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PubMed1992

Infertility treatment: relative effectiveness of conventional and assisted conception methods.

The effectiveness of infertility treatments is still questioned, particularly the assisted conception methods because of their complexity and cost. Furthermore, pregnancies often occur independent of treatment but many treatments have not been properly evaluated. The most basic audit of outcome with or without treatment requires pregnancy and preferably birth rates to be calculated in a cycle-specific and/or time-specific way; cumulative rates are the preferable method of calculation, in order to account for the usual tendency for fecundity to fall progressively. The choice of treatment usually depends on a balance of the chances of conceiving with or without treatment, and with more or less complicated treatments, and on other factors such as duration of infertility and the woman's age. This review aims to address those choices by assessing the actual and comparative effectiveness of treatments insofar as there are well defined and strictly comparable time-specific or cycle-specific published data available. Cumulative rates are described wherever possible and presented graphically for easy reference.

Female↗
PubMed1986

Drug therapy in the management of acute renal failure.

Pharmacologic intervention aimed at altering the natural history of acute renal failure is a routine practice without scientific support of efficacy. Oliguria has become a separate disease entity with an apparent disregard for the underlying condition that caused it. Volume expansion is clearly beneficial in preventing many volume depleted patients from progressing to acute renal failure. While mannitol and furosemide have been used to "convert" oliguric acute renal failure to the more easy to manage non-oliguric acute renal failure, published reports suggest that responders were not as ill as non-responders. The use of dopamine to increase urine flow in patients with established acute renal failure is the current fashion, but there is little evidence that this drug raises the glomerular filtration rate or shortens the course of acute renal failure. These pharmacologic therapies increase the complexity and cost of care with little tangible evidence of benefit to the patient or the physician caring for the patient.

Acute Kidney Injury↗
PubMed2001

HIV surveillance among men who have sex with men.

OBJECTIVES: To review current approaches to HIV surveillance among men who have sex with men (MSM), identify illustrative best practices and lessons learned, and outline ways to enhance surveillance systems. METHODS: Review of the literature and institutional guidelines for HIV/AIDS, sexually transmitted infection (STI), and behavioral surveillance and summary of results of an international workshop. RESULTS: On-going formative research, HIV/AIDS and STI case reporting, HIV prevalence and incidence studies, and behavioral surveys are essential components of an effective HIV surveillance system for MSM. Alliances with key organizations and actors in MSM communities provide points of access, assist in the development of measures, and guide appropriate use of data. Sampling techniques (convenience, snowball, quota, microsite, time-location, and population-based) offering a range of methods, complexity, and cost have been successfully implemented in MSM communities. Plausible estimates of the size of MSM populations, which are ultimately crucial to the interpretation of surveillance data, can be improved upon using primary and secondary data. CONCLUSIONS: The purpose of HIV surveillance among MSM is not only to monitor disease occurrence and its antecedents, but to regularly use data to plan and evaluate prevention and care programs, advocate for prevention resources, and improve the health, social welfare and human rights of MSM. Practical, incremental steps can be taken to improve HIV surveillance among MSM in all regions of the world in all stages of the epidemic.

Cluster Analysis↗
PubMed1997

Patient education in rheumatology.

Patient education programs in rheumatology are emerging as important therapeutic interventions. The current evidence for their efficacy, economic benefits, and underlying causal mechanisms is discussed. Current meta-analytic studies suggest that patient education can affect knowledge, pain, joint counts, depression, exercise, and coping behaviors. Evidence is presented suggesting that self-efficacy and social support are strong underlying causal mechanisms. Although studies of the economic impact of patient education are still scant, most that exist indicate that the programs evaluated tended to reduce health care service utilization. An example of a complex cost-effectiveness study is discussed.

Adaptation, Psychological↗
PubMedDate not supplied

Development of a new disposable pulsatile pump for cardiopulmonary bypass: computational fluid-dynamic design and in vitro tests.

