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Regulation is often seen as the dull end of science. The recent storm over the introduction of genetically modified foods and the calls to regulate their consumption have had a negative effect on development of the science. Assuring the safety of genetically modified foods might raise questions where existing scientific data is limited and underline the need for further research.
Melatonin is being touted as the latest cure-all. But in their eagerness to explain to the public the possible health benefits of this natural hormone, the mass media as well as some scientists have misrepresented the scientific data.
Myocardial viability is of established importance to the management of cardiac patients being considered for revascularization. Existing noninvasive imaging tests to examine myocardial viability, such as stress echocardiography and nuclear scintigraphy, are of recognized utility but are subject to intrinsic limitations. Over the past few years delayed-enhancement MRI (DE-MRI) has emerged as an alternative to traditional tests and for the first time allows direct visualization of the transmural extent of myocardial viability. In this paper we review the scientific data that underlie the use of DE-MRI in patients with ischemic heart disease. Progress in this area is largely the result of the development of a new MRI pulse sequence in the late 1990s, which improved the detection of necrotic and scarred myocardial tissue. Following this technical development, a series of detailed histologic comparisons in large animal models revealed that both acute and healed myocardial infarcts appeared as brighter (hyperenhanced) areas than viable regions, and that the effect is independent of contractile function. The resulting 'bright is dead' hypothesis has thus far proven of significant use in patients with ischemic heart disease. Data are now emerging which suggest that the DE-MRI technique also has important implications for patients with nonischemic forms of cardiomyopathy.
The scientific process, and scientific progress, require a critical examination of all published reports. Recent publications detailing errors in the draft human genome sequence are an integral part of our quest to better understand nature and demonstrate the value of free access to scientific data.
The aim of this paper is to present a wide range of professional and lay viewpoints on obesity. Different perspectives surrounding how obesity is viewed, primary etiological factors contributing to obesity and intervention aims are brought together for review and discussion. Factors which may contribute to different perspectives include: familiarity with the scientific data showing the health risks associated with obesity, personal experience with weight and weight control, experiences encountered in working with clients in weight management, and professional training. In addition to describing and comparing the different approaches, possibilities for reconciling their differences and drawing from each of their strengths, are explored. The predominant viewpoint among health professionals regarding the etiology of obesity is that multiple factors contribute to its onset and progression. However, viewpoints tend to differ with regard to the main contributing factors and range from those in which the major focus is on genetic factors, to those which focus more on familial and/or individual choices regarding behavioural implementation. Although the predominant viewpoint on obesity in western societies is not a positive one, there is a growing size acceptance movement which has had a significant impact on both the fashion industry and on the health field. Aims of treatment may vary in accordance with beliefs about key etiological factors leading to obesity (for example, primarily genetic vs primarily behavioural) and with opinions regarding potential consequences and benefits of obesity. Aims of treatment may include weight loss, healthy eating and exercise, weight maintenance, improved self-esteem, fat accepTance and/or advocacy for decreased weight discrimination. An increased awareness, understanding and openness towards different philosophical perspectives surrounding weight issues may be the first step towards working with colleagues and clients whose viewpoints on weight-related issues differ from our own.
OBJECTIVE: To update physicians, especially paediatricians, in the rapidly developing field of pharmacotherapy of childhood and adolescent obesity. METHODS: The paper reviews current and investigational antiobesity drugs. RESULTS: At present, there are only few drugs approved by the Food and Drug Administration (FDA) for the treatment of adult obesity. The most important ones are sibutramine and orlistat. The FDA in the USA approved the latter drug in 2003, and it has recently been approved by the European Union for the treatment of adolescents. There are several investigational antiobesity agents but only few new and promising substances like Rimonabant (a cannabinoid receptor antagonist) and axokine (ciliary neutrotrophic factor) are already at an advanced stage of development. CONCLUSION: In adults, it seems to be justified using drugs for long-term treatment of 'medically important' obesity. Strict guidelines concerning the treatment of obese adolescents with orlistat are needed. It is only hoped that double-blind placebo-controlled studies investigating the new and promising drugs will also include adolescents and provide sufficient scientific data to get them licensed for the treatment of obese adolescents.
