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Of rescue and responsibility: learning to live with limits.

Universal access to health care is still a dream rather than a reality in the United States. This is partly because a rule of rescue, by impelling us to help people in need, urges us to ignore the limits of our health care policies wherever those limits would adversely affect a given individual. As the rule of rescue undermines whatever limits we set on health care entitlements, it can thwart the cost containment so essential to expanding access. Rather than accept unlimited expense, we have thus far declined to universalize health care. The situation is exacerbated by an economic insulation shielding patients and physicians from the costs of care, prompting both to regard health care as free, an unlimited right. To reverse this costly entitlement mentality and place reasonable limits on rescue, patients must exercise greater personal responsibility for the costs of their care by directly experiencing some of the economic consequences of their health care decisions. Several mechanisms are available to accomplish this goal without posing economic barriers to needed care or penalizing people for becoming ill.

Federal Government↗

[Medical informatics education at medical schools in Bosnia and Herzegovina].

AIM: Standardization of education process and almost every aspect of life in EU moved the authors of this paper to evaluate medical informatics education at medical schools in Bosnia and Herzegovina. A very complex political structure and existence of two entities, one district and ten cantons in the Federation of Bosnia and Herzegovina caused great differences in the curricula, teaching methods and quality of acquired knowledge among medical schools in the country. Also, on the example of the teaching process at the Medical School, University of Sarajevo, the authors propose a future united and integrated system in the area. METHOD: Method of the study is descriptive, comparing education in medical informatics at five B&H medical schools. Over 500 students answered questionnaires designed at medical schools in Sarajevo and Tuzla. The questions tackled the contents of the subject of medical informatics, the possibility of acquiring knowledge from both practical and theoretic lessons, "good" and "bad" sides of the curricula as well as students' computer literacy. RESULTS: The subject of medical informatics is being taught in at least 3-4 different ways. Medical schools in Banja Luka and Foca/Srbinje are under a strong influence of the University of Belgrade, Serbia and Montenegro; the teaching staff in Mostar are from Croatia; the University of Tuzla has its own way; and Medical School in Sarajevo maintains high quality values and principles. Things and events that distinguish the Medical School, University of Sarajevo is the fact that it is the only medical school in Bosnia and Herzegovina which has a web site of of the Department of Medical Informatics, organized a number of events including a distance learning course, and has a highly competent teaching staff. Medical School in Sarajevo is the oldest medical school in Bosnia and Herzegovina established in 1944. As a required subject, medical informatics was introduced in the academic year 1992/1993, and it is the only medical school in Bosnia and Herzegovina where medical informatics is taught in two semesters, second and eleventh. DISCUSSION: Three important areas are discussed: the quality of education in secondary schools should be improved; the lack of multimedia equipment, good LAN, high-speed connection to Internet and well organized web design, and issues related to maintenance of equipment; and students should have free access to computer rooms to enable them to extend their knowledge in spare time; general information about health system should be available to students to allow them to require the role and importance of medical informatics in "real life". Naturally, we raise the question of unique and systematic medical informatics education in the whole country, irrespective of entities, nationality or religion of students. CONCLUSION: Medical informatics education at Medical School, University of Sarajevo, is based on the same concept as on prestigious universities all over the world and in accordance with recommendations of the working groups on education of EFMI and IMIA. Other medical schools in Bosnia and Herzegovina should employ the same methodology and system of work in order to have standardized education in medical informatics and to achieve high quality in education. To enable us to follow the European and global achievements in this area, the power of fact should predominate in the education system as well as in the health system.

Bosnia and Herzegovina↗

Clinical and prophylactic trials with assured new treatment for those at greater risk: I. A design proposal.

OBJECTIVES: The accepted sine qua non for estimating the difference in efficacy between a new and a standard treatment is a randomized controlled clinical trial. Yet in some situations it is either practically or ethically impossible to conduct such a trial. For example, patients who are desperately ill may decline to participate when they learn they may not receive the new treatment, especially when that treatment is readily available outside the experimental protocol. Likewise, in a prophylactic trial of a promising vaccine, recruitment of persons at greater risk may falter or fail. Our objective is to demonstrate that a rigorous comparison of treatments may still be attainable. METHODS: The features of a controlled clinical or prophylactic trial are reviewed from the perspectives of Food and Drug Administration regulations, ethical considerations, and practical problems. RESULTS: An explicit risk-based allocation method of design and analysis is proposed, one guaranteeing that all subjects at greater risk will receive the new treatment. CONCLUSIONS: Under certain conditions, a risk-based allocation trial can furnish consistent estimates of both standard and experimental treatment effects for those at greater risk while avoiding certain difficulties caused by randomized treatment allocation.