A newly conceived blood pump for pulsatile cardiopulmonary bypass (CPB) is presented. The new device's main design features (fully disposable pumping head with ring shaped valves) were intended to overcome the factors that today limit the use of pulsatile blood pumps, i.e., the complexity and costs of devices. The pump was designed and analyzed by means of three-dimensional computational models, including solid computer assisted design of the pumping head and computational fluid-dynamic (CFD) analyses of the fluid domain and of its interaction with deformable components. A prototype of the device, integrated with the venous reservoir, was built to perform hydraulic in vitro tests with aims of both validating CFD results and verifying the new device's pumping behavior. Functional evaluation of the pump was carried out by using the device in a model circuit made with standard CPB components plus a mock hydraulic bench representing an adult patient's systemic circulation. A roller pump used in pulsatile mode (RP-PM) was used for comparison. At a 5 L/min flow rate, the pulsatile hydraulic power ( ) delivered to the patient was approximately 15 mW for the RP-PM. The new pump proved to be able to deliver up to 40 mW, thus providing a more physiological condition, closer to the delivered by the natural heart (90-140 mW).

Cardiopulmonary Bypass↗
PubMed2001

Computer-assisted learning in critical care: from ENIAC to HAL.

Computers are commonly used to serve many functions in today's modern intensive care unit. One of the most intriguing and perhaps most challenging applications of computers has been to attempt to improve medical education. With the introduction of the first computer, medical educators began looking for ways to incorporate their use into the modern curriculum. Prior limitations of cost and complexity of computers have consistently decreased since their introduction, making it increasingly feasible to incorporate computers into medical education. Simultaneously, the capabilities and capacities of computers have increased. Combining the computer with other modern digital technology has allowed the development of more intricate and realistic educational tools. The purpose of this article is to briefly describe the history and use of computers in medical education with special reference to critical care medicine. In addition, we will examine the role of computers in teaching and learning and discuss the types of interaction between the computer user and the computer.

Computer Simulation↗
PubMed1996

Risks from radionuclide migration to groundwater in the Chernobyl 30-km zone.

Remediation of contaminated groundwater in the Chernobyl 30-km evacuation zone is frequently identified as a priority by technical experts and Chernobyl site officials in Ukraine. In order to evaluate the health risk basis for this groundwater remediation, we have estimated both on-site and off-site health risks caused by radionuclide migration to the groundwater and compared these risks with those from exposure to radioactive contamination on the ground surface. A simple and conservative analytical model was developed to assess radionuclide transport to the groundwater from the soil surface contaminated by radioactive fallout. 90Sr, the primary radioactive contaminant of concern for the groundwater-migration exposure pathway, was evaluated in the analysis. The estimated health risk to hypothetical, self-sufficient residents in the 30-km zone is dominated by external and internal irradiation (due primarily to ingestion of agricultural products) from 137Cs, which is present in soils of the 30-km zone in roughly equal proportion with 90Sr. The estimated risk from contaminated groundwater is approximately an order of magnitude lower. Analysis of 90Sr migration via groundwater to surface water and down-river population centers shows that, despite generally unfavorable environmental conditions in the 30-km exclusion zone, radionuclide transport via the groundwater pathway has potential to contribute only marginally to the off-site radiological risk, which is governed by wash-out of radionuclides from the contaminated river flood plain and catchment areas by surface water during spring snowmelt and rains. Health risks due to off-site radionuclide migration via groundwater are below the level requiring application of counter-measures. This analysis implies that, relative to other exposure pathways, there is little current or future health risk basis for the proposed complex and costly groundwater remediation measures in the 30-km zone. Therefore, these activities should be abandoned in favor of more pressing health issues caused by the Chernobyl accident.

Humans↗
PubMedDate not supplied

Comprehensive radiological equipment management program.

