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Internal medicine residents at one school identified barriers to and predictors of publishing their research. Insufficient time was the key obstacle to completing research. Residents with previous research experience, senior residents, and men were more likely to publish.
In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.
Health status measures offer scientific, humanistic, and economic benefits for clinical medicine. The main problem is the many intellectual and pragmatic obstacles that block successful development of these measures. The inventory of such problems includes the following: definition of health; medical components of health status; who makes the choice about what to include and emphasize; attributes to be rated by patients or clinicians; indexes to be created from those attributes (including mega-variable indexes, global indexes, and oligo-category indexes); different measurements of the same entity; and clinimetric problems in nonclinimetric models. Several solutions to these multiple, complex difficulties can be offered: 1) ensure that a specific purpose, focus, and setting are clearly identified for every health status index; 2) recognize that an off-the-shelf index with high statistical scores for so-called reliability and validity may not be pertinent for a given current situation in which it is to be used; 3) avoid indexes involving combinations of excessive numbers of variables; 4) let patients choose the most significant foci and components of the indexes; 5) seek greater communication and understanding among multidisciplinary collaborators, who may have many differences in the ethos and goals with which they approach the construction of health status indexes; and 6) recognize that the construction of suitable health status indexes is an outstanding challenge in basic scientific inquiry, and, in this spirit, support major alterations in the current ideology for conceptualization and funding of what is basic science in clinical medicine.
Genetic association studies have the potential to advance our understanding of genotype-phenotype relationships, especially for common, complex diseases where other approaches, such as linkage, are less powerful. Unfortunately, many reported studies are not replicated or corroborated. This lack of reproducibility has many potential causes, relating to study design, sample size, and power issues, and from sources of true variability among populations. Genetic association studies can be considered as more similar to randomized trials than other types of observational epidemiological studies because of "Mendelian randomization" (Mendel's second law). The rationale and methodology for synthesizing randomized trials is highly relevant to the meta-analysis of genetic association studies. Nevertheless, there are a number of obstacles to overcome when performing such meta-analyses. In this review, the impacts of Type I error, lack of power, and publication and reporting biases are explored, and the role of multiple testing is discussed. A number of special features of association studies are especially pertinent, because they may lead to true variability among study results. These include population dynamics and structure, linkage disequilibrium, conformity to Hardy-Weinberg Equilibrium, bias, population stratification, statistical heterogeneity, epistatic and environmental interactions, and the choice of statistical models used in the analysis. Approaches to dealing with these issues are outlined. The supreme importance of complete and consistent study reporting and of making data readily available is also highlighted as a prerequisite for sound meta-analysis. We believe that systematic review and meta-analysis has an important role to play in understanding genetic association studies and should help us to separate the wheat from the chaff.
PURPOSE: This study reports reliability of the Standardized Walking Obstacle Course (SWOC) and concurrent validity with the Timed Up and Go (TUG) for use in children with and without developmental disabilities. METHODS: Seventy-three children completed the SWOC and TUG during each of two sessions scheduled one week apart. Two raters took measures of time and number of steps on the SWOC to correlate with the same measures on the TUG. RESULTS: Very high interrater reliabilities for time (intercorrelation coefficient [ICC] 0.99) and number of steps (ICC 0.94-0.99) noted. High intrarater reliabilities recorded for time (ICC 0.83-0.97) and number of steps (ICC 0.84-0.96). Significant correlations (p < 0.05) between the TUG and SWOC were moderate to very high for time (r = 0.72-0.90) and number of steps (r = 0.63-0.92). CONCLUSION: The SWOC demonstrates good reliability within and between raters and concurrent validity with the TUG for use with children to establish their functional ambulation capability. The SWOC could easily be used in any setting for any child who can follow the directions and walk without an assistive device. Further testing is needed of the use of the SWOC to detect change and measure the extent of the environment's influence on activity and participation for different populations of children.