Control Groups↗

[Psychological situation of home care patients in the Federal Republic of Germany].

The demographic development, advances in medicine and also the increase in AIDS and paraplegia at an early age means that we must assume approximately two million people in Germany requiring care and attention or nursing on a longterm basis. Object of the explorative pilot-study is to analyse the conditions for mental well-being in the case of homecare patients and the influence on behaviour, enjoyment of life and the quality of their hopes for the future. In the study two comparable random surveys have been examined in all their demographic and medical characteristics: (1) homecare patients (n = 60) and (2) patients in old people's or nursing homes (n = 30); in so far as they can be compared, another random survey of younger homecare patients (n = 33) will be taken into consideration in some of the questions. Under examination is the hypothesis that the well-being of people requiring nursing is considerably dependent upon (1) the quality, activity and diversity of their social network (social assistance), (2) the extent of their own competence and deficiences (subjective level of performance), (3) the history of illness and the subjective health status (subjective health status), (4) the way in which they interpret and cope with their own illness (situative positioning), (5) their domestic surroundings, the sociodemographic situation and the subjective creative freedom (ecology), (6) the person's lifestyle and the quality of his prophylactic behaviour (biographical behavioural manner), (7) their ideas, opinions and convictions relating to the alternatives homecare and old people's or nursing home. General findings to be emphasized in the case of homecare patients--compared with patients in old people's or nursing homes--are that: homecare facilitates and/or encourages (1) greater personal freedom, own control over the environment, familiarity, security, variety, challenge, individuality, good care and attention, activation of needs, appetite, future orientation (well-being). (2) a higher level of active social contacts (ringing other people; visiting friends, neighbours, family; writing letters, holidays) and passive social contacts (visits, telephone calls and mail from friends, relatives, etc.) Instead of resignedly conforming to the situation, they are receptive for stimulation, learning, positive interpretation of the situation. (3) more possibilities for social contacts, communication, social stimulation: everyday pleasures are experienced more frequently.(ABSTRACT TRUNCATED AT 400 WORDS)

Acquired Immunodeficiency Syndrome↗

The EMS response to the Oklahoma City bombing.

This is a descriptive study of the Emergency Medical Services response to a bombing of a United States Federal Building in Oklahoma City, Oklahoma on 19 April 1995. The explosion emanated from a rented truck parked in the front of the building. The force of the explosion destroyed three of the four support columns in the front of the building and resulted in a pancaking effect of the upper floors onto the lower floors. There were three distinct phases of the medical response: 1) Immediately available local EMS ambulances and staff; 2) Additional ambulances staffed by recalled, off-duty personnel; and 3) mutual-aid ambulances and personnel from the surrounding communities. There were 361 persons in the building at the time of the explosion, 163 of these perished. Within the first hour of the explosion, 139 patients were transported to area hospitals. Of these, 32% were in critical condition. During the day of the explosion, 444 persons were treated for physical injuries: 410 of these were related to the explosion and 14, including one with fatal injuries, were sustained during search and rescue attempts. A total of 354 (80%) were treated and released from emergency departments, and 90 (20%) were admitted to hospitals. Six of the transported victims either were dead on arrival to the emergency department or died after admission to the hospital. Of those who died, 95% of the deaths were related to blunt trauma associated with the collapse of the structure. Only three persons were extricated alive after the first five hours following the explosion. The scene became flooded with volunteers who, although their intentions were to provide help and aid to those injured, created a substantial logistical problem for Incident Command. Several other lessons were learned: 1) Telephone lines and cells became overloaded, but the Hospital Emergency Administrative Radio system was operational only in three of the 15 hospitals; 2) Volunteer personnel should have responded to the hospitals and not to the scene; and 3) Training was an essential for the success of such a response. Thus, the success of this operation was a function of the intense training, practice, and coordination between multiple agencies.

