ms prior to the onset of masseter and digastric electromyograms (EMGs), respectively, and gradually increasing in magnitude to the peak within 100 ms before the EMG onset. Thus, the RFs appeared long before the reported onset of the excitability increase of pyramidal tract neurons. The current sources producing the RFs were located in the precentral gyrus bilaterally, with no bilateral differences in strength. We conclude that the primary motor cortex is involved bilaterally in central programming as well as in execution of bilaterally symmetrical voluntary jaw movements.

Adult↗
PubMed2006

Psychoeducation: a basic psychotherapeutic intervention for patients with schizophrenia and their families.

Psychoeducation was originally conceived as a composite of numerous therapeutic elements within a complex family therapy intervention. Patients and their relatives were, by means of preliminary briefing concerning the illness, supposed to develop a fundamental understanding of the therapy and further be convinced to commit to more long-term involvement. Since the mid 1980s, psychoeducation in German-speaking countries has evolved into an independent therapeutic program with a focus on the didactically skillful communication of key information within the framework of a cognitive-behavioral approach. Through this, patients and their relatives should be empowered to understand and accept the illness and cope with it in a successful manner. Achievement of this basic-level competency is considered to constitute an "obligatory-exercise" program upon which additional "voluntary-exercise" programs such as individual behavioral therapy, self-assertiveness training, problem-solving training, communication training, and further family therapy interventions can be built. Psychoeducation looks to combine the factor of empowerment of the affected with scientifically founded treatment expertise in as efficient a manner as possible. A randomized multicenter study based in Munich showed that within a 2-year period such a program was related to a significant reduction in rehospitalization rates from 58% to 41% and also a shortening of intermittent days spent in hospital from 78 to 39 days. Psychoeducation, in the form of an obligatory-exercise program, should be made available to all patients suffering from a schizophrenic disorder and their families.

Cognition↗
PubMedDate not supplied

Academic incentives for students can increase participation in and effectiveness of a physical activity program.

The authors sought to determine whether a greater academic incentive would improve the effectiveness and student adherence to a 12-week voluntary exercise program designed to decrease students' percentage of body fat. They randomly assigned 210 students to 1 of 2 groups with different academic reward structures. The group with the greater reward structure showed better exercise adherence and lost more body fat than those without the additional incentive. These findings suggest that an academic incentive can increase overall student adherence to a voluntary exercise program and can boost the effectiveness of the program in a university environment. The findings also have potential implications for on-campus promotion of physical activity.

Exercise↗
PubMed1992

Enalapril to lisinopril: economic impact of a voluntary angiotensin-converting enzyme-inhibitor substitution program in a staff-model health maintenance organization.

OBJECTIVE: The cost-effectiveness of a voluntary program that switched enalapril to lisinopril therapy in patients with benign essential hypertension in a staff-model health maintenance organization (HMO) was evaluated. DESIGN: The one-year nonrandomized, controlled trial was performed from November 1989 through October 1990. PARTICIPANTS: One hundred twenty-seven patients were entered into the study: 75 who converted from enalapril to lisinopril and 52 who remained on enalapril throughout the study period. Patients were excluded from analysis because of diagnosis (not benign essential hypertension) or insufficient data collection. INTERVENTIONS: Patients taking enalapril were asked by staff pharmacists if they were willing to consider switching from enalapril to lisinopril. To encourage patients, the HMO agreed to waive the drug rider copayment for three months. If patients were willing, their physicians were contacted and they established the lisinopril dosage. MAIN OUTCOME MEASURES: Total direct cost and savings resulting from converting patients from enalapril to lisinopril were measured and compared with costs of therapy for patients who remained on enalapril. RESULTS: The control and study groups were evenly matched according to demographics and concomitant drug therapy. Drug acquisition costs, costs associated with waiving drug rider copayment, pharmacy administrative costs, costs of managing adverse events, costs of visits to physicians, and laboratory test costs were assessed. Depending on the cost of capital assumed, net savings ranged from $85 to $110 per patient converted from enalapril to lisinopril. Monthly net savings that ranged from $2.04 to $2.61 per patient were required to result in overall net savings within the first two years. CONCLUSIONS: In a regular practice setting, a net savings is realized in less than 12 months when patients are converted from enalapril to lisinopril for treatment of benign essential hypertension. The voluntary therapeutic interchange program provided a good means for achieving cost controls for pharmacy expenses.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1987

The complexities of managed care: operating a voluntary system.

The implementation of state-sponsored voluntary case management programs for public assistance recipients creates provider and recipient recruiting problems that are unique to the state's economic environment, its political climate, its historic relationship with providers, its program goals, and its implementation strategies. This implementation study discusses the factors that influenced the operationalization of the Massachusetts managed care program for AFDC families. The issues of provider recruitment and recipient enrollment are examined in relation to the formal program goals of cost containment and access. The operational and bureaucratic problems the state Medicaid staff has experienced in maintaining the program evokes questions of who should administer the programs, who the best types of providers are in light of program goals, and how recipients can be enrolled in a voluntary program.

Aid to Families with Dependent Children↗
PubMed2002

[Paratuberculosis eradication programs in Northrhine-Westfalia].

Since 1993 a voluntary eradication program for bovine paratuberculosis is established in Northrhine-Westfalia. After an effectivity control of the serological diagnostics it is combined with the fecal culture since August of 2000. Parallel use of both methods is necessary for a successful eradication. It could be monitored that a high percentage of the newly bought cattle in the herds participating in the eradication program was considered positive. Since paratuberculosis eradication is time and cost extensive besides intensive eradication programs the spread of the disease must be stopped.

Animals↗