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PubMed2004

Two mid-pregnancy interventions to increase the initiation and duration of breastfeeding: a randomized controlled trial.

BACKGROUND: Despite high levels of breastfeeding initiation in Australia, only 46 percent of women are still breastfeeding (exclusively or partially) 6 months later, with marked differences between social groups. This study aimed to determine the influence of mid-pregnancy breastfeeding education on the proportions of women breastfeeding at hospital discharge, and on the duration of breastfeeding. METHODS: A randomized controlled trial to compare two strategies for increasing the initiation and duration of breastfeeding was conducted, in which 981 primiparas who attended a public, tertiary women's hospital in Melbourne, Australia, were randomized to one of two interventions or to standard care (327 in each group). The interventions were a 1.5-hour class on practical aspects of breastfeeding using a previously tested tool (Practical Skills), and two 1-hour classes exploring family and community attitudes toward, and experiences of, breastfeeding (Attitudes). Both interventions took place in interactive small groups when women were in mid-pregnancy. Breastfeeding initiation was ascertained by interview 2 to 4 days after birth, and breastfeeding duration was assessed by telephone interview 6 months after birth. RESULTS: Neither intervention increased breastfeeding initiation or duration compared with standard care. Rates at initiation were 97 percent (296/306) for the Practical Skills intervention, 95 percent (291/308) for the Attitudes intervention, and 96 percent (297/310) for standard care. Rates at 6 months were, respectively, 55 percent (162/297), 50 percent (146/293), and 54 percent (162/299). CONCLUSIONS: In settings where breastfeeding initiation is already high, neither study intervention could be recommended as an effective strategy to increase breastfeeding initiation or duration.

Adult↗
PubMed1992

Standardized use of simple criteria from case history improves selection of patients for cardiac-care unit (CCU) admission.

A simple algorithm, which improves the diagnostic performance in patients arriving with acute chest pain in the emergency room, has been developed. The algorithm is solely based on information immediately available to the physician and includes elements from ECG, clinical findings and case history. As postulated, a stepwise use of all these variables improved the diagnostic accuracy and reduced the false positive cardiac-care unit (CCU) referral rate in a prospective study of 1450 patients admitted with acute chest pain. Compared to previous hospital practice during a preceding control period, sensitivity in diagnosing patients with unstable ischaemic heart diseases increased from 86% to 94% (P < 0.01), and specificity increased from 44% to 56% (P < 0.001). Accordingly, accuracy increased from 67% to 81% (P < 0.001), and false positive CCU-admission rate decreased from 35% to 19%. The greatest improvement in physician's diagnostic decisions was observed among patients without clear-cut signs of acute ischaemic heart disease on admission.

Algorithms↗
PubMed1995

Structural characterizations of neuropeptide tyrosine (NPY) and its agonist analog [Ahx5-17]NPY by NMR and molecular modeling.

The structures of human NPY and of its centrally truncated agonist analog [Ahx5-17]NPY have been investigated in DMSO-d6 by two-dimensional NMR and by molecular modeling. For both peptides, a complete resonance assignment was achieved and a large number (more than 200) of inter-residue NOE connectivities were observed, including long-range connectivities between the N- and C-terminal ends of the chain. Molecular models were calculated using NOE constraints by distance geometry, simulated annealing and conjugate gradient energy minimization. The results indicate that both peptides are folded in the center of their chain, NPY adopting the hairpin shape, whereas the central portion of [Ahx5-17]NPY is characterized by relatively large loops. In contrast to previous models, practically no alpha-helical structure exists for these peptides under our conditions, but two beta-turns are found in NPY and one in [Ahx5-17]NPY. The proximity of the terminal ends could be the determinant factor for their activity.

Amino Acid Sequence↗
PubMed1996

Folded conformations of the delta-selective opioid dermenkephalin with head-to-tail interactions. A simulated annealing study through NMR restraints.