Emergency Medical Services↗

Protecting rare, old-growth, forest-associated species under the Survey and Manage Program guidelines of the Northwest Forest Plan.

The Survey and Manage Program of the Northwest Forest Plan (NWFP) represents an unparalleled attempt to protect rare, little-known species associated with late-successional and old-growth forests on more than 9.7 million ha of federal lands. Approximately 400 species of amphibians, bryophytes, fungi, lichens, mollusks, vascular plants, arthropod functional groups, and one mammal were listed under this program because viability evaluations indicated the plan's network of reserve land allocations might not sustain the species over time. The program's standards and guidelines used an adaptive approach, protecting known sites and collecting new information to address concerns for species persistence and to develop management strategies. Since implementation in 1994, approximately 68,000 known sites have been recorded at an expense of several tens of millions of dollars. New knowledge from surveys reduced concern for nearly 100 species, and they were removed from the protection list. Although successful in protecting hundreds of rare species not typically considered in most conservation programs, some of the enacted conservation measures created conflicts in meeting other management objectives of the plan, particularly timber harvest. The program accrued important gains in knowledge, reduced uncertainty about conservation of a number of species, and developed new methods of species inventory that will be useful in future management planning and implementation at many scales. The program, however was not completed because of changes in land-management philosophy. Ongoing litigation regarding its termination and potential changes to the plan cast further uncertainty on how the original goal of maintaining persistence of late-successional and old-growth species will be met and measured. The outcomes, controversies, and management frustrations of the program exemplify the inherent difficulties in balancing broad, regional conservation goals with social and economic goals of the NWFP Defining acceptable trade-offs to reach that balance and developing practical conservation solutions remain challenges for the science and management communities. Lessons learned from the program provide a valuable biological and managerial reference to benefit future discussion on meeting those challenges.

Amphibians↗

Deception methods in psychology: have they changed in 23 years?

To learn whether criticism and regulation of research practices have been followed by a reduction of deception or use of more acceptable approaches to deception, the contents of all 1969, 1978, 1986, and 1992 issues of the Journal of Personality and Social Psychology were examined. Deception research was coded according to type of (non)informing (e.g., false informing, consent to deception, no informing), possible harmfulness of deception employed (e.g., powerfulness of induction, morality of the behavior induced, privacy of behavior), method of deception (e.g., bogus device or role, false purpose of study, false feedback), and debriefing employed. Use of confederates has been partly replaced by uses of computers. "Consent" with false informing declined after 1969, then rose in 1992. Changes in the topics studied (e.g., attribution, socialization, personality) largely accounted for the decline in deception in 1978 and 1986. More attention needs to be given to ways of respecting subjects' autonomy, to appropriate debriefing and desensitizing, and to selecting the most valid and least objectionable deception methods.

Behavioral Research↗

In their own words: lessons learned from those exposed to anthrax.

OBJECTIVES: We evaluated perceptions of workers at the US Postal Service Brentwood Processing and Distribution Center and US Senate employees regarding public health responses to the anthrax mailings of October 2001. We generated recommendations for improving responses to bioterrorism on the basis of the perceptions we recorded. METHODS: Transcripts from focus groups conducted with Brentwood and US Senate employees were examined, and qualitative analysis identified common domains. RESULTS: Brentwood focus groups consisted of 36 participants (97% African American and 19% hearing impaired). US Senate focus groups consisted of 7 participants (71% White and 0% hearing impaired). The focus groups revealed that participants' trust in public health agencies had eroded and that this erosion could threaten the effectiveness of communication during future public health emergencies. Among Brentwood participants, lack of trust involved the perception that unfair treatment on the basis of race/ethnicity and socioeconomic status had occurred; among US Senate participants, it derived from perceptions of inconsistent and disorganized messages. CONCLUSIONS: Effective communication during a public health emergency depends on the provision of clear messages and close involvement of the affected community. Diverse populations may require individualized approaches to ensure that messages are delivered appropriately. Special attention should be given to those who face barriers to traditional modes of communication.

Black or African American↗

Coastal seas as a context for science teaching: a lesson from Chesapeake Bay.

