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An introduction to the collaborative methodology and its potential use for the management of heart failure.

BACKGROUND: Heart failure (HF) is responsible for significant disease burden in developed countries internationally. Despite significant advances and a strong evidence base in therapies and treatment strategies for HF, access to these therapies continues to remain elusive to a significant proportion of the HF population. The reasons for this are multifactorial and range from the financial cost of treatments to the individual attitudes and beliefs of clinicians. The collaborative methodology, based upon a quality improvement philosophy, has been identified as a potentially useful tool to address this treatment gap. AIM: In this manuscript, we review the published literature on the collaborative methodology and assess the evidence for achieving improvement in the management of HF. METHODS: Searches of electronic databases, the reference lists of published materials, policy documents, and the Internet were conducted using key words including "collaborative methodology," "breakthrough series," "quality improvement," "total quality improvement," and "heart failure." Because of the paucity of high-level evidence, all English-language articles were included in the review. RESULTS: On the basis of the identified search strategy, 43 articles were retrieved. Key themes that emerged from the literature included the following: (1) The collaborative methodology has a significant potential to reduce the treatment gap. (2) Leadership is an important characteristic of the collaborative method. (3) The collaborative methodology facilitates sustainability of the quality improvement process. CONCLUSION: The collaborative methodology, when implemented and conducted according to key conceptual principles, has significant potential to improve the outcomes of patients, particularly those with HF and chronic cardiovascular disease.

Cooperative Behavior↗
PubMed2001

A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known?

BACKGROUND: Many studies have explored the role of "classic" sexually transmitted diseases (STDs) in determining the pattern of HIV epidemics. However, the many different STDs may contribute in different ways, at different magnitudes. GOAL: To review available studies on the bidirectional interactions of HIV and STDs to explore the extent of current knowledge on the different influences of the varied STDs in heterosexual HIV epidemics. METHODS: Longitudinal studies on susceptibility and controlled studies on infectiousness and duration of disease identified on electronic databases through reference lists and citation indices up to the end of 1999 were systematically reviewed, including meta-analyses assessing the influence of STDs on susceptibility to HIV. RESULTS: Studies have a clear publication bias with a significant result that hinders robust interpretation. However, genital ulcerative disease appears to have a greater impact than nonulcerative disease, and men are more affected than women by the effects of STDs on susceptibility to HIV. There is evidence that STDs increase the infectiousness of HIV from men to women, whereas the evidence is more equivocal for the infectiousness of women. Few studies identify the impact of different STDs, and there is a marked lack of studies investigating the impact of HIV infection on the transmission of other STDs. CONCLUSIONS: A large body of work has measured the association between STDs and HIV. However, publication bias and gaps in the focus of studies mean that a detailed, quantitative understanding of the interaction requires much more attention.

Comorbidity↗
PubMed2001

Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group.

STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To evaluate the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults. SUMMARY OF BACKGROUND DATA: Multidisciplinary biopsychosocial rehabilitation programs for neck and shoulder pain require substantial staff and financial resources. They are widely used, despite questionable evidence of their effectiveness. METHODS: The reviewed randomized controlled and controlled trials appraising the effectiveness of biopsychosocial rehabilitation for working age patients with neck and shoulder pain were identified by searching electronic bibliographic databases, checking references, and consulting experts in the rehabilitation field. Four blinded reviewers selected the trials. Two specialists on rehabilitation evaluated the clinical relevance. Two other blinded reviewers extracted the data and assessed the main results and the methodologic quality of the studies. A qualitative analysis was performed to evaluate the level of scientific evidence. RESULTS: After 1808 abstracts and the references of 65 reviews were screened, only two relevant studies were found that satisfied the criteria. One of these was considered a methodologically low-quality randomized controlled trial, and the other was a methodologically low-quality controlled clinical trial. The clinical relevance of included studies was satisfactory. The level of scientific evidence for the effectiveness of multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain was limited. CONCLUSIONS: There appears to be little scientific evidence for the effectiveness on neck and shoulder pain of multidisciplinary biopsychosocial rehabilitation compared with other rehabilitation methods. There is an urgent need for high-quality trials in this field.

