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Application of new vaccine technologies for the control of transboundary diseases.
Vaccines have played an important role in the control of diseases of livestock and poultry, including Transboundary Diseases. In the future, vaccines will play a greater role in controlling these diseases. Historically, inactivated whole viruses in various adjuvant systems have been used and will continue to be used in the near future. For the future, emerging technologies will allow targeted use of only the protective antigens of the pathogen and will provide the opportunity for differentiating between vaccinated and field-exposed animals. Furthermore, the expression of cytokines by vaccines will afford earlier or greater enhancement of protection than can be achieved by the protective response elicited by the antigenic epitopes of the pathogen alone. Avian influenza (AI) is a good case for studying future trends in vaccine design and use. Inactivated AI virus (AIV) vaccines will continue as the primary vaccines used over the next 10 years. These vaccines will use homologous haemagglutinin sub-types, either from the use of field strains or the generation of new strains through the use of infectious clones produced in the laboratory. The latter will allow creation of high growth reassortants, which will provide consistent high yields of antigen and result in potent vaccines. New viral and bacterial vectors with inserts of AIV haemagglutinin gene will be developed and potentially used in the field. Such new vectors will include herpesvirus-turkey, infectious laryngotracheitis virus, adenoviruses, various types of paramyxoviruses and Salmonella sp. In addition, there is a theoretical possibility of gene-deleted mutants that would allow the use of live AIV vaccines, but the application of such vaccines has inherent dangers for gene reassortment with field viruses in the generation of disease-causing strains. Subunit haemagglutinin protein and DNA haemagglutinin gene vaccines are possible, but with current technologies, the cost is prohibitive. In the future, effective AI vaccines must prevent clinical signs and death, increase resistance of the host to infection, decrease the rate of replication and shedding of a challenge or field virus and provide uniform protection following single immunization. Mass application technologies of new virus or bacterial vector systems will provide economic incentives for adoption over current labour-intensive manual individual bird injection methods used with today's AI vaccines.
[Home therapy approach in cancer patients-nutrition therapy (case 1-1)--a case of recurrent gastric cancer with home parenteral nutrition].
This paper describes a case of recurrent gastric cancer with home parenteral nutrition (HPN). A 48-year-old man underwent nutrition support with HPN for the last 6 months. We treated the patient with adjuvant chemotherapy and provided pain management along with HPN treatment. The patient was able to achieve a meaningful and satisfactory quality of life. We concluded that HPN for recurrent cancer patients is a relatively safe and effective means of improving and maintaining the nutritional status. We think the following is important in order to establish home infusion therapy. 1) Organization of a home care team (physician, nurse, pharmacist, dietitian, and caseworker) and a practice-team approach. 2) Establishment of a home infusion system in home care. 3) Preparation of patient manuals by the medical staff. 4) Establishment of sterility preparation and delivery system in home infusion therapy. 5) Establishment of a patient-information-communication system by connection with other hospitals, clinics, and home care companies.
The genetics of autism.