Lessons that employ authentic environmental data can enhance the ability of students to understand fundamental science concepts. This differs from traditional "environmental education" in that school curricula need not set aside time for educators to teach only environmental topics. Rather, the "environment" is used to advance student learning in science and technology. The success of this approach depends on programs that encourage scientists to communicate more effectively with teachers at all education levels. The expanding diversity of research and monitoring activities on the world's marine waters constitutes an outstanding potential education resource. Many of these projects involve remote sensing with sophisticated instrumentation and employ Internet technology to compile measurements, interpret data using graphs and satellite imagery, and share the results among scientific colleagues and the general public alike. Unfortunately, these resources, which constitute a much shortened path between research findings and textbook presentation, are seldom interpreted for use by K-12 educators. We have developed an example that uses the Chesapeake Bay as a paradigm to demonstrate how such interpretation can assist educators in teaching important principles in physical oceanography and marine ecology. We present this example using PowerPoint to conduct a virtual tour of selected Internet sources. Our example begins with the conceptual "salt wedge" circulation model of Chesapeake Bay as a partially mixed estuary. Teachers have the opportunity to explore this model using salinity, temperature, and dissolved oxygen data taken from a research vessel platform during summer professional development programs. This source of authentic data, originally obtained by teachers themselves, clearly demonstrates the presence of a picnocline and deep-water anoxia. Our lesson plan proceeds to interpret these data using additional Internet-based resources at increasing scales of time and space. The "salt wedge," picnocline, and anoxia are examined using graphics derived from data taken by researchers using "ScanFish," a towed instrument that samples temperature, salinity, and dissolved oxygen at a resolution of only a few meters vertically and horizontally. The seasonal dynamics of these parameters at a given location are interpreted using biweekly monitoring data obtained as part of the state-federal Chesapeake Bay Program. The influence of annual variations in freshwater input is examined using stream flow data from US. Geological Survey gauging stations. Satellite remote sensing images from the TOPEX/Poseidon project are used to show how El Niño and La Niña events in the mid-Pacific affect the Chesapeake Bay system via rainfall on its watershed. Finally, the life cycle of the blue crab (Callinectes sapidus) is presented to show how an estuarine organism has adapted to this truly unique and dynamic coastal environment.

Animals↗

Uncertainties for endocrine disrupters: our view on progress.

The hypothesis that hormonally active compounds in the environment--endocrine disrupters--are having a significant impact on human and ecological health has captured the public's attention like no other toxicity concern since the publication of Rachel Carson's Silent Spring 1962. In the early 1990s, Theo Colborn and others began to synthesize information about the potential impacts of endocrine-mediated toxicity in the scientific literature (Colborn and Clement, 1992) and the popular press (Colborn et al., 1997). Recognizing the possibility of an emerging health threat, the U.S. Environmental Protection Agency (EPA) convened two international workshops in 1995 (Ankley et al., 1997; Kavlock et al., 1996) that identified research needs relative to future risk assessments for endocrine-disrupting chemicals (EDCs). These workshops identified effects on reproductive, neurological, and immunological function, as well as carcinogenesis as the major endpoints of concern and made a number of recommendations for research. Subsequently, the EPA developed a research strategy to begin addressing the recommendations (EPA, 1998a), and the federal government as a whole, working through the White House's Committee on the Environment and Natural Resources, increased funding levels and coordinated research programs to fill the major data gaps (Reiter et al., 1998). In parallel with these research efforts that were attempting to define the scope and nature of the endocrine disruptor hypothesis, the U.S. Congress added provisions to the Food Quality Protection Act (FQPA) and the Safe Drinking Water Act of 1996 to require the testing of food-use pesticides and drinking water contaminants, respectively, for estrogenicity and other hormonal activity. These bills were enacted into law, giving the EPA the mandate to implement them. The EPA, with the help of an external advisory committee, the Endocrine Disruptor Screening and Testing Advisory Committee (EDSTAC), determined that other hormonal activity should include androgens and compounds that affect thyroid function, and expanded the mandate to include all chemicals under EPA's jurisdiction, potentially including the 70,000 chemicals regulated under the Toxic Substances Control Act (Endocrine Disruptor Screening and Testing Advisory Committee [EDSTAC], 1998). EDSTAC recommended an extensive process of prioritization, screening, and testing of chemicals for endocrine-disrupting activity, including a screening battery that involves a combination of at least eight in vitro and in vivo assays spanning a number of taxa (EDSTAC, 1998). What started out as a hypothesis has become one of the biggest testing programs conceived in the history of toxicology and the only one that has ever been based on mechanism of action as its premise. As we pass the 10th anniversary of the emergence of the endocrine disruptor hypothesis, it is useful to look back on the progress that has been made in answering the nine questions posed as data gaps in the EPA's research strategy (EPA, 1998a)--not only to see what we have learned, but also to examine whether the questions are still appropriate for the goal, what gaps remain, and what directions should be emphasized in the future.