Despite similar tripeptide N-termini, dermorphin (Tyr-D-Ala-Phe-Gly-Tyr-Pro-Ser-NH2) and dermenkephalin (Tyr-D-Met-Phe-His-Leu-Met-Asp-NH2), naturally occuring opioid peptides from frog skin, exhibit high affinity but contrasting selectivity for the mu- and delta-opioid receptors, respectively. Structure-activity relationship studies have shown that the N-terminal tripeptide, Tyr-D-Xaa-Phe (where Xaa is either Ala or Met), is necessary for binding with both the mu- and delta-receptors while the nature and/or the conformation of the C-terminus His-Leu-Met-Asp-NH2 of dermenkephalin are responsible for addressing the peptide to the delta-receptor. In order to examine the conformational characteristics that are related to the selectivity of dermenkephalin towards the delta-receptor, 50 NOE restraints (10 between non-adjacent residues), and 7 dihedral angles, derived from a two-dimensional 1H-NMR study of dermenkephalin in dimethyl sulfoxide, were used in simulated annealing and energy minimization procedures. Twenty-four resulting conformers (60% of the generated structures) with no severe distance restraint violation were pooled into seven groups and three related families. These 24 conformers show close proximity between the two methionine residues, S-shaped structures, mean planes of N-terminal and C-terminal moieties almost at right angles to each other, a C-terminus region above the plane of the N-terminal region and g- as preferential orientation in the side chain of Phe. Aside these similarities, families of conformers differ by the preferential orientation in the side chain of Tyr (t or g-) and proximity between Tyr and Asp, or Tyr and the C-terminus. In contrast to previous models, practically no beta-turn structures exist for dermenkephalin, most of the NH hydrogen bonds participating to gamma-turns. The possible relationship between the conformational characteristics of dermenkephalin and the delta-opioid receptor selectivity is discussed.

Animals↗
PubMed2006

Actual number of tumor budding as a new tool for the individualization of treatment of T1 colorectal carcinomas.

BACKGROUND AND AIM: Treatment of T1 colorectal carcinomas, either local excision including endoscopic polypectomy or radical surgery, has always been problematic in everyday practice. Although previous studies have revealed that tumor budding at the invasive margin can be a marker for the malignant potential of T1 colorectal carcinomas, the evaluation of tumor budding has not been standardized as yet. In the present study, we attempted to apply the actual number of tumor budding units for the individualization of treatment in T1 colorectal carcinomas. METHODS: In 76 T1 colorectal carcinomas, associations between lymph node metastasis and clinicopathological parameters were examined statistically. A mathematical formula for predicting the risk of lymph node metastasis was constructed and decision analysis was attempted to determine individually the indication for additional surgery after endoscopic mucosal resection of T1 colorectal carcinomas. RESULTS: Of the clinicopathological parameters examined, multivariate analysis showed that the actual number of tumor budding units alone was significantly associated with lymph node metastasis. The probability of lymph node metastasis was calculated as Z = 0.07 x (budding counts) - 3.726, probability = 1/1 + e(-Z). The more the budding counts, the higher the probability of lymph node metastasis. This formula was able to accurately predict lymph node metastasis in successive cases. The actual number of tumor budding units can be applied to decision analysis in determining an indication for additional surgery after endoscopic mucosal resection of T1 colorectal carcinomas. CONCLUSIONS: The actual number of tumor budding units may be useful in the decision making for patient-oriented treatment of T1 colorectal carcinomas.

Adult↗
PubMed1991

Trends in contraception and sterilization in Australia.

Life-history data collected in a national survey of women in 1986 are used to derive the first national estimates of trends in contraception and sterilization in Australia over the last 30 years. The pill rapidly became the method of choice after its release in 1961. The intrauterine device, the other truly modern method, has never attained the same popularity. The move toward sterilization dates from the early 1970s and has been so complete that women of 35 or older are now more likely to be protected by a ligation or laparoscopic sterilization than by the pill or, indeed, by all other methods combined. Unmarried women are now indistinguishable from married women on the basis of their use of contraception, and childless married women are now more likely to be using a reversible method than married women with children.