Molecular pathways and mechanisms underlying human cancer are frequently investigated in animal models. Studies to identify and dissect molecular pathways include the discovery of genes and their subsequent analysis in transgenic and 'knock-out' mice. A critical aspect in such investigations is the evaluation of organ integrity and histology upon the alteration or inactivation of specific genes. Results from such studies are usually published in scientific journals. However, due to print space and costs the display of large high quality images is limited. Furthermore, the printed media does not permit an easy comparison of histological images published in different journals and different years. The Internet provides a tool for the timely and inexpensive dissemination of scientific data to the research community. However, its potential for the analysis of histological images has not been explored. Here we present a web-based interactive histology atlas (http://histology.nih.gov) that permits the retrieval of annotated, high-resolution histology images via the Internet. This histology atlas also takes advantage of the interactive nature of the Internet to support the communication between different research groups. As an outline forum this atlas provides the framework to evaluate and understand cancer pathology, and to develop a consensus between veterinary and human pathologists.
The exercise of organ and tissue transplantation is a common occurrence in our society. Expectations of future advances in this arena are raising many ethical, moral and public-policy questions. The scientific data base supporting the usefulness of fetal tissue to repair or reverse disease is modest, and uses are speculative. Should fetal tissue transplantation research proceed and, if so, under what conditions? This paper examines the issues related to the use and procurement of fetal tissue for research and transplantation.
AIM: The aim of this study was to clarify issues around the patient-nurse interaction during pulsed dose rate (PDR) brachytherapy. BACKGROUND: Cancer diagnosis, response and survival rates as well as the side-effects of radiation therapy are well described in international literature. However, no scientific data apparently exist on the reactions and behaviour of cancer patients during stressful irradiation treatments nor on nursing performance in these situations. The study involved gynaecological and anal cancer patients. Treatment needles (10-20 cm) were implanted in the tumours of these patients during the PDR brachytherapy. This treatment was administered during a 15-30-minute period each hour, for a duration of 30-60 hours. Patients were partially isolated and immobilized, and typically positioned on the back or side. In preparation for the therapy, patients had to fast and drink sparingly. Observation and nursing care could only be performed during pauses in the treatment. METHOD: This paper is based on 142 hours of continuous video recording of patients undergoing PDR brachytherapy. Data were collected on five patients and 17 nurses. FINDINGS: The study shows that nurses were with patients for approximately 1/4 of the available time. The majority (75%) of any communication with patients centred around physical care. Although patients were in a stressful situation, they did not anticipate receiving any psychological support from nursing staff. Patients showed individual patterns of behaviour and coping. CONCLUSIONS: Continuous video recording, as a research tool can document accurately interaction and behaviour between cancer patients and nursing staff. Video recording discloses examples of both eminent and negligent nursing care and as such can be a useful tool for instruction and for future research. The credibility, validity and limitations of using video recording are discussed.
The emphasis provided by quality improvement strategies on performance measurement and evaluation often results in our understanding of processes of care and, perhaps, better outcomes. There are different references for process evaluation: external peers, regional profiles of performance or a trending of one's own performance patterns. This paper proposes a methodology that enables learning from the daily practice of medicine by comparing alternative care processes and outcomes. Since it is estimated that 15-20% of medical practices are based on rigorous scientific data establishing their effectiveness, we have much to learn. We propose to learn from our daily practice by combining clinical research methods with quality improvement tools. The products comprise modified clinical trial and case-control studies. In a modified clinical trial, we would use a practice guideline as a control group and modify the guideline to create an experimental group. This method would maintain the internal validity of efficacy research while maintaining the external validity of effectiveness research. In the case-control method, it is possible to quantitate risk for a given outcome and focus improvement effort on factors associated with that outcome. We believe physicians will accept this learning approach because it is a more valid learning method than traditional quality improvement and, unlike randomized clinical trials, learning will occur in the daily practice of medicine.