Animals↗

The teaching of anatomy: the first hundred years (1905-2005).

The Straits and Federated Malay States Government Medical School started on 3 July 1905 with the admission of 16 young persons for the full 5-year course. In 1910, 7 successful candidates qualified as medical practitioners and they were no more than 19 years of age. The medical course was based largely on the British system and consisted of 2 years of training in the basic sciences followed by 3 years of clinical clerkships in Medicine, Surgery and Midwifery. Anatomy was taught in the first year and extended into the second year, using cadavers (which were possibly fixed in formalin and glycerin) as study materials. The first Chair of Anatomy was established in 1922 and with the provision of full-time staff, the curriculum was brought in line with those conducted in the British colonies. From the mid-1960s to the mid-1990s, the Anatomy course for medical students spanned 1 1/2 years, with special emphasis on clinical applications, thereby projecting the professional relevance of the course. Big class lectures introduced and previewed important structures that were encountered in dissections and small group tutorials reviewed the tutorial objectives that had been made available earlier. In the late 1990s and early 2000s, the medical curriculum was further revised to meet the challenges of the 21st century. A track system was developed and Human Anatomy came under the "Human Structure and Development Track". The original 1 1/2 -year programme was tailored into a 1-year programme with a drastic reduction in teaching/contact hours, but the big class lectures and small group tutorials plus dissections/prosections were retained. Beginning in the academic year 2003/2004, prosected cadavers (dissected by professional staff) were employed for teaching purposes due to a progressive fall in the availability of cadavers and time constraints imposed by the introduction of several new modules. Teachers demonstrate and students learn on prosected materials and the success of this new mode of teaching-learning can only be seen in the near future.

Anatomy↗

[Teaching of psychosomatic medicine and psychotherapy as an element of the Dresden DIPOL-Curriculum -- the PBL-course "Nervous system" and psyche].

A federal law, the "Approbationsordnung für Arzte", regulates Medical education in Germany. In 2002 a revised version of this law demanded of the medical faculties to implement interdisciplinary and problem-based (PBL) courses in their curriculum. Already in 1998 the faculty of medicine of the TU Dresden decided to reform the traditional curriculum. The reform-curriculum is being created in close co-operation with the Harvard Medical School. It is a hybrid curriculum retaining traditional elements as lectures and bedside teaching with PBL-tutorials and a special doctor-patient-communication-training, which is based on role-play exercises. Psychosomatic Medicine is taught together with neurology and psychiatry as a major topic of the 7,5-week PBL-course "Nervous System and Psyche" but there are also lectures and special skills training exercises in other PBL-courses like "Oncology" or "Emergency medicine". Data of the external evaluation showed, that the students accepted psychosomatic topics of the curriculum very well. This paper describes concept, implementation and evaluation data of the PBL-course "Nervous System and Psyche".

Clinical Competence↗

Learning from our patients: one participant's impact on clinical trial research and informed consent.

This Perspective includes an essay on modifying phase I clinical trials, written by George Zimmer, who was a professor of English and a commentary on that essay. Professor Zimmer was a cancer patient who participated in the phase I clinical trial program at the University of Chicago. His ideas are eloquently expressed and have had a profound effect on our investigational research for anticancer agents. Although at times his suggestions may seem radical, Professor Zimmer urges us to reconsider the 50-year-old Nuremberg paradigm that participants in human research are ignorant and vulnerable and must be protected. Although we must protect patients who have life-threatening diseases from coercive inducements and misplaced hopes, we must also listen carefully and thoughtfully to our patients. This is particularly true when, as research participants in the face of sacrifice and the threat of a life-ending diagnosis, they have made the effort to express their concerns. With the effect of the acquired immunodeficiency syndrome movement on clinical studies and on drug research and development, a precedent has been set that allows patients to reshape their role as participants in research trials. On a personal level, the essay by Professor Zimmer has had a significant effect on our research methods and, indeed, the focus of our research efforts. Thus, it is with a sense of respect and honor that we share George Zimmer's thoughts and our comments about the influence he has had on our research practices.

