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At least 685 records · Page 38Linked to original sources
PubMed2004

Contextual tensions of the clinical environment and their influence on teaching and learning.

BACKGROUND: Academic medical centres face major challenges, and finding creative, effective strategies to support patient care and teaching are critical for survival. At the centre of these challenges is clinical teaching. AIM: To characterise how context influences clinical teaching. METHODS: Multiple embedded case-study design analysed 3 internal medicine in-patient teams. Direct observations, interviews and documents were data sources. Triangulated data, audit trails and member checks enhanced trustworthiness. RESULTS: Three tensions influenced clinical teaching: 1, patient census; 2, time sensitivity of the context; and 3, the multiple and conflicting commitments of participants. Patient census exhibited the greatest influence and was the catalyst for teaching, learning, and the allocation of total time. Time functioned as an important element influencing the pace of action, reflective and interpretative cognitive processes of the team, time available for action, and the general fatigue of the team. Conflicts among the multiple roles of ward team members disrupted individual and team teaching and learning. CONCLUSION: Clinical teaching is an open system influenced by multiple forces. Learning, teaching and patient care were very closely coupled, and learning knowledge and using knowledge were parts of the same process within the clinical context.

Clinical Competence↗
PubMed2001

[Efficient multicentric data acquisition via internet - a method evaluation].

Data input in web-htm-forms with a browser is much more efficient in comparison with write in paper mask documents. The specification-compliant forms for data entry as htm-forms are downloaded from the homepage of the project manager by the participants of the study. The transformation of content of different formatted htm-forms is made by the program "security-based form converter (SFC)", which is located on a web server respectively a proxy server. From there the transformed data are returned the project manager via e-mail. Those incoming data are imported into databases by means of ODBC-data source. The data are pivoted from sequential format to table format. The data entry principle presented here is a client-server-structured, web based intranet program. For this purpose only standard software and relational databases with ODBC-interfaces are used; no further registered commercial programs are needed. General data protection is ensured by encrypted data transmission.

Computer Security↗
PubMedDate not supplied

The diet-induced proinflammatory state: a cause of chronic pain and other degenerative diseases?

BACKGROUND: It is the rare physician who includes diet therapy and nutritional supplements in patient care. Perhaps this is because chiropractic and medical schools devote very few classroom hours to nutrition. It is also possible that physicians are under the misconception that a detailed biochemical understanding of each individual disease is required before nutritional interventions can be used. OBJECTIVE: The purpose of this article is two-fold: (1) to demonstrate that chronic pain and other degenerative conditions encountered in clinical practice have similar biochemical etiologies, such as a diet-induced proinflammatory state, and (2) to outline a basic nutritional program that can be used by all practitioners. DATA SOURCES: The data were accumulated over a period of years by reviewing contemporary articles and books and subsequently by retrieving relevant articles. Articles were also selected through MEDLINE and manual library searches. RESULTS: The typical American diet is deficient in fruits and vegetables and contains excessive amounts of meat, refined grain products, and dessert foods. Such a diet can have numerous adverse biochemical effects, all of which create a proinflammatory state and predispose the body to degenerative diseases. It appears that an inadequate intake of fruits and vegetables can result in a suboptimal intake of antioxidants and phytochemicals and an imbalanced intake of essential fatty acids. Through different mechanisms, each nutritional alteration can promote inflammation and disease. CONCLUSION: We can no longer view different diseases as distinct biochemical entities. Nearly all degenerative diseases have the same underlying biochemical etiology, that is, a diet-induced proinflammatory state. Although specific diseases may require specific treatments, such as adjustments for hypomobile joints, beta-blockers for hypertension, and chemotherapy for cancer, the treatment program must also include nutritional protocols to reduce the proinflammatory state.

Antioxidants↗
PubMed2006

Comparing bloodstream infection rates: the effect of indicator specifications in the evaluation of processes and indicators in infection control (EPIC) study.