The increasing cost and complexity of state-of-the-art radiological equipment, and the need for more comprehensive safety and performance assurance, have increased maintenance expenditures to a level where they have become one of the largest operating expenses of radiology departments. To cope with this ever increasing expenditure, a comprehensive in-house maintenance program was implemented in our institution. This program properly balanced the capability of the radiology department's in-house technical personnel with support provided by equipment manufacturers' service organizations. Quality assurance activities are also included as an integral part of the entire program. Since the implementation of the program, an average 40% reduction in the annual maintenance expenditure has been observed.

Hospital Bed Capacity, 300 to 499↗
PubMed1995

Drug profiles: maximizing therapeutic effectiveness.

Major cardiac events are inevitably followed with a pharmacologic plan of therapy for cardiac patients. Careful assessment of the patient's drug regimen is an important aspect of cardiovascular nursing practice. Such assessment will reveal implications for education, compliance counseling, and side effect evaluation. A thorough drug history should include information about both prescription and nonprescription drug use. Assessment for adherence is improved by using supportive, open-ended questions. Assessment for side effects that affect quality of life is important, particularly in the area of sexual dysfunction. Sexual function should be assessed before beginning cardiovascular drug therapy and monitored for changes during treatment. Using principles of chronopharmacology, or therapy based on the time-dependent effects of drugs, nurses can schedule cardiovascular medications and evaluate patient responses in relation to circadian variability in vulnerability and symptoms. Assessment for ease of self-management of the drug regimen should be a particular focus with non-English-speaking patients and those with complex or costly drug regimens.

Cardiovascular Agents↗
PubMed2004

Evaluating the chief nurse executive: reflections on the process.

Performance improvement of chief nurse executives (CNEs) is an integral part of a healthcare organization's program of continuous improvement. However, the process of evaluating CNEs is an increasingly complex and costly one. This is, in part, because the formal evaluation process for a CNE of a stand-alone hospital building is considerably different from that of a CNE in an integrated health-care system of hundreds or several thousand nursing personnel. Reflecting on staff's perceptions of the CNE evaluation process in a large system, the author highlights major concerns related to issues of trust, their careers, the organization, their patients, and themselves.

Adult↗
PubMed1990

Risk reduction from low osmolality contrast media. What do patients think it is worth?

Decisions regarding the use of and reimbursement for new medical technologies frequently involve complex cost-quality trade-offs. Among physicians, hospital administrators, and insurers, interindividual variation in the value of benefits attributable to these technologies often leads to conflicting opinions about their appropriate use. Although society now encourages patient involvement in such decisions, few methods for obtaining patient valuations have been developed and systematically applied. In order to assess patient valuations of a particular new technology, low osmolality contrast media (LOM), a survey of 100 outpatients was conducted. Participants were asked about their willingness to pay (WTP) for the benefits of this expensive medical technology. Of the 95 subjects who completed the study questionnaire, a majority were unwilling to pay the minimum extra per procedure cost of LOM ($50) in return for a reduced risk of minor side effects alone (pain, nausea, hives, and flushing). For a reduced risk of both major side effects (death, renal insufficiency, severe allergic reaction, and cardiac arrhythmia) and minor side effects, the median WTP was $50; patient income and education were directly associated with WTP $50 or more. We conclude that similar WTP surveys may be helpful in addressing other difficult cost-quality issues.

Adult↗
PubMed1999

Effects of physical inactivity and obesity on morbidity and mortality: current evidence and research issues.