Autism is a complex, behaviorally defined, static disorder of the immature brain that is of great concern to the practicing pediatrician because of an astonishing 556% reported increase in pediatric prevalence between 1991 and 1997, to a prevalence higher than that of spina bifida, cancer, or Down syndrome. This jump is probably attributable to heightened awareness and changing diagnostic criteria rather than to new environmental influences. Autism is not a disease but a syndrome with multiple nongenetic and genetic causes. By autism (the autistic spectrum disorders [ASDs]), we mean the wide spectrum of developmental disorders characterized by impairments in 3 behavioral domains: 1) social interaction; 2) language, communication, and imaginative play; and 3) range of interests and activities. Autism corresponds in this article to pervasive developmental disorder (PDD) of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and International Classification of Diseases, Tenth Revision. Except for Rett syndrome--attributable in most affected individuals to mutations of the methyl-CpG-binding protein 2 (MeCP2) gene--the other PDD subtypes (autistic disorder, Asperger disorder, disintegrative disorder, and PDD Not Otherwise Specified [PDD-NOS]) are not linked to any particular genetic or nongenetic cause. Review of 2 major textbooks on autism and of papers published between 1961 and 2003 yields convincing evidence for multiple interacting genetic factors as the main causative determinants of autism. Epidemiologic studies indicate that environmental factors such as toxic exposures, teratogens, perinatal insults, and prenatal infections such as rubella and cytomegalovirus account for few cases. These studies fail to confirm that immunizations with the measles-mumps-rubella vaccine are responsible for the surge in autism. Epilepsy, the medical condition most highly associated with autism, has equally complex genetic/nongenetic (but mostly unknown) causes. Autism is frequent in tuberous sclerosis complex and fragile X syndrome, but these 2 disorders account for but a small minority of cases. Currently, diagnosable medical conditions, cytogenetic abnormalities, and single-gene defects (eg, tuberous sclerosis complex, fragile X syndrome, and other rare diseases) together account for <10% of cases. There is convincing evidence that "idiopathic" autism is a heritable disorder. Epidemiologic studies report an ASD prevalence of approximately 3 to 6/1000, with a male to female ratio of 3:1. This skewed ratio remains unexplained: despite the contribution of a few well characterized X-linked disorders, male-to-male transmission in a number of families rules out X-linkage as the prevailing mode of inheritance. The recurrence rate in siblings of affected children is approximately 2% to 8%, much higher than the prevalence rate in the general population but much lower than in single-gene diseases. Twin studies reported 60% concordance for classic autism in monozygotic (MZ) twins versus 0 in dizygotic (DZ) twins, the higher MZ concordance attesting to genetic inheritance as the predominant causative agent. Reevaluation for a broader autistic phenotype that included communication and social disorders increased concordance remarkably from 60% to 92% in MZ twins and from 0% to 10% in DZ pairs. This suggests that interactions between multiple genes cause "idiopathic" autism but that epigenetic factors and exposure to environmental modifiers may contribute to variable expression of autism-related traits. The identity and number of genes involved remain unknown. The wide phenotypic variability of the ASDs likely reflects the interaction of multiple genes within an individual's genome and the existence of distinct genes and gene combinations among those affected. There are 3 main approaches to identifying genetic loci, chromosomal regions likely to contain relevant genes: 1) whole genome screens, searching for linkage of autism to shared genetic markers in populations of multiplex families (families with >1 affected family member; 2) cytogenetic studies that may guide molecular studies by pointing to relevant inherited or de novo chromosomal abnormalities in affected individuals and their families; and 3) evaluation of candidate genes known to affect brain development in these significantly linked regions or, alternatively, linkage of candidate genes selected a priori because of their presumptive contribution to the pathogenesis of autism. Data from whole-genome screens in multiplex families suggest interactions of at least 10 genes in the causation of autism. Thus far, a putative speech and language region at 7q31-q33 seems most strongly linked to autism, with linkages to multiple other loci under investigation. Cytogenetic abnormalities at the 15q11-q13 locus are fairly frequent in people with autism, and a "chromosome 15 phenotype" was described in individuals with chromosome 15 duplications. Among other candidate genes are the FOXP2, RAY1/ST7, IMMP2L, and RELN genes at 7q22-q33 and the GABA(A) receptor subunit and UBE3A genes on chromosome 15q11-q13. Variant alleles of the serotonin transporter gene (5-HTT) on 17q11-q12 are more frequent in individuals with autism than in nonautistic populations. In addition, animal models and linkage data from genome screens implicate the oxytocin receptor at 3p25-p26. Most pediatricians will have 1 or more children with this disorder in their practices. They must diagnose ASD expeditiously because early intervention increases its effectiveness. Children with dysmorphic features, congenital anomalies, mental retardation, or family members with developmental disorders are those most likely to benefit from extensive medical testing and genetic consultation. The yield of testing is much less in high-functioning children with a normal appearance and IQ and moderate social and language impairments. Genetic counseling justifies testing, but until autism genes are identified and their functions are understood, prenatal diagnosis will exist only for the rare cases ascribable to single-gene defects or overt chromosomal abnormalities. Parents who wish to have more children must be told of their increased statistical risk. It is crucial for pediatricians to try to involve families with multiple affected members in formal research projects, as family studies are key to unraveling the causes and pathogenesis of autism. Parents need to understand that they and their affected children are the only available sources for identifying and studying the elusive genes responsible for autism. Future clinically useful insights and potential medications depend on identifying these genes and elucidating the influences of their products on brain development and physiology.