Adult↗
PubMed1999

Manganese in gasoline. Council on Scientific Affairs, American Medical Association.

This report responds to a resolution that asked the American Medical Association (AMA) to take action to reduce potential health risks from the use of methylcyclopentadienyl manganese tricarbonyl (MMT) in gasoline. Information for this report was derived from a search of the MEDLINE database and references listed in pertinent articles, as well as through communications with medical and public health experts. Based on this information, the AMA Council on Scientific Affairs determined that there is insufficient scientific evidence to assess the public health impact of MMT use. While limited evidence indicates that general-population exposures to manganese from the use of MMT in gasoline are low, more research is needed to determine possible health effects from long-term, low-dose exposures to MMT and its combustion products. Until such data are available, educational and informational strategies should be developed to improve public awareness of the health and environmental issues surrounding MMT use.

Air Pollutants↗
PubMed2004

Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses.

BACKGROUND: Because recent research in primary care has challenged the findings of previous reviews on the efficacy of brief interventions (BIs) on hazardous drinkers, we conducted a systematic review and meta-analysis to update the evidence of BIs as applied in the primary care setting. METHODS: We obtained source material by searching electronic databases and reference lists and hand-searching journals. We selected randomized trials providing frequency data that allowed assessment of the efficacy of BIs on an intention-to-treat basis. Results were summarized by the odds ratio (OR) of response. When appropriate, risk difference (RD) and its inverse (number needed to treat [NNT] to achieve a positive result) were also computed. Fixed and/or random effect models were fitted according to heterogeneity estimates. RESULTS: Thirteen studies provided data for a dose-effect analysis, 12 for comparison of BIs with reference categories. No clear evidence of a dose-effect relationship was found. BIs outperformed minimal interventions and usual care (random effects model OR = 1.55, 95% confidence interval [CI] = 1.27-1.90; RD = 0.11, 95% CI = 0.06-0.16; NNT = 10, 95% CI = 7-17). Similar results were obtained when two influential studies were removed (fixed effect model OR = 1.57, 95% CI = 1.32-1.87; RD = 0.11, 95% CI = 0.07-0.15; NNT = 9, 95% CI = 7-15). The heterogeneity between individual estimates was accounted for by the type of hazardous drinkers (heavy versus moderate) and by the characteristics of the included individuals (treatment seekers versus nontreatment seekers). The funnel plot did not show evidence of publication bias. CONCLUSION: Our results, although indicating smaller effect sizes than previous meta-analyses, do support the moderate efficacy of BIs. Further research is outlined.

Alcohol Drinking↗
PubMed2005

Assessing the neonatal safety of indomethacin tocolysis: a systematic review with meta-analysis.

OBJECTIVE: To systematically review and summarize the medical literature regarding the effects of tocolysis with indomethacin on neonatal outcome. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies pertaining to indomethacin tocolysis and neonatal outcome. METHODS OF STUDY SELECTION: We evaluated, abstracted data, and performed quantitative analyses in studies assessing the neonatal outcomes of patients undergoing tocolysis with indomethacin. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS: Forty-six studies were identified, 28 of which met criteria for systematic review and meta-analysis. These 28 studies included 6,008 infants. Of these infants, 1,621 were exposed to indomethacin for tocolysis antenatally; 4,387 infants not exposed to indomethacin served as the comparison group. An estimate of pooled odds ratios with 95% confidence intervals was calculated for dichotomous outcomes using random- and fixed-effects models. Observational studies and randomized trials were analyzed separately. Pooled estimates from observational studies and randomized trials revealed no significant differences in the rates of intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, or neonatal mortality between infants exposed to indomethacin antenatally and those not exposed. Meta-analysis of randomized trials revealed increased risk of bronchopulmonary dysplasia. However, the meta-analysis included only 3 randomized clinical trials, one of which showed increased risk. An association of bronchopulmonary dysplasia and indomethacin use was not noted in our analysis of observational studies. CONCLUSION: Although our pooled results did not identify significantly increased risks of adverse effects, the limited statistical power of published randomized trials does not allow us to exclude the possibility that indomethacin tocolysis increases the risk of adverse neonatal outcomes.