Adolescent↗
PubMed1990

Coding guidelines for ICD-9 section on mental disorders and reliability of chart clinical diagnoses.

A major innovation of the ICD-10 draft is provision of diagnostic guidelines. This is assumed to be appropriate for use in clinical situations. In Norway a similar approach was adopted when ICD-9 was introduced as the official classification system in 1987. This was done in order to avoid national diagnostic bias and increase diagnostic reliability. A comparison with the DSM-III criteria was included in the diagnostic guidelines. The effectiveness of this approach was investigated by comparing the chart ICD-9 diagnoses of 104 psychiatric in- and outpatients from 2 teaching hospitals with the diagnoses obtained by using case record rating forms (criterion diagnosis). According to the criterion diagnoses, the base rate of chart diagnoses of schizophrenia and manic-depressive psychosis was too low, and the base rate of reactive psychosis too high. Several chart diagnoses proved to have low reliability, particularly reactive psychosis, paranoid psychosis, depressive neurosis and personality disorders. The study suggests that the provision of extensive diagnostic guidelines does not necessarily alter previous diagnostic practice. Reasons for these findings and the implications for the ICD-10 diagnostic criteria and diagnostic guidelines are discussed.

Adolescent↗
PubMed2005

Current asthma and respiratory symptoms among pupils in relation to dietary factors and allergens in the school environment.

UNLABELLED: The aim was to study asthma and allergy in relation to diet and the school environment. Pupils (5-14 years) in eight schools received a questionnaire, 1014 participated (68%). Settled dust was collected on ALK-filters and analyzed for allergens from cat (Fel d 1), dog (Can f 1), horse (Equ cx), house dust mites (Der p 1, Der f 1), and cockroach (Bla g 1) by ELISA. In total, 6.8% reported cat allergy, 4.8% dog allergy, 7.7% doctor's diagnosed asthma and 5.9% current asthma, and 7.8% reported wheeze. Current asthma was less common among those consuming more fresh milk (P < 0.05) and fish (P < 0.01). Poly-unsaturated fatty acids was associated with more wheeze (P < 0.05), olive oil was associated with less doctors' diagnosed asthma (P < 0.05). Totally, 74% of the classrooms had mean CO(2) <1000 ppm. The median concentration per gram dust was 860 ng/g Fel d 1, 750 ng/g Can f 1 and 954 U/g Equ cx. Horse allergen was associated with more wheeze (P < 0.05), daytime breathlessness (P < 0.05), current asthma (P < 0.05) and atopic sensitization (P < 0.05). Dog allergen was associated with wheeze (P < 0.05) and daytime breathlessness (P < 0.05). The associations between allergens and respiratory symptoms were more pronounced among those consuming margarine, not consuming butter, and with a low intake of milk. In conclusion, cat, dog and horse allergens in schools could be a risk factor for asthma and atopic sensitization, and dietary factors may interact with the allergen exposure. PRACTICAL IMPLICATIONS: Previous school studies performed by us in mid-Sweden, showed that most classrooms did not fulfill the ventilation standards. In this study, most of the classrooms fulfilled the ventilation standard, but despite that had widespread allergen contamination. Most previous studies have focused on cat allergen, but our study has shown that also dog and horse allergens can be risk factors for asthma and allergy in schools. As allergens are transported from other environments, mainly the home environment, the main prevention should be to minimize transfer of allergens. This could be achieved by reducing contacts with furry pets and horses, or using different clothes at home and at school (e.g. school uniforms). Increased cleaning in the schools may reduce allergen levels, but the efficiency of this measure must be evaluated in further intervention studies. Finally, our study supports the view that dietary habits among pupils should not be neglected and interaction between dietary factors and indoor allergen exposure needs to be further investigated.

Adolescent↗
PubMed1991

A longitudinal study of back pain and radiological changes in the lumbar spines of middle aged women. I. Clinical findings.