Cancer patients' perception of the quality of communication before and after the implementation of a communication strategy in a regional cancer center in India.
PURPOSE: Physician communication is one of the areas that cancer patients have expressed their lowest level of satisfaction. Very few studies have used patient-based outcomes in the Developing world. METHODS: We conducted a survey of 400 consecutive patients attending our outpatient clinic (Step I). Survey results were used to make changes in the physical layout of the setting to increase privacy and to educate staff regarding practical techniques on communication (Step II). A second group of 400 patients were interviewed immediately after the implementation of the new communication strategy (Step III). RESULTS: Comparing Step I (n = 400) and Step III (n = 400) we observed a favorable response ("yes" v "no") with regard to overall satisfaction with communication in 52 patients (13%) versus 132 patients (33%; P = .0001), privacy in 21 patients (5%) versus 279 patients (70%; P = < .001), no interruptions in 170 patients (42%) versus 330 patients (82%; P = < .001), clear language in 57 patients (14%) versus 227 patients (57%; P = < .001), sufficient time in 88 patients (22%) versus 168 patients (42%; P = < .001), doubts cleared by the doctor in 105 patients (26%) versus 225 patients (56%; P = < .001). Patients older than 65 years and manual laborers were significantly more satisfied compared with younger patients and those patients with nonmanual occupations, during both Steps I and III. CONCLUSION: We conclude that cancer patients in Developing countries have many unmet needs regarding communication and that simple changes in the organization of clinics and oncologist education can result in major improvements in satisfaction with the quality of communication.
Enterolith small-bowel obstruction caused by jejunal diverticulosis: Report of a case.
We report the successful surgical treatment of intestinal obstruction caused by enteroliths formed in jejunal diverticula. A 78-year-old man with bowel obstruction of unknown etiology was initially managed conservatively, but suffered recurrence of the obstruction. Thus, we performed a laparotomy, which revealed multiple diverticula in the jejunum, with one enterolith inside a diverticulum and one enterolith in the terminal ileum. There was no abnormal communication between the gallbladder and the intestinal tract, excluding the possibility of a gallstone ileus. The stone in the terminal ileum could not be broken manually, so we performed an enterotomy to remove the stones. Intestinal obstruction caused by enteroliths in small-bowel diverticula is a rare event, which is difficult to diagnose and manage. To our knowledge, only 35 such cases have ever been reported.
Cutoff scores of the cognitive abilities screening instrument, Chinese version in screening of dementia.
The purpose of this study of dementia screening was to obtain different cutoff scores of the Cognitive Abilities Screening Instrument, Chinese versions (CASI C-2.0) for subjects with different educational backgrounds. The diagnosis of dementia was based on the Diagnostic and Statistical Manual of Mental Disorders, ed 3 revised or ed 4 criteria. To diagnose Alzheimer's disease, the guidelines of the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association was followed. The severity of dementia was determined on the Clinical Dementia Rating scale. Altogether 2,096 subjects, aged 65 years and more, were included. Of them, 1,178 were normal and 918 were demented. Their performance on CASI C-2.0 was influenced by their education and age. Gender difference on CASI C-2.0 scores was only significant in the illiterate, but not in the literate group. We recommend that the population be divided into three levels, namely those who (1) had no formal education (Edu = 0); (2) received 1-5 years of schooling (Edu = 1-5), and (3) received 6 or more years of education (Edu >/=6). The cutoff scores of CASI C-2.0 in the diagnosis of dementia in these three educational groups were as follows: Edu = 0: 49/50 (sensitivity = 0.83; specificity = 0.85); Edu = 1-5: 67/68 (sensitivity = 0.83; specificity = 0.91), and Edu >/=6: 79/80 (sensitivity = 0.89; specificity = 0.90).