Adult↗
PubMed2004

Prevention of hospital-associated pneumonia and ventilator-associated pneumonia.

OBJECTIVE: To synthesize the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator-associated pneumonia (VAP) into a practical guideline for clinicians. DATA SOURCE: A Medline database and references from identified articles were used to perform a literature search relating to the prevention of HAP/VAP. CONCLUSIONS: There is convincing evidence to suggest that specific interventions can be employed to prevent HAP/VAP. The evidence-based interventions focus on the prevention of aerodigestive tract colonization (avoidance of unnecessary antibiotics and stress ulcer prophylaxis, use of sucralfate for stress ulcer prophylaxis, chlorhexidine oral rinse, selective digestive decontamination, short-course parenteral prophylactic antibiotics in high-risk patients) and the prevention of aspiration of contaminated secretions (preferred oral intubation, appropriate intensive care unit staffing, avoidance of tracheal intubation with the use of mask ventilation, application of weaning protocols and optimal use of sedation to shorten the duration of mechanical ventilation, semirecumbent positioning, minimization of gastric distension, subglottic suctioning, avoidance of ventilator circuit changes/manipulation, routine drainage of ventilator circuit condensate). Clinicians caring for patients at risk for HAP/VAP should promote the development and application of local programs encompassing these interventions based on local resource availability, occurrence rates of HAP/VAP, and the prevalence of infection due to antibiotic-resistant bacteria (Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus).

Cross Infection↗
PubMed2005

Mechanical ventilation and acute renal failure.

OBJECTIVE: To review the current literature on possible mechanisms by which mechanical ventilation may initiate or aggravate acute renal failure. DATA SOURCE: A Medline database and references from identified articles were used to perform a literature search relating to mechanical ventilation and acute renal failure. DATA SYNTHESIS: Acute renal failure may be initiated or aggravated by mechanical ventilation through three different mechanisms. First, strategies such as permissive hypercapnia or permissive hypoxemia may compromise renal blood flow. Second, through effects on cardiac output, mechanical ventilation affects systemic and renal hemodynamics. Third, mechanical ventilation may cause biotrauma-a pulmonary inflammatory reaction that may generate systemic release of inflammatory mediators. The harmful effects of mechanical ventilation may become more significant when a comorbidity is present. In these situations, it is more difficult to maintain normal gas exchange, and moderate arterial hypoxemia and hypercapnia are often accepted. Renal blood flow is compromised due to a decreased cardiac output as a consequence of high intrathoracic pressures. Furthermore, the effects of biotrauma are not limited to the lungs but may lead to a systemic inflammatory reaction. CONCLUSIONS: The development of acute renal failure during mechanical ventilation likely represents a multifactorial process that may become more important in the presence of comorbidities. Development of optimal interventional strategies requires an understanding of physiologic principles and greater insight into the precise molecular and cellular mechanisms that may also play a role.

Acute Kidney Injury↗
PubMed2005

Strategies to prevent antimicrobial resistance in the intensive care unit.

OBJECTIVE: To assemble the available clinical data for the prevention of antimicrobial resistance into practical recommendations for clinicians. DATA SOURCE: A Medline database and references from identified articles were employed to perform a literature search relating to the prevention of antimicrobial resistance. CONCLUSIONS: Antimicrobial resistance has emerged as an important determinant of mortality for patients in the intensive care unit. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antimicrobial agents, resulting in the administration of inappropriate treatment. Effective strategies for the prevention of antimicrobial resistance within intensive care units are available and should be aggressively implemented. These strategies can be divided into nonpharmacologic infection control strategies (e.g., routine hand hygiene, implementation of infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotic treatment, narrowing of antimicrobial spectrum based on culture results). Increasing current efforts aimed at the prevention of antimicrobial resistance is especially important given the limited availability of new antimicrobial drug classes for the foreseeable future.