OBJECTIVE: Bloodstream infection (BSI) rates are used as comparative clinical performance indicators; however, variations in definitions and data-collection approaches make it difficult to compare and interpret rates. To determine the extent to which variation in indicator specifications affected infection rates and hospital performance rankings, we compared absolute rates and relative rankings of hospitals across 5 BSI indicators. DESIGN: Multicenter observational study. BSI rate specifications varied by data source (clinical data, administrative data, or both), scope (hospital wide or intensive care unit specific), and inclusion/exclusion criteria. As appropriate, hospital-specific infection rates and rankings were calculated by processing data from each site according to 2-5 different specifications. SETTING: A total of 28 hospitals participating in the EPIC study. PARTICIPANTS: Hospitals submitted deidentified information about all patients with BSIs from January through September 1999. RESULTS: Median BSI rates for 2 indicators based on intensive care unit surveillance data ranged from 2.23 to 2.91 BSIs per 1000 central-line days. In contrast, median rates for indicators based on administrative data varied from 0.046 to 7.03 BSIs per 100 patients. Hospital-specific rates and rankings varied substantially as different specifications were applied; the rates of 8 of 10 hospitals were both greater than and less than the mean. Correlations of hospital rankings among indicator pairs were generally low (rs=0-0.45), except when both indicators were based on intensive care unit surveillance (rs = 0.83). CONCLUSIONS: Although BSI rates seem to be a logical indicator of clinical performance, the use of various indicator specifications can produce remarkably different judgments of absolute and relative performance for a given hospital. Recent national initiatives continue to mix methods for specifying BSI rates; this practice is likely to limit the usefulness of such information for comparing and improving performance.

Cross Infection↗
PubMed2005

Kernel methods for predicting protein-protein interactions.

MOTIVATION: Despite advances in high-throughput methods for discovering protein-protein interactions, the interaction networks of even well-studied model organisms are sketchy at best, highlighting the continued need for computational methods to help direct experimentalists in the search for novel interactions. RESULTS: We present a kernel method for predicting protein-protein interactions using a combination of data sources, including protein sequences, Gene Ontology annotations, local properties of the network, and homologous interactions in other species. Whereas protein kernels proposed in the literature provide a similarity between single proteins, prediction of interactions requires a kernel between pairs of proteins. We propose a pairwise kernel that converts a kernel between single proteins into a kernel between pairs of proteins, and we illustrate the kernel's effectiveness in conjunction with a support vector machine classifier. Furthermore, we obtain improved performance by combining several sequence-based kernels based on k-mer frequency, motif and domain content and by further augmenting the pairwise sequence kernel with features that are based on other sources of data. We apply our method to predict physical interactions in yeast using data from the BIND database. At a false positive rate of 1% the classifier retrieves close to 80% of a set of trusted interactions. We thus demonstrate the ability of our method to make accurate predictions despite the sizeable fraction of false positives that are known to exist in interaction databases. AVAILABILITY: The classification experiments were performed using PyML available at http://pyml.sourceforge.net. Data are available at: http://noble.gs.washington.edu/proj/sppi.

Algorithms↗
PubMed2006

Prevention of mother-to-child transmission of HIV infection: Ukraine experience to date.

BACKGROUND: Despite the availability of effective interventions for the prevention of mother-to-child transmission (PMTCT), questions remain regarding implementation of programmes in settings with limited resources. This article sets out to describe the first 2 years of the implementation of the national PMTCT programme in Ukraine. METHODS: National data sources and data from a cohort of pregnant HIV-infected women delivering in 13 centres in Ukraine since 2000 were analysed. RESULTS: Interventions for prevention of MTCT have been implemented as a national programme within Ukraine's well developed infrastructure for maternal and child health. Implementation of an 'opt-out' model of counselling and HIV testing in antenatal clinics resulted in a 97% uptake of women who agreed to be HIV tested. In 2002, approximately 91% of HIV-positive pregnant women received ARV prophylaxis (mainly single-dose nevirapine or short-course zidovudine) for PMTCT. The MTCT rate has decreased from 30% in 2000 to 10% in 2002. The need to scale-up prevention interventions in pregnant women with risky behaviour and late access to medical services was identified in a review of the national programme in 2003. CONCLUSIONS: Further implementation of a comprehensive approach for the prevention of HIV infection in infants, including more extensive ART regimen, as recommended by WHO, would help Ukraine to achieve the strategic goal of virtual elimination of HIV infection in infants by 2010.