Acquired Immunodeficiency Syndrome↗

Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions.

The threat of a BT event has catalyzed serious reflection on the troublesome issues that come with event management and triage. Such reflection has had the effect of multiplying the efforts to find solutions to what could become a catastrophic public health disaster. Management options are becoming more robust, as are reliable detection devices and rapid access to stockpiled antibiotics and vaccines. There is much to be done, however, especially in the organizing, warehousing, and granting/exercising authority for resource allocations. The introduction of these new options should encourage one to believe that, in time, evolving standards of care will make it possible to rethink the currently unthinkable consequences. Unfortunately the cost of such preparedness is high and out of reach of most governments. Most of the developing world has neither the will nor the means to plan for BT events and remains overwhelmed with basic public health concerns (i.e., water, food, sanitation, shelter) that must take priority. Therefore, developed countries will be expected to respond using international exogenous resources to mitigate the effects of such a disaster. As a result, the state capacity of the effected government will be severely compromised. If triage and management of casualties is further compromised, terrorists will have met their goals. One could argue that health sciences will continue for decades to play catch up with the advanced technology driving potential bioagent weaponry. If one lesson was learned from the review of the former Soviet Union's biological weapons program, it is that the unthinkable remains an option to terrorists who have comparable expertise. It is crucial to develop realistic strategies for a BT event. Triage planning (the process of establishing criteria for health care prioritization) permits society to see cases in the context of diverse moral perspectives, limited resources, and compelling health care demands. This includes a competent and compassionate management and triage system and an in-depth and accurate health information system that appropriately addresses every level of threat or consequence. In a PICE stage I to III BT event resources will be compromised. Triage and management will be one process requiring multiple levels of cooperation, coordination, and decision-making. An immediate challenge to existing emergency medical services systems (EMSS) is the recognition that locally there will be a shift of emphasis and decision-making from prehospital first responders to community public health authorities. The author suggests that a working relationship, in most areas, between EMSS and the public health system is lacking. As priorities shift in a BT event to hospitals and public health care systems, they need to: 1. Improve their capabilities and capacities in surveillance, discovery, and in the consequences of different triage and management decisions and interventions in a BT environment, starting at the local level. 2. Develop triage and management systems (with clear lines of authority) based on public health and epidemiologic requirements, capability, and capacity (triage teams, categories, tags, rapid response, established operational priorities, resource-driven responsible management process), and link local level surveillance systems with those at the national or regional level. 3. Use a triage and management system that reflects the population (cohort) at risk, such as the epidemiologic based SEIRV triage framework. 4. Develop an organizational capacity that uses lateral decision-making skills, pre-hospital outpatient centers for triage-specific treatments, health information systems, and resource-driven hospital level pre-designated protocols appropriate for a surge of unprecedented proportions. Such standards of care, it is recommended, should be set at the local to federal levels and spelled out in existing incident-management system protocols.

Bioterrorism↗

Imaging and neural modelling in episodic and working memory processes.