Mandibular range of motion (ROM), vertical and horizontal, is often measured as a part of a diagnostic assessment of temporomandibular joint disorders. In the literature, a fixed ratio between the vertical and the horizontal ROM has been suggested, i.e. 4:1. The ratio is frequently used to predict the vertical ROM on the basis of the horizontal ROM and vice versa. However, no scientific data are available to substantiate the ratio suggested. The aim of this study was to determine whether the fixed ratio of 4:1 exists and, if so, whether this ratio has a predictive value. Vertical and horizontal mandibular ROM was measured in 91 healthy subjects, 59 women, and 32 men (mean age 27.2 years, s.d. 7.4 years) using vernier callipers. We found a mean ratio between vertical and horizontal ROM ranging from 6.0:1-6.6:1. On an individual basis the ratio ranged from 3.6-15.5. Correlations between vertical and horizontal ROM were weak. On the basis of the results on this study it is concluded that the ratio between vertical and horizontal ROM is approximately 6:1 rather than 4:1, and that the ratio has poor predictive value.
Providing high-quality mental health nursing care should be an important and continuous preoccupation in the gerontological nursing field. As the proportion of elderly people in our society is growing, the emphasis on high-quality care will receive increasing attention from administrators, politicians, organized groups, researchers and clinical nurses. Recent findings illustrate unequivocally the important contribution of nurses to achieving the goal of high-quality geriatric care. However, the quality of care for the elderly with psychological difficulties has not been addressed. The objective of this article is to illustrate that while nurses can accomplish much to improve the well-being and mental health of the elderly, their skills are often underutilized. Psychotropic drugs are often the first-line interventions used by health-care professionals to treat mental health concerns of elderly persons. Alternative therapies that could be implemented and evaluated, such as psychological counselling, supportive counselling, education and life review, are infrequently used. Nevertheless, current scientific data suggest that it would be very advantageous if nurses were to play a dominant role in the care of elderly people who are depressed or experiencing sleep pattern disturbances. The same can be said about elderly chronic users of benzodiazepines, as well as those with cognitive impairment. Evidence for the use of psychotropic medications as a viable treatment option for the elderly both in the community and in the long-term care setting who are experiencing mental health challenges is examined. Alternative non-pharmacological approaches that nurses can use to augment care are also briefly discussed.
Traditional weight loss (TWL) treatments have been unsuccessful at reducing the prevalence of obesity in the population. Health-care professionals and consumers have criticized TWL treatments as being detrimental to the obese person's health. Consequently, an alternative approach to obesity treatment, the health at any size (H@AS) paradigm, has been proposed. The H@AS paradigm is based on the philosophy that once diet restrictions and barriers to activity have been removed, the individual will develop healthier eating and activity patterns that lead to a naturally healthy body weight. This paper reviews the philosophical foundation and the scientific data that support and oppose the H@AS paradigm and compares it with that of TWL treatments.
Over a century has passed since Ignaz P. Semmelweis demonstrated the association between hand hygiene and nosocomial infections, but this simple procedure is still not recognized by many healthcare workers as one of the most important measures to prevent cross-transmission of microorganisms. A relatively large amount of research has been done, in particular to try to understand why compliance remains so low, in order to implement successful promotion campaigns. This research has generated a fair amount of strong scientific data which are sometimes misunderstood and misused because of myths or certain beliefs. Observational or intervention studies have consistently shown a number of risk factors associated with non-compliance, such as high workload, professional category, or type of ward. Others are thought to be barriers to adequate compliance but have not yet been properly assessed. These include skin irritation due to hand hygiene agents, lack of knowledge of hand hygiene recommendations, or lack of institutional policy. Future interventions to promote hand hygiene will need to address these risk factors, and target the individual healthcare worker, as well as the group or institution if a significant degree of success is to be achieved.
BACKGROUND: The efficacy of acute tissue expansion (ATE) in achieving skin closure has been strongly debated. Proponents maintain that ATE is efficacious, whereas critics have argued for lack of supporting scientific data and that ATE is no more effective than skin undermining in closure of surface defects. OBJECTIVE: To compare and actually quantify gain in skin length after extensive undermining of skin edges alone or in combination with ATE in skin defects. METHODS: Twenty-one consecutive patients undergoing excision and closure of wounds in certain anatomical areas where primary closure is difficult were studied. Actual measurements of the undermined skin before and after ATE were recorded. Immediate problems and long-term follow-up data were analyzed. RESULTS: ATE, in addition to undermining, provides 1:1.61 +/- 0.23 more skin on each margin than undermining used alone. It is effective, easy to perform, inexpensive, and reproducible, with clearly quantifiable increments of skin stretch. Long-term morbidity is minimal with excellent cosmetic results. CONCLUSION: ATE provides a useful tool for closure of skin defects that are resistant to simple primary closure even when deeply undermined. It is simple and easily performed in an office setting without much preparation or special equipment.