Adult↗
PubMed1998

A comparative analysis of surveyors from six hospital accreditation programmes and a consideration of the related management issues.

PURPOSE: To gather data on how accreditors manage surveyors, to compare these data and to offer them to the accreditors for improvement and to the scientific community for knowledge of the accreditation process and reinforcement of the credibility of these processes. DATA SOURCE: The data were gathered with the aid of a questionnaire sent to all accreditors participating in the study. RESULTS: An important finding in this comparative study is the different contractual relationships that exist between the accreditors and their surveyors. CONCLUSION: Surveyors around the world share many common features in terms of careers, training, work history and expectations. These similarities probably arise from the objectives of the accreditors who try to provide a developmental process to their clients rather than an 'inspection'.

Accreditation↗
PubMed1999

The effect of age, diabetes, and other comorbidity on the survival of patients on dialysis: a systematic quantitative overview of the literature.

BACKGROUND: The UK Renal Registry quotes a 1-year death rate for patients established on dialysis of 19.4 per 100 patient years. Clinical experience, reflected in the UK Renal Association Standards Document (RASD), recognizes qualitatively that age, diabetes, and other comorbidities increase the risk of death. The aim of this paper is to provide quantitative estimates of the relative risk of death associated with particular patient characteristics. METHODS: Quantitative techniques were used to estimate relative risk of death in the seven studies quoted in the RASD document and 17 other papers identified in a systematic literature search. Relative risk data from each study were pooled using a fixed effects model (f). A random effects model (r) was applied to pool relative risks if heterogeneity was found to exist between studies. A meta-regression analysis was also carried out to investigate whether study covariates substantially explained the heterogeneity between studies. RESULTS: Pooling the papers identified in the systematic literature search with those from the RASD gave rise to a relative risk of death of 1.029 (95% CI 1.013-1.045) (r) associated with each year's increase in age. The relative risk associated with the presence of diabetes was 1.91 (95% CI 1.67-2.17) (r), whilst that associated with heart disease was 1.59 (95% CI 1.49-1.69) (f), and with peripheral vascular disease 1.58 (95% CI 1.29-1.93) (r). Heterogeneity was found in the estimates of risk associated with age, diabetes, and peripheral vascular disease. Important study covariates included the use of incident or prevalent cases, the use of routine data sources or data collected specifically for a particular study, the country in which the study was located, the use of a P value to infer the standard error of a relative risk estimate in a particular study, and the method of classifying diabetes. CONCLUSIONS: Published studies can be used to quantify the relative risk of death for dialysis patients with various comorbidities. This information is important if attempts are to be made to set standards for the performance of dialysis units, and to compare the performance of one dialysis unit with that of another.

Aging↗
PubMedDate not supplied

Patients with diagnosed diabetes mellitus can be accurately identified in an Indian Health Service patient registration database.

OBJECTIVE: The computerized patient registration databases maintained by the Indian Health Service (IHS) represent a potentially important source of data about the epidemic of diabetes among American Indian and Alaskan Native people. The purpose of this study is to determine the accuracy of this data source, and to identify the optimal search criteria to identify patients with a diagnosis of diabetes in an IHS patient registration database. METHODS: The authors compared the results of a series of computerized searches to a "gold standard" sample of 465 manually reviewed charts from a large IHS facility. RESULTS: Among patients ages 15 years and older, the best criterion for identifying patients diagnosed with diabetes was the presence of at least one purpose of visit narrative identified by a 250.00 to 250.93 ICD-9 code. The presence of a single computerized code for diabetes identified patients with diagnosed diabetes with a sensitivity of 92% (95% confidence interval [CI] 81, 97), a specificity of 99% (95% CI 98, 99), and a calculated positive predictive value of 94% (95% CI 85, 99). In a separate chart review of 462 charts of patients who had at least one 250.00 to 250.93 ICD-9 code recorded in the database, 435 had a diagnosis of diabetes for an observed positive predictive value of 94%. Because the prevalence of diabetes varies by age of the patient, the positive predictive value of the ability to identify patients with diabetes also varies by age. CONCLUSION: A computerized search of an IHS patient database can identify patients with a diagnosis of diabetes with an accuracy that is similar to the reported accuracy from other health care system databases.