Neuroimaging studies using positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) have revealed the involvement of distributed brain regions in memory processes mainly by the use of subtraction strategy based data analyses. Covariance analysis based data analysis strategies have been introduced more recently which allow functional interactions between brain regions of a neuronal network to be assessed. This contribution focuses on studies aiming to (1) establish the functional topography of episodic and working memory processes in young and old normal volunteers, (2) to assess functional interactions between modules of networks of brain regions by means of covariance based analyses and systems level modelling, (3) to characterise the temporal dynamics by the use of magnetoencephalography (MEG) and (4) to relate neuroimaging data to the underpinning neural networks. Male normal young and old volunteers without neurological or psychiatric illness participated in neuroimaging studies (PET, fMRI, MEG). Studies were approved by the ethical committee and federal authorities. Our results in young volunteers show distributed brain areas that are involved in memory processes (episodic and working memory) and show much of an overlap with respect to the network components. Systems level modelling analyses support the hypothesis of bihemispheric, asymmetric networks subserving memory processes and revealed both similarities in general and differences in the interactions between brain regions during episodic encoding and retrieval as well as working memory. Changes in memory function with ageing are evident from functional topographic studies in old volunteers activating more brain regions as compared to young volunteers. There are more and stronger influences of prefrontal regions in elderly volunteers comparing the functional models between old and young subjects. We discuss the way that the systems level models of the PET and fMRI results have implications for the underlying neural network functioning of the brain. This is done by developing simplifying assumptions, which lead from the equations describing the activities of the coupled neural modules to the systems level model equations. The resulting implications for the neural interactions are then discussed, in terms of a set of synaptically coupled neural modules. Finally, we consider how a similar analysis could be extended from the spatial to the temporal domain thus including the EEG and MEG results. The implication of preliminary MEG results presented here for the temporality arising in the interaction between the coupled neural modules in a working memory paradigm is discussed in terms of the previously developed neural network models arising from the PET and fMRI data.

Adult↗

Relevance of basic laboratory and clinical research activities as part of the vascular surgery fellowship: an assessment by program directors and postfellowship surgeons.

INTRODUCTION: Decreased federal monies for graduate medical education, increased clinical training demands, and a decreased pool of general surgery trainees applying to vascular surgery fellowships have brought into question the relevance of the fellowship research experience. This study sought to describe the recent laboratory experience of the fellows, the value of this experience to program directors (PDs) and the trainees, and what factors related to this experience contributed to the trainee entering an academic career versus a private practice career. METHODS: A survey regarding the relevance of research experience during fellowship training was mailed in 2001 to all Accreditation Council for Graduate Medical Education-approved vascular surgery fellowship PDs and vascular surgery fellows (VSFs) from 1988 to 2000 applying for the American Board of Surgery Certificate of Added Qualification in General Vascular Surgery. RESULTS: Survey responses were received from 89% of the PDs (74/83) and 69% of the VSFs (259/378). Among the PDs, 70% had completed an approved fellowship, and current bench research was performed by 46%. The PDs afforded protected research time to 69% of the VSFs (with a mean duration of 12 months). This research was in the basic science laboratory 34% of the time. Only 42% of the PDs considered basic laboratory research to be an important part of the fellowship, whereas 99% believed that clinical research was important. Among the PDs, 42% believed that more practice-oriented fellowships with no basic research were needed, whereas 35% believed that basic research should remain an integral component of the fellowship. VSF basic science productivity was significantly greater from those programs that offered protected research time as compared with those that did not (mean basic science paper published, 1.7 +/- 0.1 versus 0.3 +/- 0.6 per VSF; P <.001). At the time of the survey, 99 VSFs had entered academic careers and 136 were in private practice. Basic science research had been undertaken by 56% of the VSFs during medical school and by 53% during general surgery residency. Research during the fellowship was performed by 65% of the VSFs. This experience was considered helpful in choosing an academic or private practice career by 44% of the VSFs. A greater proportion of academic surgeons had research experience as VSFs when compared with VSFs who became private practitioners (71% versus 57%; P <.05). VSFs who entered academic careers had a more productive publication record in fellowship than did those who chose private practice (mean paper, 2.4 versus 1.5; P <.05). Overall, 78% of the VSFs believed that their research experience was maturing beyond the technical skills learned. CONCLUSION: This report provides a benchmark of the vascular surgery fellowship research experience. Most VSFs considered the research experience as it now exists to be worthwhile, and less than half of the PDs believed that it should remain as it is. Research experience in fellowship seemed more influential than that in medical school or general surgical residency in promoting an academic career.

Biomedical Research↗

Teaching hypothesis-oriented thinking to medical students: the University of Florida's clinical investigation program.