Our objective was to describe and compare the use of complementary and alternative medicine (CAM) in gynecology and gynecological oncology patients. Five hundred and twenty-nine gynecology and gynecological oncology patients completed a questionnaire regarding CAM use. Overall, 56.3% of gynecology and gynecological oncology patients reported current use of CAM. Therapies used included nutritional supplements (20%), prayer as medical therapy (17%), exercise as medical therapy (12%), megavitamins (10%), and green tea (10%). While 69.5% believed CAM to be beneficial, only 31.6% discussed these therapies with their physician. The women spent a mean of $656.22 on CAM (range $0-$7,000), with 31.7% receiving some insurance reimbursement. Gynecologic oncology patients (n = 161) used CAM significantly more than gynecology patients (n = 368) (66% vs. 52%, 95% CI = 0.046-0.230, P = 0.004). Gynecological oncology patients also spent more for CAM, with a mean expenditure of $711 versus $622 by gynecology patients. Within the gynecological oncology patient group, there were 69 patients currently receiving modern medical treatments for cancer; among these patients, 58% reported using CAM; of these, 39.3% communicated their use of CAM to their physician. Patients in this group spent an average of $1,178 on CAM during their illness, with only 6.3% receiving insurance reimbursement. Benefits from CAM were perceived by 54.5% in this group. We concluded that cancer patients have a higher usage rate and expenditure for CAM, particularly while they are receiving medical therapy, and are more likely to discuss the use of alternative therapies with their physicians. CAM was perceived as helpful by patients despite the lack of scientific data about its effect.
INTRODUCTION: homocysteine, a sulphur-containing non-essential amino acid, appears to play a role in the pathophysiology of atherosclerosis. However, its role in myointimal hyperplasia, the cause of almost 30% of failures of interventional therapeutic procedures, is much less clear. METHODS: a review of the published scientific data concerning the role of homocysteine in myointimal hyperplasia was performed using MEDLINE and other on-line databases. Evidence was sought from cell culture experiments, animal models and clinical studies. RESULTS: several clinical studies have recently been published linking plasma homocysteine levels to restenosis in coronary and peripheral arterial disease. However, several contradictory studies also exist making the role of homocysteine unclear. There are currently no published randomised trials. Cell culture and animal model experiments have elucidated several potential mechanisms by which may stimulate myointimal hyperplasia. Possible mechanisms include endothelial cell activation with the enhanced release of inflammatory cytokines and growth factors and a direct effect on vascular smooth muscle cell migration and proliferation. CONCLUSIONS: further studies are required before the true role of homocysteine in the pathogenesis of myointimal hyperplasia can be clearly evaluated. If evidence does confirm a role, the ease with which homocysteine levels can be normalised makes it an attractive alternative therapeutic target for intervention.
AIMS: In spite of increasing reuse of disposable catheters, there are few scientific data on potential viral transmission and infection after reuse. To determine the theoretical risk of virus transmission during reuse of catheters an in vitro study was performed using an RNA virus (echovirus-11) and a DNA virus (adenovirus-2). METHODS AND RESULTS: After deliberate contamination of the catheters, reprocessing and reuse of the cleaned and glutaraldehyde sterilized catheters was simulated. The presence of residual virus was determined by cell culture and by polymerase chain reaction (PCR). After the sterilization step, infectious enterovirus was detectable in one (10%) of the samples, whereas two (20%) contained detectable enterovirus RNA. After simulated reuse, enterovirus was cultured from one (10%) of the catheters, but no less than six (60%) of the samples were enterovirus PCR positive and one (10%) contained detectable adenovirus DNA. After sonification of the catheter tips no infectious virus could be detected, but enterovirus RNA was detected in two (20%) and adenovirus DNA in three (30%) of the samples. CONCLUSIONS: It has been clearly demonstrated in this in vitro study that, even after rigorous cleaning and sterilization, virus was still present in the catheter. Reuse of catheters, labelled for single-use only, is dangerous and should be prevented.