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PubMed2004

Meeting between experts: evaluation of the first UK forum for lay and professional experts in intersex.

At present the clinical management of intersex is in turmoil. The policy of non-disclosure of diagnosis is widespread and cosmetic genital surgery is routinely performed on infants throughout the world. Some clinicians feel such practices are in the interest of the intersex child and the family, but some intersex adults are calling for a moratorium on sex assignment genital surgery. These widely opposing views have led to distrust between groups. One way to begin to address these critical issues is to facilitate dialogue with equal input from clinicians and intersex people and families. Clinicians are experts by training, but patients and families are experts through lived experiences. Our paper reports the rationale, process and outcome of the first UK forum bringing together these different experts to address some of the most complex issues in clinical services. In communicating our experiences, we hope that it will provide a useful reference point for those seeking similar service-user/provider collaboration in other areas of medicine.

Attitude of Health Personnel↗
PubMed1998

An evidence-based approach to round tables and consensus conferences.

In current clinical practice, it is important to be able to evaluate the evidence supporting each of our actions. Physicians can no longer rely on tradition or habit; however, with the increasing number of journals available, it is impossible for the practicing clinician to keep abreast of all the relevant literature. One valuable method of gathering and summarizing the latest information and opinions is the use of round tables and consensus conferences. Published reports of round table and consensus conference findings can be invaluable in guiding the clinician.

Consensus Statements as Topic↗
PubMed2001

[Quality assurance program for postoperative pain management: impact of the Consensus Conference of the French Society of Anesthesiology and Intensive Care].

OBJECTIVE: To assess the impact of a pain management quality assurance program (PQAP) after abdominal surgery. The means used were mainly based on the French Society of anaesthesiology's pain management guidelines. STUDY DESIGN: Prospective evaluation using a before after study design: two audits among surgical patients: a first one in 1997 before implementation of PQAP, and a second one year later. PATIENTS AND METHODS: First, standards were defined including objectives about pain relief and patient satisfaction. After analysis of discrepancy observed between these objectives and the data of the first audit, a pain management program was introduced that included education of physicians, nurses and patients, systematic assessment of pain, organized pain relief protocols and implementation of modern analgesic technologies. RESULTS: 201 consecutive inpatients were evaluated in the first audit, and 117 in the second one. Comparing the second audit with baseline, the visual analog pain scores decreased during the five postoperative days, and the rate of very satisfied patients increased (36% versus 26%). 43% of the patients were given a regular analgesic medication in 1998 versus 15% in 1997. 65% of medications were administered with an effective interval between doses versus 47% in 1997. Patient-controlled techniques were used in 28% of the cases in 1998 versus 9% in 1997. CONCLUSION: The PQAP provided an improvement in efficacy of postoperative pain management in our unit, with the help of the overall ward staff, but without requiring personnel specially qualified.

Analgesia↗
PubMed2004

Chronoastrobiology: proposal, nine conferences, heliogeomagnetics, transyears, near-weeks, near-decades, phylogenetic and ontogenetic memories.