Algorithms↗
PubMed2006

Critical care considerations of hematopoietic stem cell transplantation.

OBJECTIVE: To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT). DATA SOURCE: The MEDLINE database and references from the identified articles related to the critical care in HSCT. CONCLUSION: HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.

Critical Care↗
PubMed2005

Limitations in the use of serum prostate specific antigen levels to monitor patients after treatment for prostate cancer.

PURPOSE: We reviewed the literature to help clarify the benefits and/or hazards associated with monitoring serum prostate specific antigen (PSA) after treatment with surgery or radiation therapy (RT) for nonmetastatic prostate cancer. MATERIALS AND METHODS: A search was performed for 1990 to 2004 using the MEDLINE database, CancerLit database and reference lists of relevant studies to obtain articles addressing the use of serum PSA to follow patients after treatment for prostate cancer. Studies were reviewed to determine 1) if serial PSA monitoring provides an early and accurate surrogate assessment of cancer cure or treatment failure, 2) if any pattern in the PSA profile after treatment provides conclusive evidence of early local vs systemic failure, 3) the magnitude of the lead time to clinical failure that serial PSA monitoring may provide and 4) if the early identification of biochemical failure (BF) with earlier intervention improves outcome. RESULTS: Although a lower PSA nadir after treatment with RT has been associated with cancer cure, 5% to 25% of patients ultimately have failure (beyond 5 years) even with the most optimal biochemical response. The most appropriate BF definitions to use after treatment for prostate cancer with RT remains controversial due to substantial differences in their accuracy, sensitivity, specificity and positive predictive value for clinical outcome. No pattern of PSA kinetics after treatment has conclusively been associated with a specific recurrence site. Biochemical failure definitions in patients treated with RT appear to provide a 6 to 18 month lead time to clinical failure but there are only limited published data to suggest that early intervention of any type (androgen deprivation, RT, surgery, etc) impacts survival. CONCLUSIONS: The overall benefit of monitoring serum PSA after treatment for prostate cancer remains controversial. Considering the potential dangers associated with incorrectly assuming the efficacy of new forms of treatment, the toxicity of administering salvage therapies of uncertain efficacy after BF has been identified and the anxiety associated with tracking posttreatment serum PSA, additional studies must be done to determine the appropriate use of this marker in properly treating patients after therapy.

Humans↗
PubMed2006

Estimating diversity of Indo-Pacific coral reef stomatopods through DNA barcoding of stomatopod larvae.

There is a push to fully document the biodiversity of the world within 25 years. However, the magnitude of this challenge, particularly in marine environments, is not well known. In this study, we apply DNA barcoding to explore the biodiversity of gonodactylid stomatopods (mantis shrimp) in both the Coral Triangle and the Red Sea. Comparison of sequences from 189 unknown stomatopod larvae to 327 known adults representing 67 taxa in the superfamily Gonodactyloidea revealed 22 distinct larval operational taxonomic units (OTUs). In the Western Pacific, 10 larval OTUs were members of the Gonodactylidae and Protosquillidae where success of positive identification was expected to be 96.5%. However, only five OTUs could be identified to species and at least three OTUs represent new species unknown in their adult form. In the Red Sea where the identification rate was expected to be 75% in the Gonodactylidae, none of four larval OTUs could be identified to species; at least two represent new species unknown in their adult forms. Results indicate that the biodiversity in this well-studied group in the Coral Triangle and Red Sea may be underestimated by a minimum of 50% to more than 150%, suggesting a much greater challenge in lesser-studied groups. Although the DNA barcoding methodology was effective, its overall success was limited due to the newly discovered taxonomic limitations of the reference sequence database, highlighting the importance of synergy between molecular geneticists and taxonomists in understanding and documenting our world's biodiversity, both in marine and terrestrial environments.