Thrombolysis in the air. Air-ambulance paramedics flying to remote communities treat patients before hospitalization.
PROBLEM ADDRESSED: First Nations* communities in the North have a high prevalence of coronary artery disease and type 2 diabetes and face an increasing incidence of myocardial infarction (MI). Many conditions delay timely administration of thrombolysis, including long times between when patients first experience symptoms and when they present to community nursing stations, delays in air transfers to treating hospitals, uncertainty about when planes are available, and poor flying conditions. OBJECTIVE OF PROGRAM: To develop a program for administration of thrombolysis on the way to hospital by air ambulance paramedics flying to remote communities to provide more rapid thrombolytic therapy to northern patients experiencing acute MIs. COMPONENTS OF PROGRAM: Critical care flight paramedics fly to northern communities from Sioux Lookout, Ont; assess patients; communicate with base hospital physicians; review an exclusion criteria checklist; and administer thrombolytics according to the Sioux Lookout District Health Centre/Base Hospital Policy and Procedure Manual. Patients are then flown to hospitals in Sioux Lookout; Winnipeg, Man; or Thunder Bay, Ont. CONCLUSION: This thrombolysis program is being pilot tested, and further evaluation and development is anticipated.
Business management and the environment of care standards.
In summary, the entire JCAHO manual is built around the concept of "know thyself." This expectation creates the need to engage in a substantial rework of existing practices to remove communication barriers and to eliminate turf warfare. The focus of the standards is on the patient. All aspects of the patient-care delivery cycle are examined during survey, as are key elements of the business-management activities. The EC standards are a case study of business management. They expect leadership and planning, development of human resources, management of information, and improvement of performance. They expect that all four of these management tools will be exercised by all managers and staff members who have an impact on or are impacted by the seven elements of the EC function. The primary focus is on teamwork among providers and maximizing benefits to patients.
Manual activity during speaking. II. Left-handers.
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Use of hearing aids by older people: influence of non-auditory factors (vision, manual dexterity).
Acquired hearing loss is prevalent among older people. As people age, they also may develop impairments in other sensory systems, such as vision and touch. The purpose of this paper is to examine the communicative effects of a combined sensory loss and discuss how non-auditory aspects of aging can affect a person's ability: (1) to manage daily communication with an acquired hearing loss; and (2) to manipulate and maintain hearing aids that may be prescribed.
[Psychopathological concepts of induced insanity exemplified by folie a deux].
We report on a case of a "folie à deux" between sister and brother (56 and 61 years of age). Based on a definition of the concept of the induced psychoses, we focus attention on some special aspects of these double psychoses. Special consideration is given to psychopathological constellations and their meaning, with etiogenetic aspects of "process" and "development" with regard to the concept of vulnerability. We could show that in such cases the new operationalised diagnostic manuals like DSM-IV and ICD-10 are based on traditional concepts.
Infant vocal-motor coordination: precursor to the gesture-speech system?
This study was designed to provide a general picture of infant vocal-motor coordination and test predictions generated by Iverson and Thelen's (1999) model of the development of the gesture-speech system. Forty-seven 6- to 9-month-old infants were videotaped with a primary caregiver during rattle and toy play. Results indicated an age-related increase in frequency of vocal-motor coordination, greater coordination with arm (specifically right arm) than leg or torso movements, and a temporal pattern similar to that in adult gesture-speech coproductions. Rhythmic vocalizations (consonant-vowel repetitions) were more likely to occur with than without rhythmic movement, and with rhythmic manual than with nonmanual activity, and the rate of vocal-manual coordination was higher in babblers than in prebabblers.
[Information technology and medical record routines in hospitals in the health care region 2].