"Chronoastrobiology: are we at the threshold of a new science? Is there a critical mass for scientific research?" A simple photograph of the planet earth from outer space was one of the greatest contributions of space exploration. It drove home in a glance that human survival depends upon the wobbly dynamics in a thin and fragile skin of water and gas that covers a small globe in a mostly cold and vast universe. This image raised the stakes in understanding our place in that universe, in finding out where we came from and in choosing a path for survival. Since that landmark photograph was taken, new astronomical and biomedical information and growing computer power have been revealing that organic life, including human life, is and has been connected to invisible (non-photic) forces, in that vast universe in some surprising ways. Every cell in our body is bathed in an external and internal environment of fluctuating magnetism. It is becoming clear that the fluctuations are primarily caused by an intimate and systematic interplay between forces within the bowels of the earth--which the great physician and father of magnetism William Gilbert called a 'small magnet'--and the thermonuclear turbulence within the sun, an enormously larger magnet than the earth, acting upon organisms, which are minuscule magnets. It follows and is also increasingly apparent that these external fluctuations in magnetic fields can affect virtually every circuit in the biological machinery to a lesser or greater degree, depending both on the particular biological system and on the particular properties of the magnetic fluctuations. The development of high technology instruments and computer power, already used to visualize the human heart and brain, is furthermore making it obvious that there is a statistically predictable time structure to the fluctuations in the sun's thermonuclear turbulence and thus to its magnetic interactions with the earth's own magnetic field and hence a time structure to the magnetic fields in organisms. Likewise in humans, and in at least those other species that have been studied, computer power has enabled us to discover statistically defined endogenous physiological rhythms and further direct effects that are associated with these invisible geo- and heliomagnetic cycles. Thus, what once might have been dismissed as noise in both magnetic and physiological data does in fact have structure. And we may be at the threshold of understanding the biological and medical meaning and consequences of these patterns and biological-astronomical linkages as well. Structures in time are called chronomes; their mapping in us and around us is called chronomics. The scientific study of chronomes is chronobiology. And the scientific study of all aspects of biology related to the cosmos has been called astrobiology. Hence we may dub the new study of time structures in biology with regard to influences from cosmo- helio- and geomagnetic rhythms chronoastrobiology. It has, of course, been understood for centuries that the movements of the earth in relation to the sun produce seasonal and daily cycles in light energy and that these have had profound effects on the evolution of life. It is now emerging that rhythmic events generated from within the sun itself, as a large turbulent magnet in its own right, can have direct effects upon life on earth. Moreover, comparative studies of diverse species indicate that there have also been ancient evolutionary effects shaping the endogenous chronomic physiological characteristics of life. Thus the rhythms of the sun can affect us not only directly, but also indirectly through the chronomic patterns that solar magnetic rhythms have created within our physiology in the remote past. For example, we can document the direct exogenous effects of given specific solar wind events upon human blood pressure and heart rate. We also have evidence of endogenous internal rhythms in blood pressure and heart rate that are close to but not identical to the period length of rhythms in the solar wind. These were installed genetically by natural selection at some time in the distant geological past. This interpretive model of the data makes the prediction that the internal and external influences on heart rate and blood pressure can reinforce or cancel each other out at different times. A study of extensive clinical and physiological data shows that the interpretive model is robust and that internal and external effects are indeed augmentative at a statistically significant level. Chronoastrobiological studies are contributing to basic science--that is, our understanding is being expanded as we recognize heretofore unelaborated linkages of life to the complex dynamics of the sun, and even to heretofore unelaborated evolutionary phenomena. Once, one might have thought of solar storms as mere transient 'perturbations' to biology, with no lasting importance. Now we are on the brink of understanding that solar turbulences have played a role in shaping endogenous physiological chronomes. There is even documentation for correlations between solar magnetic cycles and psychological swings, eras of belligerence and of certain expressions of sacred or religious feelings. Chronoastrobiology can surely contribute to practical applications as well as to basic science. It can help develop refinements in our ability to live safely in outer space, where for example at the distance of the moon the magnetic influences of the sun will have an effect upon humans unshielded by the earth's native magnetic field. We should be better able to understand these influences as physiological and mechanical challenges, and to improve our estimations of the effects of exposure. Chronoastrobiology moreover holds great promise in broadening our perspectives and powers in medicine and public health right here upon the surface of the earth. Even the potential relevance of chronoastrobiology for practical environmental and agricultural challenges cannot be ruled out at this early stage in our understanding of the apparently ubiquitous effects of magnetism and hence perhaps of solar magnetism on life. The evidence already mentioned that fluctuations in solar magnetism can influence gross clinical phenomena such as rates of strokes and heart attacks, and related cardiovascular variables such as blood pressure and heart rate, should illustrate the point that the door is open to broad studies of clinical implications. The medical value of better understanding magnetic fluctuations as sources of variability in human physiology falls into several categories: 1) The design of improved analytical and experimental controls in medical research. Epidemiological analyses require that the multiple sources causing variability in physiological functions and clinical phenomena be identified and understood as thoroughly as possible, in order to estimate systematic alterations of any one variable. 2) Preventive medicine and the individual patients'care. There are no flat 'baselines', only reference chronomes. Magnetic fluctuations can be shown statistically to exacerbate health problems in some cases. The next step should be to determine whether vulnerable individuals can be identified by individual monitoring. Such vulnerable patients may then discover that they have the option to avoid circumstances associated with anxiety during solar storms, and/or pay special attention to their medication or other treatments. Prehabilitation by self-help can hopefully complement and eventually replace much costly rehabilitation. 3) Basic understanding of human physiological mechanisms. The chronomic organization of physiology implies a much more subtle dynamic integration of functions than is generally appreciated. All three categories of medical value in turn pertain to the challenges for space science of exploring and colonizing the solar system. The earth's native magnetic field acts like an enormous umbrella that offers considerable protection on the surface from harsh solar winds of charged particles and magnetic fluxes. The umbrella becomes weaker with distance from the earth and will offer little protection for humans, other animals, and plants in colonies on the surface of the moon or beyond. Thus it is important before more distant colonization is planned or implemented to better understand those magnetism-related biological- solar interactions that now can be studied conveniently on earth. (ABSTRACT TRUNCATED)

Chronobiology Phenomena↗
PubMed2006

Delivery of primary percutaneous coronary intervention for the management of acute ST segment elevation myocardial infarction: summary of the Cardiac Care Network of Ontario Consensus Report.