PURPOSE: The purpose of this review was to address three specific questions. 1) Do higher levels of physical activity attenuate the increased health risk normally observed in overweight or obese individuals? 2) Do obese but active individuals actually have a lower morbidity and mortality risk than normal weight persons who are sedentary? 3) Which is a more important predictor of mortality, overweight or inactivity? METHODS: We initially identified more than 700 articles that included information on the exposure variables of body habitus (body mass index, body composition, or body fat pattern) and physical activity habits, and on outcomes such as morbidity or mortality. To be included in the review, we required that an article include an analysis of one of our outcomes by strata of the two exposure variables. We excluded review articles and reports of cross-sectional analyses. We used an evidence-based approach to evaluate the quality of the published data. RESULTS: We summarized results from 24 articles that met all inclusion criteria. Data were available for the outcomes of all-cause mortality, cardiovascular disease mortality, coronary heart disease (CHD), hypertension, type 2 diabetes mellitus, and cancer. Summary results for all outcomes except cancer were generally consistent in showing that active or fit women and men appeared to be protected against the hazards of overweight or obesity. This apparent protective effect was often stronger in obese individuals than in those of normal weight or who were overweight. There were too few data on cancer to permit any conclusions. CONCLUSIONS: There are no randomized clinical trials on the topics addressed in this review. All studies reviewed were prospective observational studies, so all conclusions are based on Evidence Category, C. The conclusions for the three questions addressed in the review are: 1) regular physical activity clearly attenuates many of the health risks associated with overweight or obesity; 2) physical activity appears to not only attenuate the health risks of overweight and obesity, but active obese individuals actually have lower morbidity and mortality than normal weight individuals who are sedentary, and 3) inactivity and low cardiorespiratory fitness are as important as overweight and obesity as mortality predictors. Research needs include extending current observations to more diverse populations, including more studies in women, the elderly, and minority groups, assessment methods need to be improved, and randomized clinical trials addressing the questions discussed in this review should be undertaken. Owing to size, complexity, and cost, these trials will need to be designed with valid noninvasive measures of subclinical disease processes as outcomes.

Cardiovascular Diseases↗
PubMed1997

Primary care management of acute low back pain.

Acute low back pain will affect more than 80% of the population, with more than 28% of the industrial workforce suffering from lost work. Acute low back pain is recognized as the third most common illness presenting to private practice groups. The psychosocial overtones of depression and anxiety that often coexist or predate the episode of acute low back pain add to its complexity and cost. Diagnosis and treatment options are reviewed based on the Agency for Health Care Policy and Research recommendations of 1994. This article reviews details of the history and physical with emphasis on the importance of a thorough neurologic and psychologic evaluation. "Red flags" that should warn the clinician of the presence of a more acute illness are discussed with recommendations for referral. The treatment of acute low back pain now centers on increasing mobility and functional use of the spine as soon as possible. Nonsteroidal anti-inflammatory agents as well as aspirin and acetaminophen are recommended as first-line drug treatments; they have been found to be equally as effective as muscle relaxants and opioids for the control of pain without the burden of dependence and potential for abuse.

Acute Disease↗
PubMed1999

A way to reduce the radius of rotation in brain SPET with a single-head system.

To optimize spatial resolution in single photon emission tomography (SPET), it is essential to minimize the radius of rotation. In brain studies, different methods have been used to avoid shoulder interference when the radius of rotation is minimized: rectangular fields of view, modifications to the shielding around circular detectors and fan or cone beam collimators. However, few single-head systems can adopt these developments, particularly older cameras. A non-standard image acquisition method to reduce the radius of rotation in brain SPET with a single-head gamma camera is presented. The method applies a defined transformation to the original acquired images, maintaining the whole of the brain inside the field of view without shoulder interference and meeting the condition: pixel size < or = FWHM/3. With this method, it is possible to reduce the radius of rotation to 16 cm and to obtain a transaxial spatial resolution of 15.98 mm, which is 3.5 mm less than with the standard method used in our laboratory. This procedure was implemented for a Siemens Gammasonics ZLC 3700 gamma camera and has been validated in single-slice brain phantom studies. The method has the advantage of not requiring any complex or costly hardware.

Brain↗
PubMedDate not supplied

Use of evidence for prevention of work-related musculoskeletal injuries.

Work-related injuries among nurses are a complex and costly problem. To thoughtfully approach this issue, one medical center developed a set of injury-reduction strategies and related tools based on a review of research literature and locally obtained evidence. This article describes the evidence-based approach to prevention of work-related musculoskeletal injuries. It also covers research-based observations about prevention strategies; provides a description of selected interventions, such as a patient handling guide; and includes sample tools that enable collection of meaningful data about local patient handling practices.