The natural history of low back pain was evaluated over a nine year period in two groups of middle aged Dutch women selected from the general population. One group had recurrent back pain (n = 236) and the other group had never experienced back pain (n = 241). At the onset of the study recurrent back pain was associated with smoking, previous use of the 'pill', pain in other joints, frequent headaches, and restricted lumbar spine movement. Nine years later 170 (72%) of the group with back pain had continuing pain and 58 (24%) of the group without previous back pain had incident pain. Pain in other joints, especially the hip and knee, was a predictor of continuing and incident pain but age, body mass index, and smoking were not.

Back Pain↗
PubMedDate not supplied

Public health 101 for informaticians.

Abstract Public health is a complex discipline that has contributed substantially to improving the health of the population. Public health action involves a variety of interventions and methods, many of which are now taken for granted by the general public. The specific focus and nature of public health interventions continue to evolve, but the fundamental principles of public health remain stable. These principles include a focus on the health of the population rather than of individuals; an emphasis on disease prevention rather than treatment; a goal of intervention at all vulnerable points in the causal pathway of disease, injury, or disability; and operation in a governmental rather than a private context. Public health practice occurs at local, state, and federal levels and involves various professional disciplines. Public health principles and practice are illustrated by a case study example of neural tube defects and folic acid. The application of information science and technology in public health practice provides previously unfathomed opportunities to improve the health of the population. Clinical informaticians and others in the health care system are crucial partners in addressing the challenges and opportunities offered by public health informatics.

Birth Certificates↗
PubMed1997

Ethical issues in long-term psychiatric management.

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky?

Adult↗
PubMed2002

Integrated care pathways for vascular surgery: an analysis of the first 18 months.

OBJECTIVES: A review of the use of previously described integrated care pathways (ICPs) established for three elective vascular surgical procedures. DESIGN: A retrospective analysis of information gathered prospectively over an initial 18 month period of use of vascular surgical ICPs. SUBJECT: Patients admitted to a single vascular unit for "open" repair of abdominal aortic aneurysm (AAA), carotid endarterectomy, or femoropopliteal bypass grafting. METHODS: An analysis of variance data, length of stay, and costings after the use of ICPs, compared with previous clinical practice. RESULTS: Variance data were gathered for each of the three procedures. Variances of medication prescribing and delays in discharge were common to all procedures. In particular: (i) gastrointestinal complications were more specific to AAA repair and (ii) wound drains were removed a day later than originally proposed after femoropopliteal bypass. Overall, improved efficiency due to use of ICPs reduced the length of stay for all procedures, which was reflected in a potential cost saving of some 25%. CONCLUSION: There are clear benefits to the use of ICPs, resulting in more structured, efficient, and cost effective patient care. Recommended changes to current practice based on variance analysis will require continued audit to sustain this "evidence based" approach.

Aortic Aneurysm, Abdominal↗
PubMed1985

Sex chromosome mosaicism and infertility in mares.

From the standpoint that cytogenetic screening in mares is seldom necessary as an aid to diagnosis of the gonadal dysgenesis syndrome, a series of double-blind trials were conducted to test the proposal that present practice failed to explore the potential for cytogenetics in clinical practice. It was demonstrated that diagnoses of infertility might be made where mares were found to be of normal phenotype by clinical examination. Such mares were found to be gonosmic mosaics. One stallion had a polymorphism of the X chromosome and had poor conception rates. It was demonstrated that the true value of chromosome testing in clinical stud practice has previously been misinterpreted and underestimated.

Animals↗
PubMed1992

Evaluation of an implantable venous access system in a general oncology population.