Abstracting and Indexing↗
PubMed2006

Medical workforce policy-making in Canada, 1993-2003: reconnecting the disconnected.

The authors set out to review Canadian medical workforce policies for 1993 to 2003 and assess if data existed in the 1990s that could have reversed the policy decision to curtail the supply of physicians from Canada's medical schools just as Canada was about to experience a developing shortage. The authors reviewed existing descriptive data sources regarding Canadian physician workforce size and activity from 1986 to 2003, including the Canadian Medical Association workforce database. The review indicated that a significant loss of physicians to retirement was imminent. Physician workforce productivity had started to fall by the early 1990s. Emigration to the United States had risen above traditional levels in the early 1990s and remained higher into the late 1990s. Despite these existing findings, an integrated adjustment to physician workforce policies taken in 1993-94 only occurred after 1999. The authors recommend that policy makers and managers must monitor the numbers from existing sources. To optimize these sources, planned data tracking and linkages are essential. The period in question demonstrated major disconnects in coordinating implementation, wherein subject experts monitoring data trends were not adequately utilized by policy makers. Finally, in complex systems with regional differences, policy decisions based on normative data are insufficient.

Canada↗
PubMed1993

Adequacy of tissue oxygenation.

OBJECTIVE: This paper reviews presently available techniques for monitoring the adequacy of tissue oxygenation, emphasizing the practical and theoretical problems that exist with presently used measurements. DATA SOURCES: The data are based on a review of the literature. DATA SYNTHESIS: Most of the presently available techniques focus on global measurements of oxygen transport and utilization that may be insensitive to changes occurring in vital tissues critically important to overall homeostasis. As a result, they are often insensitive, nonspecific, and become abnormal only at a very late stage of disease. CONCLUSIONS: In attempting to develop tools to assess adequate tissue oxygenation, emphasis should be placed on the monitoring of individual tissues that are felt to be highly susceptible to reduced oxygen delivery and key to overall survival. Preliminary data involving measurements of the interstitial pH of the gastrointestinal tract suggest that this measurement may be one approach to pursue.

Cell Hypoxia↗
PubMed1998

Evaluation of Institutional Review Board review and informed consent in publications of human research in critical care medicine.

OBJECTIVE: To examine the frequency of obtaining Institutional Review Board (IRB) approval and informed consent in critical care research. DATA SOURCES AND DATA EXTRACTION: One-year retrospective review of original critical care research in humans published in seven journals, including American Journal of Respiratory and Critical Care Medicine, Chest, Critical Care Medicine, Intensive Care Medicine, The Journal of the American Medical Association, Lancet, and The New England Journal of Medicine. Studies were examined for general information (country/state where the research was performed, affiliation of the hospital to a medical school, and whether the work was supported by a grant and specifically by a pharmaceutical company), approval by IRB, method of consent, design of research, and interventions involved in the study. DATA SYNTHESIS: Two hundred seventy-nine studies were reviewed, 124 (44%) of which were conducted in the United States. Two hundred forty-three (87%) studies were performed in a university institution, 96 (34%) studies were supported by a grant, and 23 (24%) studies were supported by a pharmaceutical company. In 66 (24%) studies, there was no evidence of IRB review and informed consent approval. IRB approval was obtained but the method of consent was not specified in 36 (13%) studies. No significant differences were found in obtaining IRB approval and informed consent between research conducted in the United States (n=71, 57%) or outside the United States (n=92, 59%). Grant support was obtained in ten (9%) of the 116 studies not fully approved, compared with 70 (50%) of the 140 studies that obtained full approval (p < .05). All studies (23) supported by the pharmaceutical industry were fully approved. CONCLUSIONS: Many published studies in critical care lack IRB approval and/or informed consent. All research supported by the pharmaceutical industry was fully approved. The findings raise ethical concerns about critical care research.

Bibliometrics↗
PubMed2002

Developing a reliable, valid, and feasible plan for quality-of-care measurement for cancer: how should we measure?