Recent studies show alarming decreases in the proportions of physicians applying for federal resources and of graduating medical students who declare strong interest in pursuing careers as physician-scientists. To expose medical students in their formative years to hypothesis-driven experimental investigations in a clinical setting, the first-year curriculum at the University of Florida has involved students as both investigators and study subjects in patient-oriented research conducted in the General Clinical Research Center (GCRC). Each year a hypothesis-driven experiment is conceived by first-year medical students in the university's MD-PhD program. Later in the year, the protocol is implemented in the GCRC by the entire freshman class, whose members serve as volunteer study subjects or as investigators. The experimental data are analyzed by the MD-PhD students, who report their findings at national biomedical research meetings and submit a manuscript on their project to a peer-reviewed journal. The authors describe students' research projects over the first six years of this GCRC-based program. They also describe the responses of former students to a questionnaire about their perceptions of the value of the research program. Most respondents considered the GCRC research exercise to have been useful and relevant to their overall education, and many more declared a current interest in pursuing research careers compared with the number who had declared such interest as freshmen. The authors conclude that early integration of hands-on, patient-oriented research into the medical school curriculum is a positive educational experience for students, and may contribute to their ultimate pursuit of academic research careers.

Attitude of Health Personnel↗

A developmental intergroup theory of social stereotypes and prejudice.

Developmental intergroup theory specifies the mechanisms and rules that govern the processes by which children single out groups as targets of stereotyping and prejudice, and by which children learn and construct both the characteristics (i.e., stereotypes) and affective responses (i.e., prejudices) that are associated with these groups in their culture. Specifically, we argue that children have a drive to understand their world, and that this drive is manifested in their tendency to classify natural and non-natural stimuli into categories, and to search the environment for cues about which of the great number of potential bases for categorization are important. The first step in the process of stereotype and prejudice formation is, therefore, the establishment of the psychological salience of some particular set of dimensions. Four factors are hypothesized to affect the establishment of the psychological salience of person attributes: (1) perceptual discriminability of social groups, (2) proportional group size, (3) explicit labeling and use of social groups, and (4) implicit use of social groups. We argue that person characteristics that are perceptually discriminable are more likely than other characteristics to become the basis of stereotyping, but that perceptual discriminability alone is insufficient to trigger psychological salience. Thus, for example, young children's ability to detect race or gender does not mean that these distinctions will inevitably become the bases of stereotypes and prejudice. Instead, for perceptually salient groups to become psychologically salient, one or more additional circumstances must hold, including being characterized by minority status, by adults' use of different labels for different groups, by adults using group divisions functionally, or by segregation. After a particular characteristic that may be used to differentiate among individuals becomes salient, we propose that children who have the ability to sort consistently will then categorize newly encountered individuals along this dimension. The act of categorization then triggers the process of social stereotyping and prejudice formation. Four factors are hypothesized to have an impact on the processes of forming stereotypes and prejudice. These include: (1) essentialism, (2) ingroup bias, (3) explicit attributions to social groups, and (4) group-attribute covariation. As noted throughout this chapter, there has been relatively little developmental work on many of the processes outlined here. Although findings from our own programs of research are consistent with the role of factors we have identified in the theory (e.g., the role of minority status, segregation, labeling and functional use of groups have all been shown to influence children's evaluations and beliefs about social groups), far more extensive research is needed. In addition to testing the reliability and generalizability of past findings to other samples, other research laboratories, and other experimentally manipulated groups, future work must move these theoretical models into the laboratory of the real world. If the tenets of developmental intergroup theory are correct, there would be many implications for social, educational, and legal policies related to social groups. We noted, for example, ways in which race and gender are made psychologically salient (e.g., the use of labels; segregated conditions). Importantly, factors such as these are largely under societal control. That is, institutions and individuals can choose to routinely label and use some particular category within children's environments or not. It is a violation of federal law, for example, for public school teachers to ask the children in their classrooms to line up at the door by race. In contrast, no federal or state law prohibits teachers from organizing their classrooms by sex. Should such laws be enacted? There can also be social controls on various forms of social segregation. Is it within individual children's rights to affiliate only with same-sex or same-race individuals? Is it acceptable for children and adolescents to exclude peers from their games, play, study groups, or other cliques on the basis of gender, race, age, or ethnicity? Finally, social institutions such as schools offer potential opportunities for intervention programs. What, if any, programs should be offered or required? Should curricula explicitly discuss social stereotyping and prejudice? Should children be taught negative information about people with whom they share some characteristic to reduce ingroup favoritism? Our hope is that developmental intergroup theory will ultimately prove valuable not only for understanding the development of social stereotypes and prejudices in children, but also for guiding social interventions that can ultimately prevent the development of stereotypes and prejudices in individuals and society.

Child↗