Structure, standard and efficient methods in paper medical records are important for a successful implementation of computerised medical records. We have conducted a survey among 26 somatic hospitals in a Norwegian region regarding present routines and use of information technology in patients records. The hospitals use six different patient administration systems, six laboratory, six radiology, and approximately 20 different specialist systems. 16 hospitals use three different electronic journal/documentation systems. Ten hospitals use the Word word processor for patient records. The full potential of word processing is not utilised. Digital dictation is seldom used; few hospitals have 24-hours service for documentation, and information technology is not used for documentation in nursing care. Four hospitals use microfilm. The survey shows that improvement is needed in order to achieve coordinated and effective use of information technology and manual routines in hospital medical records.
Creating an IHE ATNA-based audit repository.
Compliance with the Health Insurance Portability and Accountability Act (HIPAA) requires gathering audit information from picture archiving and communications systems (PACS) regarding evidence trails of human interactions. Until recently, most PACS users have had limited access to auditing information. Access required resources to handle manual inspection of audit logs, and access to proprietary databases was not always available. Some vendors now produce eXtensible Markup Language (XML) audit logs based on certain events occurring in PACS. However, it is up to the user to convert this information into an easily mined data repository supporting compliance and quality control. This process can be handled in multiple ways, which could mean different audit mechanisms depending on the PACS (or other hospital system) used. It is apparent that an organized method of dealing with audit information is needed. This help may be provided within the Integrating the Healthcare Environment (IHE) framework. The IHE initiative defines a set of profiles, actors, and transactions that create common scenarios for particular workflow processes. The Integration Profiles depict security as a fundamental requirement of the framework. Specifically, the Audit Trail and Node Authentication (ATNA) profile defines standards based mechanisms for securely transmitting and storing audit records in a central repository. The data structure defined by the profile provides a number of record types that capture different audit events. A general feasibility study for storing currently available PACS audit information following the profile is defined, and steps to an automated solution are discussed.
Patient information and patient preparation in orthognathic surgery. The role of an information brochure a medical audit study.
In a retrospective study on 166 patients who had undergone orthognathic surgery, the influence of an information brochure on patient information, satisfaction and dissatisfaction was investigated. Although the use of an information manual was appreciated by the patients and can be recommended, its influence on patient preparation for surgery was poorer than was expected. Verbal information by effective communication between the surgeon and the patient remains the key to patient preparation.
Impact of speech presentation level on cognitive task performance: implications for auditory display design.
Speech displays and verbal response technologies are increasingly being used in complex, high workload environments that require the simultaneous performance of visual and manual tasks. Examples of such environments include the flight decks of modern aircraft, advanced transport telematics systems providing invehicle route guidance and navigational information and mobile communication equipment in emergency and public safety vehicles. Previous research has established an optimum range for speech intelligibility. However, the potential for variations in presentation levels within this range to affect attentional resources and cognitive processing of speech material has not been examined previously. Results of the current experimental investigation demonstrate that as presentation level increases within this 'optimum' range, participants in high workload situations make fewer sentence-processing errors and generally respond faster. Processing errors were more sensitive to changes in presentation level than were measures of reaction time. Implications of these findings are discussed in terms of their application for the design of speech communications displays in complex multi-task environments.
Does functional communication training compete with ongoing contingencies of reinforcement? An analysis during response acquisition and maintenance.
We examined the effectiveness of functional communication training (FCT) in reducing self-injurious behavior (SIB) and in shaping an alternative (communicative) response while SIB continued to be reinforced. Following a functional analysis of 3 individuals' SIB, we attempted to teach an alternative response consisting of a manual sign to each individual, using the reinforcer that maintained SIB. When FCT was implemented without extinction. SIB remained at baseline rates for all participants, and none of the participants acquired the alternative response. When extinction was added to the training procedure, SIB decreased and manual signing increased for all participants. To determine if signing, when established, would compete with SIB when both were reinforced, extinction was then withdrawn. Signing was maintained and SIB occurred at low rates for 2 individuals, but SIB returned to baseline rates for the 3rd individual, necessitating the reimplementation of extinction. These results suggest that it may be difficult to establish alternative behaviors if inappropriate behavior continues to be reinforced, but that, when established, alternative behavior might compete successfully with ongoing contingencies of reinforcement for inappropriate behavior.