BACKGROUND: Recent changes in the US health care delivery system have raised expectations that the medical marketplace will compete on quality and cost of care. This effort will require a systematic evaluation of the measurement of quality of care as it applies to cancer and other critical conditions. OBJECTIVES: To articulate the components of the design of quality-of-care measurement systems that must be considered and optimally manipulated to generate feasible, reliable, and valid data pertinent to patients with cancer. RESEARCH DESIGN: A synthesis of information obtained from literature reviews and experience. MEASURES: Four key areas of design that influence quality-of-care measurement scores are discussed: case identification, data source, data-collection strategies, and the quality of the care-measurement model. RESULTS: Challenges associated with these design and measurement strategies are defined and discussed. CONCLUSIONS: Policy analyses vary as a function of measurement domains. The design of a quality-of-care measurement system should consider trade-offs between validity and burden by considering the intricate relations between domains of measurement.

Data Collection↗
PubMed1996

Fractures of the lateral process of the talus: a clinical review. "Snowboarder's ankle".

OBJECTIVE: This is a review article discussing the incidence, aetiology, investigation, and management of fractures of the lateral process of the talus, an uncommon but increasingly recognised complication of snowboarding. DATA SOURCES: The data regarding aetiology, investigation, and management of these fractures were obtained through a comprehensive literature review utilising the Medline, Sport discus, Medline Orthopaedic, and Cinahl databases. Injury data were obtained through published prospective epidemiological studies of snowboarding injuries. STUDY SELECTION: All studies of talar fractures, particularly of the lateral process, were included in the review. All prospective and retrospective studies of snowboarding injuries were reviewed. DATA SYNTHESIS: The mechanism of this injury appears to be a combination of dorsiflexion and inversion of the ankle. The combination of soft-shell snowboarding boots and aerial maneuvers increase the likelihood of injury. Clinically these injuries resemble severe ligamentous ankle sprains and are commonly misdiagnosed. The fractures can be classified into three subtypes based on the severity of the bony injury. The management of each injury subtype differs and although no prospective treatment trials have been performed the published risk of long term degenerative subtalar joint damage warrant aggressive early management of this injury. CONCLUSIONS: With the increasing popularity of snowboarding, the possibility of this injury should be considered in all ankle injuries related to this sport. Once diagnosed, management guidelines should be followed in order to minimise long term problems.

Ankle Injuries↗
PubMed2002

The fenestration operation of Lempert: a historical perspective.

OBJECTIVE: To describe the events surrounding the introduction of the one-stage fenestration operation for otosclerosis and the presentation of the paper given to the American Otological Society in 1938. DATA SOURCES: Published data in scientific journals and news media, archival material from the New York Academy of Medicine and the John Q. Adams Center of The American Academy of Otolaryngology-Head and Neck Surgery, and a personal interview with the late Gordon D. Hoople, M.D. CONCLUSION: This article describes Dr. Gordon Hoople's exclusive account of the events surrounding the presentation of the first paper of the Lempert one-stage fenestration operation to the American Otological Society, why it was never published, why detailed proceedings of The Society were expunged from the record, and why Samuel J. Kopetzky was expelled from the American Otological Society.

Fenestration, Labyrinth↗
PubMed2004

World Health Organization systematic review of screening tests for preeclampsia.