Tremendous debate has developed over the efficacy of primary percutaneous coronary intervention (PCI) compared with fibrinolysis as the preferred treatment for acute ST segment elevation myocardial infarction (STEMI). In 2002, the Ontario Ministry of Heath and Long-Term Care commissioned the Cardiac Care Network of Ontario to develop consensus recommendations regarding the provincial coordination and provision of urgent PCI for STEMI patients. The panel's work has provided important insights into the acute treatment of STEMI that may be useful to other jurisdictions and may provide a reference for other regions considering the implementation of primary PCI for the management of STEMI patients in their community. In the present report, the evidence for primary PCI is reviewed, the important barriers to implementing this strategy are summarized and several recommendations and models of care for the delivery of primary PCI for STEMI on a wide scale are presented.

Angioplasty, Balloon, Coronary↗
PubMed1999

Third molars: a dilemma! Or is it?

The purpose of this article is to review some of the pertinent studies related to the management of third molars in an orthodontic context. The clinician should base his or her decision to extract or not extract third molars on the most current scientific information and what is best for each individual patient.

Adult↗
PubMedDate not supplied

Prioritization of NTP reproductive toxicants for field studies.

Population studies that evaluate human reproductive impairment are time consuming, expensive, logistically difficult, and with limited resources must be prioritized to effectively prevent the adverse health effects in humans. Interactions among health scientists, unions, and industry can serve to identify populations exposed to potential hazards and develop strategies to evaluate and apply appropriate controls. This report describes a systematic method for prioritizing chemicals that may need human reproductive health field studies. Rodent reproductive toxicants identified from the National Toxicology Program (NTP) Reproductive Assessment by Continuous Breeding (RACB) protocol were prioritized on the basis of potency of toxic effect and population at risk. This model for prioritization links NTP findings with data from the National Occupational Exposure Survey (NOES) and the Hazardous Substance Data Base (HSDB) or the High Production Volume Chemical Database (HPVC) to prioritize chemicals for their potential impact on worker populations. The chemicals with the highest priority for field study were: dibutyl phthalate, boric acid, tricresyl phosphate, and N, N-dimethylformamide.

Animals↗
PubMed2000

[Office-based pediatricians' knowledge and adherence to a consensus statement on acute rhinopharyngitis in the child].

AIM: To assess the impact on community-based pediatricians of the conclusions of the 10th Conférence de Consensus en Thérapeutique Anti-Infectieuse (CCTAI) on the antibiotic treatment in acute nasopharyngitis (ANP). METHODS: Fifty-six pediatricians took part in the study. Over a period of 15 days in October 1998, all the children (n = 997) presenting an ANP were prospectively included. The prescription of an antibiotic treatment as well as the clinical criteria authorizing it, according to the conclusions of the 10th CCTAI, were recorded. The participants were not told the purpose of the study. RESULT: Sixty percent of the pediatricians questioned were familiar with the 10th CCTAI. Forty-five percent said they complied with it, but only 7% stated it had changed their day-to-day clinical practice. Based on the conclusions of the 10th CCTAI, an antibiotic treatment would have been discussed for 38% of the children. Twenty-four percent of them were given one. For 54% of the children that were given an antibiotic, such treatment was disapproved by the 10th CCTAI. No significant association has been established between familiarity with the 10th CCTAI and the following criteria: gender, age, hospital activity, years of practice, medical journals read, and belief in the existence of a license for one or more antibiotics for ANP in children. However, this last criterion was significantly (P = 0.03) associated with an increase in the percentage of antibiotics prescribed: 29% vs 16%. DISCUSSION AND CONCLUSION: The 10th CCTAI has had a moderate impact on the day-to-day practice of the pediatricians who took part in our study. Several explanations are discussed. The authors emphasize the virtual lack of indications of antibiotics in ANP.

Adult↗
PubMed2003

Proposition: the benefit of cardiac transplantation in stable outpatients with heart failure should be tested in a randomized trial.

Recent data suggest that cardiac transplantation is associated with a survival benefit only in patients at high risk for dying of advanced heart failure without this procedure. To test the hypothesis that survival and quality of life advantages associated with cardiac transplantation exist in stable outpatients, a 3-stage approach is proposed: 1). to establish a database within the International Society for Heart and Lung Transplantation/United Network for Organ Sharing/Eurotransplant infrastructure that will provide an estimate of the survival benefit of heart transplantation in various heart failure risk strata by prospectively following cohorts of patients listed for heart transplantation; 2). to organize an international consensus conference that will define, based on the review of the Stage 1 data, the feasibility of a prospective randomized trial; and 3). pending consensus, to perform a clinical trial, perhaps with an augmented, randomized design that allocates cardiac transplantation to all patients at high risk for dying of heart failure while randomizing patients at low risk to either conventional treatment or cardiac transplantation. Generating such scientific evidence is important in light of today's donor organ crisis and the associated difficulties of equitable resource allocation.

Cohort Studies↗