Venous access has been a problem for the practicing oncologist. Previous approaches, such as arteriovenous fistulas, grafts, or percutaneous catheters, have not gained widespread acceptability. We report our experiences with 230 Port-a-Cath devices, a totally implantable venous access system. The catheters were placed in 218 general oncology patients for the administration of chemotherapy. One patient had three catheters placed and 10 patients had two catheters each. Most patients received standard bolus chemotherapy, while 25 patients were treated with continuous ambulatory infusions. The catheters were in place for an average of 271 days (range 2-1,427 days) for a total of 62,330 catheter days, representing the largest published experience with devices of this type in cancer patients. A total of 24 complications occurred in 22 patients. Catheter insertion was associated with four pneumothoraces, two of which required chest tube drainage. Five catheters were removed because of infection. There were 6 cases of venous thrombosis, but none resulted in pulmonary embolism. Other complications were manageable and included catheter occlusion, migration, and extravasation of chemotherapy agents. The Port-a-Cath is safe and is associated with a low rate of complications. Implantable venous access systems represent a significant advantage in the management of oncology patients with poor venous access.

Catheters, Indwelling↗
PubMed1996

Patient compliance with crucial drug regimens: implications for prostate cancer.

Understanding of patient compliance with crucial drug regimens has improved markedly since 1986, based on data from two objective methods for monitoring drug dosing by ambulatory patients. Electronic monitoring records times and dates of drug package use, and chemical markers, incorporated into drug dosage forms, are assayed in plasma. These methods remove the camouflage that masks many poor compliers. In contrast, other methods (returned tablet counts, interviews, questionnaires) allow patients easily to censor evidence for delayed or omitted doses. The new methods show many more and larger errors of omission in both trials and practice than previously believed. One patient in about six is punctually compliant, but a modest majority of patients make errors probably too small to attenuate or otherwise modify the actions of all but the most unforgiving medicines. About a third of patients delay or omit many prescribed doses, thus attenuating or otherwise modifying the actions of all but the most forgiving drugs. One patient in about six takes little medicine, though camouflaged as a good complier. Similar patterns of delayed and omitted does prevail, essentially independent of drug, disease, prognosis, or symptoms. In summary, patients take the prescribed dose at intervals longer than prescribed--often by hours, sometimes by days, occasionally by weeks. The clinical and economic consequences of these lapses in dosing are unique to the treatment situation and the severity of disease and comorbidity. The new methods have not yet been applied to androgen-blocking agents, but if the findings resemble those with, e.g. tamoxifen in breast cancer, it will doubtless trigger some rethinking about failed treatment, trial design, and clinical management.

Androgen Antagonists↗
PubMed2005

Competency mapping and analysis for public health preparedness training initiatives.

Competency-based education and assessment initiatives have been completed in a number of health care and health management professions during the past decade. In addition, several competency specification endeavors have been similarly undertaken in relation to the field of public health, including the development of the Council on Linkages between Academia and Public Health Practice competency model and the initial competency modeling Delphi survey completed by the Association of Schools of Public Health. All of these organizations have subsequently had to address the many challenges and barriers to the dissemination and integration of their models into specific educational and professional development practices. As previously addressed by many researchers in the field of competency modeling and deployment, understanding and acceptance of competency-based systems are formidable goals, often rife with controversy. This article describes the processes undertaken by The University of Michigan Center for Public Health Preparedness to integrate competency-based learning and assessment in educational and training initiatives with its many community partners.

Bioterrorism↗
PubMed2004

Atraumatic sutures can be made locally.

The usefulness of fishing line in surgical practice has previously been described in this journal. Now, this usefulness is further enhanced by the possibility of producing an atraumatic suture using a pair of modified pliers.

Dermatologic Surgical Procedures↗
PubMed2003

Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association for Psychopharmacology.

The British Association for Psychopharmacology guidelines specify the scope and target of treatment for bipolar disorder. They are based explicitly on the available evidence and presented, similar to previous Clinical Practice guidelines, as recommendations to aid clinical decision-making for practitioners. They may also serve as a source of information for patients and carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from participants and interested parties. The strength of supporting evidence was rated. The guidelines cover the diagnosis of bipolar disorder, clinical management and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment.

Antidepressive Agents↗