OBJECTIVE: We sought to assess the usefulness of clinical, biophysical, and biochemical tests in the prediction of preeclampsia. DATA SOURCES: The sources of data we used to conduct this review included the computerized databases MEDLINE (1966 to February 2003), EMBASE, Popline, CINAHL, and LILACS plus reference lists, conference proceedings, textbooks, and contact with experts. METHODS OF STUDY SELECTION: All cohort or cross-sectional studies reporting data on the relationship between a predictive test that was performed during pregnancy and the development of preeclampsia were eligible for inclusion, whereas case-control studies were excluded. Eighty-seven (211,369 women) of 7,191 potentially relevant articles met inclusion criteria. We evaluated the methodologic quality for each included study. TABULATION, INTEGRATION, AND RESULTS: Using a standardized protocol, one reviewer selected and extracted data on study characteristics, quality, and accuracy. Data abstracted from each study were arranged in 2 x 2 tables to construct receiver operating characteristics plots (sensitivity against 1 - specificity) and pooled to produce summary likelihood ratios for positive and negative tests results. Moderate predictive accuracy of anticardiolipin antibodies, the presence of bilateral diastolic notches during Doppler ultrasonography, and urinary kallikrein were found in women at low risk of developing preeclampsia. Nevertheless, because the pretest probability of preeclampsia with a positive result was but minimally increased, the clinical use of these tests is limited. Other ultrasonography characteristics and the measurement of fetal and placental peptides showed low predictive accuracy. In populations that were deemed at high risk for preeclampsia, the use of Doppler ultrasonography had low predictive accuracy. No definitive conclusions were possible in the case of many other tests, because the number of studies that met the minimal inclusion criteria was limited. CONCLUSION: As of 2004, there is no clinically useful screening test to predict the development of preeclampsia. Further prospective, longitudinal studies are needed.

Blood Pressure Monitoring, Ambulatory↗
PubMed2004

Oral decontamination is cost-saving in the prevention of ventilator-associated pneumonia in intensive care units.

OBJECTIVE: Although the development of ventilator-associated pneumonia (VAP) is assumed to increase costs of intensive care unit stay, it is unknown whether prevention of VAP by means of oropharyngeal decontamination is cost-effective. Because of wide ranges of individual patient costs, crude cost comparisons did not show significant cost reductions. DESIGN: Based on actual cost data of 181 individual patients included in a former randomized clinical trial, cost-effectiveness of prevention of VAP was determined using a decision model and univariate sensitivity analyses, and bootstrapping was used to assess the impact of variability in the various outcomes. DATA SOURCE: Published data on prevention of VAP by oropharyngeal decontamination, which resulted in a relative risk for VAP of 0.45, with a baseline rate of VAP of 29% among control patients. The mean costs of the intervention were 351 dollars per patient (32 dollars per patient per day). All other costs were derived from the hospital administrative database for all individual patients. RESULTS OF BASE-CASE ANALYSIS: Prevention of VAP led to mean total costs of 16,119 dollars and 18,268 dollars for patients without preventive measures administered. Thus, costs were saved and instances of VAP were prevented. Similar results were observed in terms of overall survival. RESULTS OF SENSITIVITY ANALYSIS: Prevention of VAP remains cost-saving if the relative risk for VAP because of intervention is <0.923, the costs of the intervention are less than 2,500 dollars, and the prevalence of VAP without intervention is >4%. Bootstrapping confirmed that, with about 80% certainty, oropharyngeal decontamination results in prevention of VAP and simultaneously saves costs. In terms of a survival benefit, the results are less evident; the results indicate that with only about 60% certainty can we confirm that oropharyngeal decontamination would result in a survival benefit and simultaneously save costs. CONCLUSIONS: This study provides strong evidence that prevention of VAP by means of oropharyngeal decontamination is cost-effective.

Antibiotic Prophylaxis↗
PubMed2006

Animal models of transfusion-related acute lung injury.

OBJECTIVE: To examine the existing animal models of transfusion-related acute lung injury (TRALI) for insight into disease pathogenesis. DATA SOURCE: The data were taken from published research and from our own experimental results. RESULTS: Animal models have disproved the microaggregate theory of acute lung injury from blood transfusions. The two major hypotheses of TRALI, passively transfused neutrophil and human leukocyte antigen antibodies and biologically active lipids that accumulate in older, cellular blood products, have been replicated in animal models. The proposed two-hit model of TRALI is also supported by animal studies. A new in vivo mouse model of TRALI based on major histocompatibility complex (MHC) I antibodies has replicated several features of human TRALI, focusing prominently on the role of neutrophils. CONCLUSIONS: Experimental animal models support both the antibody and lipid theories of TRALI. The essential role of neutrophils to producing lung injury is common to all existing models of TRALI. There is a lack of clinically relevant animal models that explain why transfusion of donor antibodies to cognate antigens in the recipient does not always lead to TRALI.

Animals↗