Animals↗
PubMed1996

An integrated YAC map of the human X chromosome.

The human X chromosome is associated with a large number of disease phenotypes, principally because of its unique mode of inheritance that tends to reveal all recessive disorders in males. With the longer term goal of identifying and characterizing most of these genes, we have adopted a chromosome-wide strategy to establish a YAC contig map. We have performed > 3250 inter Alu-PCR product hybridizations to identify overlaps between YAC clones. Positional information associated with many of these YAC clones has been derived from our Reference Library Database and a variety of other public sources. We have constructed a YAC contig map of the X chromosome covering 125 Mb of DNA in 25 contigs and containing 906 YAC clones. These contigs have been verified extensively by FISH and by gel and hybridization fingerprinting techniques. This independently derived map exceeds the coverage of recently reported X chromosome maps built as part of whole-genome YAC maps.

Chromosome Mapping↗
PubMed2002

The genetic aetiology of childhood depression: a review.

BACKGROUND: We review the evidence for the familiality of major depressive disorder (MDD) and the genetic aetiology of depressive symptoms in children and adolescents. METHODS: Databases and reference lists were searched for family, twin and adoption studies of childhood MDD and childhood depressive symptoms. Data from independent family studies that fulfilled specified inclusion criteria were pooled and odds ratios were calculated for top-down and bottom-up family studies. RESULTS: Estimates of familial risk differ by control group and by study design (odds ratio range 1.70, 3.98). Twin studies show that depressive symptoms in young people are heritable although rater and measurement issues are important. Adoption studies show little evidence for a genetic influence on depressive symptoms. CONCLUSIONS: MDD in young people is familial although control group and study design affect the magnitude of the familial risk. Estimates of heritability from twin and adoption studies vary widely and few firm conclusions can be made regarding the genetic aetiology of depressive symptoms in childhood. Areas that require future work include the examination of rater effects, measurement issues, the effects of age and comorbidity and reasons for the discrepancy between twin and adoption findings.

Adolescent↗
PubMed2006

Which drugs cause preventable admissions to hospital? A systematic review.

AIMS: Previous systematic reviews have found that drug-related morbidity accounts for 4.3% of preventable hospital admissions. None, however, has identified the drugs most commonly responsible for preventable hospital admissions. The aims of this study were to estimate the percentage of preventable drug-related hospital admissions, the most common drug causes of preventable hospital admissions and the most common underlying causes of preventable drug-related admissions. METHODS: Bibliographic databases and reference lists from eligible articles and study authors were the sources for data. Seventeen prospective observational studies reporting the proportion of preventable drug-related hospital admissions, causative drugs and/or the underlying causes of hospital admissions were selected. Included studies used multiple reviewers and/or explicit criteria to assess causality and preventability of hospital admissions. Two investigators abstracted data from all included studies using a purpose-made data extraction form. RESULTS: From 13 papers the median percentage of preventable drug-related admissions to hospital was 3.7% (range 1.4-15.4). From nine papers the majority (51%) of preventable drug-related admissions involved either antiplatelets (16%), diuretics (16%), nonsteroidal anti-inflammatory drugs (11%) or anticoagulants (8%). From five studies the median proportion of preventable drug-related admissions associated with prescribing problems was 30.6% (range 11.1-41.8), with adherence problems 33.3% (range 20.9-41.7) and with monitoring problems 22.2% (range 0-31.3). CONCLUSIONS: Four groups of drugs account for more than 50% of the drug groups associated with preventable drug-related hospital admissions. Concentrating interventions on these drug groups could reduce appreciably the number of preventable drug-related admissions to hospital from primary care.

Adolescent↗
PubMed2005

Gatekeepers in sickness insurance: a systematic review of the literature on practices of social insurance officers.