Ergonomics↗
PubMed1993

Dose-response and concentration-response relationships: clinical and regulatory perspectives.

There are a number of effective but highly toxic drugs that exhibit a narrow therapeutic index and marked intersubject variability in pharmacokinetics (PK). Examples of these drugs included digoxin, theophylline, aminoglycosides, and anticancer (methotrexate) and immunosuppressive agents (cyclosporin A and FK-506). Optimal therapy with such drugs requires therapeutic drug monitoring (TDM) in order to safely obtain the desired clinical effects. The success of concentration-guided therapy with these drugs underscores the importance of using TDM and pharmacodynamic response (PD) to establish an appropriate balance of efficacy and toxicity through individualization of dosing. Although dose control has been the traditional paradigm for defining efficacy, safety, and dose response, it has recently been proposed that a concentration-oriented strategy of drug evaluation may facilitate the discovery of optimal doses and expedite new drug approval. However, as in medical therapeutics, the implementation of concentration-guided drug development may add to the complexity and cost. Therefore, it is important to assess the relative merits and limitations of dose-response and concentration-response (CR) strategies for establishing rational dosage information (e.g., a useful therapeutic range). Critical factors that have an effect on the ability to characterize dose-response/concentration-response relationships in clinical trials include study design, compliance, method of analysis, and sources of pharmacologic (PK-PD) variability. In this report, we describe the state of the art, based on a selected survey of successful dose-response studies. We give an example of a promising alternative strategy for evaluating CR for an immunosuppressive drug (FK-506) based on target drug concentrations extrapolated from preclinical models.

Animals↗
PubMed2002

CD3 monitoring of antithymocyte globulin therapy in thoracic organ transplantation.

BACKGROUND: Antithymocyte globulin is frequently used as a component of induction therapy in thoracic organ transplantation. This study evaluates the utility of monitoring peripheral CD3 lymphocytes to rationally adjust antithymocyte globulin therapy in this patient population. METHODS: A total of 17 heart and 19 lung transplant recipients received antithymocyte globulin (ATGAM or thymoglobulin) as induction therapy or to treat steroid-resistant acute or chronic rejection. Absolute CD3 counts were maintained between 50 and 100 cells/microl. RESULTS: With CD3 monitoring, the doses of antithymocyte globulin were reduced from 10-15 mg/kg to 1-5 mg/kg during the course of therapy. The total amount of antithymocyte globulin given to each CD3 monitored patient was reduced by 48%. Dose reduction did not alter the number of acute rejection or infectious episodes, and hematological side effects were infrequent. CONCLUSION: CD3 monitoring of antithymocyte globulin therapy in thoracic organ recipients reduced the amount of drug received by each patient, while maintaining CD3 counts less than 100 cells/microl.

Acute Disease↗
PubMed1986

Biological monitoring of agricultural workers exposed to pesticides: II. Monitoring of intact pesticides and their metabolites.

Analytical methods have been developed for the detection of a variety of compounds that are found intact or as metabolites in biological samples from workers exposed to pesticides. Such tests are used primarily in research settings to describe patterns of absorption, metabolism, and excretion, to derive exposure limits for occupational exposure, to evaluate the adequacy of these limits and of work practices in field settings, and to confirm the etiology of poisonings for medicolegal purposes. We review here methods used in studies of occupational pesticide exposure, with particular attention to validation in terms of dose-response relationships, to technical complexity and cost, to the requirements for analytical quality control, and to the utility of these methods for field research purposes. Biological monitoring for intact pesticides or metabolites in agricultural workers is limited to a few chemicals, notably, pentachlorophenol, methyl bromide, and chlordimeform. These programs and their use in regulation and enforcement are described.

Agricultural Workers' Diseases↗