OBJECTIVE: The aim of this study was to evaluate the role and efficacy of a total 360 degrees wrap, Nissen-Rossetti fundoplication, after esophagogastromyotomy in the treatment of esophageal achalasia. SUMMARY BACKGROUND DATA: Surgery actually achieves the best results in the treatment of esophageal achalasia; the options vary from a short extramucosal esophagomyotomy to an extended esophagogastromyotomy with an associated partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to esophageal emptying. MATERIALS AND METHODS: Since 1992 to November 2003, a total of 195 patients (91 males, 104 females), mean age 45.2 years (range, 12-79 years), underwent laparoscopic treatment of esophageal achalasia. Intervention consisted of Heller myotomy and Nissen-Rossetti fundoplication with intraoperative endoscopy and manometry. RESULTS: In 3 patients (1.5%), a conversion to laparotomy was necessary. Mean operative time was 75 +/- 15 minutes. No mortality was observed. Overall major morbidity rate was 2.1%. Mean postoperative hospital stay was 3.6 +/- 1.1 days (range, 1-12 days). At a mean clinical follow up of 83.2 +/- 7 months (range, 3-141 months) on 182 patients (93.3%), an excellent or good outcome was observed in 167 patients (91.8%) (dysphagia DeMeester score 0-1). No improvement of dysphagia was observed in 4 patients (2.2%). Gastroesophageal pathologic reflux was absent in all the patients. CONCLUSIONS: Laparoscopic Nissen-Rossetti fundoplication after Heller myotomy is a safe and effective treatment of esophageal achalasia with excellent results in terms of dysphagia resolution, providing total protection from the onset of gastroesophageal reflux.
Alcohol-related injuries comprise a large percentage of injuries in the United States. As the impact of these injuries on society increases, a well-functioning trauma system becomes increasingly important. During the last decade, evidence-based guidelines to reduce alcohol-related injuries have emerged. Further, evidence supports the effectiveness of brief intervention programs to reduce alcohol-related injuries and demonstrates that trauma centers can improve patient outcomes by integrating them into care. Although many obstacles have inhibited progress and made implementing preventive interventions a difficult task, economic constraints are among the biggest challenges to implementing intervention programs as part of routine trauma care.
Despite the demonstrated clinical benefits and decreased risks of injury recurrence, brief alcohol interventions are still not routine practice in trauma centers. Although alcohol and drugs play a significant role in trauma, few trauma specialists are aware of the potential benefits of interventions because alcohol treatment specialists have not widely disseminated their findings to other specialties. This article addresses some key obstacles that must be overcome to facilitate brief interventions as routine trauma practice. Included are discussions on training, cost and reimbursement factors, responsibility of the trauma surgeon, patient privacy and confidentiality issues, insurance laws and regulations, needed collaboration with partners, and research priorities and funding.
The ability to follow gaze (i.e. head and eye direction) has recently been shown for social mammals, particularly primates. In most studies, individuals could use gaze direction as a behavioural cue without understanding that the view of others may be different from their own. Here, we show that hand-raised ravens not only visually co-orient with the look-ups of a human experimenter but also reposition themselves to follow the experimenter's gaze around a visual barrier. Birds were capable of visual co-orientation already as fledglings but consistently tracked gaze direction behind obstacles not before six months of age. These results raise the possibility that sub-adult and adult ravens can project a line of sight for the other person into the distance. To what extent ravens may attribute mental significance to the visual behaviour of others is discussed.
Nonlinear waves in a forced channel flow of two contiguous homogeneous fluids of different densities are considered. Each fluid layer is of finite depth. The forcing is due to an obstruction lying on the bottom. The study is restricted to steady flows. First a weakly nonlinear analysis is performed. At leading order the problem reduces to a forced Korteweg-de Vries equation, except near a critical value of the ratio of layer depths which leads to the vanishing of the nonlinear term. The weakly nonlinear results obtained by integrating the forced Korteweg-de Vries equation are validated by comparison with numerical results obtained by solving the full governing equations. The numerical method is based on boundary integral equation techniques. Although the problem of two-layer flows over an obstacle is a classical problem, several branches of solutions which have never been computed before are obtained.
We describe the escape transition of an ideal chain compressed between finite-sized obstacles. Three different theoretical methods are used and each provides a similar description of the escape transition, as predicted by earlier and less detailed mean-field theories. The first two methods show that thermal fluctuations near the transition can blur what was previously described as a sharp transition. The last method is an exact calculation of the partition function that shows unambiguously the character of the escape transition. This exact calculation overcomes the inherent uncertainties associated with previous theory and computer simulation.