Decisions concerning entitlement to sickness benefits have a substantial impact on the lives of individuals and on society. In most countries, such decisions are made by staff of private or public insurance organisations. The work performed by these professionals is debated, hence more knowledge is needed on this subject. The aim of the present study was to review scientific studies of the practices of social insurance officers (SIOs) published in English, Danish, Norwegian and Swedish. Studies were searched for in literature databases, in reference lists, and through personal contacts. Analyses were made of type of study, areas investigated, research questions, theories used, and the results. Sixteen studies were included. SIOs and several other actors are responsible for applying measures to minimise sick-leave and promote return to work (RTW). The studies focusing on coordination of such measures revealed that SIOs felt unsure about how to handle their contacts with clients and other actors. One study indicated that the SIOs, partly due to lack of time, accepted the recommendations of physicians instead of making their own judgments about granting sickness benefits. While all SIOs must make decisions concerning entitlement to sickness benefits on a daily basis, few of the reviewed studies scrutinised the actual granting of sickness compensation. The studies were also deficient in that they investigated the decision latitude of the SIOs from a very limited perspective, mainly on an individual level and often primarily in relation to colleagues and/or clients rather than to the laws and regulations of the sickness insurance. The concepts and framework in this area of research need to be developed to facilitate elucidation of the interaction between different actors in local spheres, professionals in different disciplines, and between welfare staff and individual citizens.

Certification↗
PubMed2002

Proteomic analysis of normal human urinary proteins isolated by acetone precipitation or ultracentrifugation.

BACKGROUND: Proteomic techniques have recently become available for large-scale protein analysis. The utility of these techniques in identification of urinary proteins is poorly defined. We constructed a proteome map of normal human urine as a reference protein database by using two differential fractionated techniques to isolate the proteins. METHODS: Proteins were isolated from urine obtained from normal human volunteers by acetone precipitation or ultracentrifugation, separated by two-dimensional polyacrylamide gel electrophoresis (2D-PAGE) and identified by matrix-assisted laser desorption ionization-time-of-flight (MALDI-TOF) mass spectrometry followed by peptide mass fingerprinting. RESULTS: A total of 67 protein forms of 47 unique proteins were identified, including transporters, adhesion molecules, complement, chaperones, receptors, enzymes, serpins, cell signaling proteins and matrix proteins. Acetone precipitated more acidic and hydrophilic proteins, whereas ultracentrifugation fractionated more basic, hydrophobic, and membrane proteins. Bioinformatic analysis predicted glycosylation to be the most common explanation for multiple forms of the same protein. CONCLUSIONS: Combining two differential isolation techniques magnified protein identification from human urine. Proteomic analysis of urinary proteins is a promising tool to study renal physiology and pathophysiology and to determine biomarkers of renal disease.

Acetone↗
PubMed2001

Chord distributions across 3D digital images of a human thoracic vertebra.

Radiation dose estimates to the trabecular region of the skeleton are of primary importance due to recent advancements in nuclear medicine. Establishing methods for accurately calculating dose in these regions is difficult due to the complex microstructure of this anatomic site and the typical ranges of beta-particles in both bone and marrow tissues. At the present time, models of skeletal dosimetry used in clinical medicine rely upon measured distributions of straight-line path lengths (chord lengths) through bone and marrow regions. This work develops a new three-dimensional, digital method for acquiring these distributions within voxelized images. In addition, the study details the characteristics of measuring chord distributions within digital images and provides a methodology for avoiding undesirable pixel or voxel effects. The improved methodology has been applied to a digital image (acquired via NMR microscopy) of the trabecular region of a human thoracic vertebra. The resulting chord-length distributions across both bone trabeculae and bone marrow cavities were found to be in general agreement with those measured in other studies utilizing different methods. In addition, this study identified that bone and marrow space chord-length distributions are not statistically independent, a condition implicitly assumed within all current skeletal dosimetry models of electron transport. The study concludes that the use of NMR microscopy combined with the digital measurement techniques should be used to further expand the existing Reference Man database of trabecular chord distributions to permit the development of skeletal dosimetry models which are more age and gender specific.

Bone Marrow↗