Neuromuscular electrical stimulation (NMES) is an important tool for research in the rehabilitation of lost movements in spinal cord injured patients. However, for NMES to be used outside the laboratory setup, the stimulation controller needs to be able to cope with challenging environmental conditions. A methodology to allow conversion of any specific motor task used to cope with one of these environmental conditions toward a control algorithm for NMES is proposed. The methodology was used in the definition of a stimulation sequence that allows overcoming small obstacles by the spinal cord injured patient. Simulations have proven the method feasibility, and clinical trials have confirmed these findings. Motor task conversion using the kinematic approach has shown better results than that of muscle activity.
To investigate the cause of the detection sensitivity difference depending on direction of the object in the obstacle sense, the experiment to measure the directional characteristics of the echo suppression was made. The conclusion is that one of the causes is the difference of the echo suppression level.
Previous studies have demonstrated that children's goals are associated with their success in peer relationships. The current study extends earlier findings by examining changes in children's goals during hypothetical conflicts. Participants were 252 children ages 9 to 12 years old (133 boys, 119 girls). As predicted, children's goals changed significantly when they encountered obstacles to conflict resolution, and these changes were predictive of their subsequent strategy choices. Both aggressive- and submissive-rejected children were more likely to evidence antisocial changes in their goals, including an increased desire to retaliate. They also showed reluctance to forego instrumental objectives. Other findings highlighted the need to investigate the combinations of goals children pursue as predictors of their strategies and the quality of their peer relationships.
The compliance problem represents a major obstacle in the development of implantable blood pumps. The motor-driven pumps are enclosed in an airtight casing with gas in the motor space. The trapped gas in the motor space either increases the load on the motor during systole or impedes blood sac filling. Potential solutions to the compliance problem include the use of a conventional blood pump with a compliance chamber, a blood pump with an isolated blood sac and accumulator, or a volume-compensated blood pump. Most experimental studies designed to investigate this problem have been performed with compliance chambers. An ideal compliance chamber should accept 100 ml gas with less than a 15-mm Hg increase in pressure and should automatically compensate for changes in atmospheric pressure. To date, two designs have been shown to be effective in laboratory and animal studies: a collapsible rectangular sac design developed by our group, and a lenticular chamber developed by Nosé and associates. Compliance chambers of the former design have now been employed to provide the required compliance for motor-driven assist pumps in long-term calf studies.
Little is known about the incidence of cancer among farmworker populations or about effective strategies for communicating with farmworkers about cancer prevention. Some studies suggest that farmworkers may have unusually high incidences of skin and cervical cancers. With these two cancers as the focus, a group of interviewers, researchers, and health communication specialists set out to create, implement, and evaluate a cancer control demonstration project geared toward farmworkers. In 1994, a situation analysis was conducted to identify constraints and opportunities for providing farmworkers with cancer control information and services. The situation analysis provided valuable information to aid in developing intervention and evaluation strategies. This paper outlines how and why the situation analysis was conducted and what was learned with regard to the farmworker population on the Delmarva Peninsula. Living conditions and the local availability of cancer control services are described. Obstacles to conducting research and interventions with farmworkers are highlighted. Based on what was learned, recommendations are made for designing cancer control research and intervention for farmworkers.
Author notes that inmate suicide continues to pose a serious public health problem within correctional facilities. He reviews the problem, the key components to comprehensive suicide prevention programming, and the obstacles to prevention.
Reported in this paper are reconstructions of shape and material parameters of two-dimensional, homogeneous, acoustic, penetrable obstacles of arbitrary cross-sections which are immersed in an infinite, homogeneous ambience. Reconstructions are based on the far-field scattering patterns of multiple incident plane acoustic waves. For remotely acquired data, practical necessities require not only that the entire data collection region be less than 2 pi, but also that each received "sees" the object over as narrow an angular aperture as possible. The inversions presented here were obtained under such conditions. Two types of data were used for each incidence namely, "near-monostatic" fields of narrow angular apertures (the narrowest aperture reported is 2 degrees), and a "duostatic" geometry consisting of backscatter plus one other receiver angle. These data sets were acquired for a series of incident angles. The theoretical formalism for inversion is algebraic in nature, requires no integral equation, and possesses a number of advantages for the implementation of a Gauss-Newton type of inversion that was used in this study. Moreover, the algorithm is shown to be inheritently parallelizable.