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Real-world trials to answer real-world questions.

Currently, there is a discrepancy between clinical trials designed to assess the efficacy and safety of a new medication under investigation and the real-life questions that need to be addressed regarding the clinical use of the medication by patients, healthcare professionals and society. The data necessary to obtain regulatory approval may be of limited relevance to policy makers when calculating economic parameters such as value for money or cost effectiveness. 'Real-world' studies examine questions relevant to health policy and reimbursement. There are many different forms of clinical trials, but in designing trials incorporating realistic budget impact estimates the important issue is to ensure we are asking a sensible question and attempting to answer it with an appropriate experimental design. As an example, a real-world trial currently underway that examines scenarios of introducing inhaled insulin into clinical practice is described.

Clinical Trials as Topic↗

Application of world class service to world class nursing.

U.S. nursing is in trouble. These numerous and multidimensional troubles include general job dissatisfaction, low morale, a severe nurse shortage, a high turnover rate, and a rapid cost increase. A brief study of the healthcare industry in other industrialized nations revealed that those nations do not face the same problems or at least their problems are not as severe. More specifically, the Japanese nursing industry has no shortage. This article addresses some of the United State's nursing problems and presents some solutions from World Class Service concepts to those problems. The concepts of flexible scheduling, simplification of processes and standardization, on-the-job training, employee involvement, and team building are discussed in the context of World Class Nursing. Finally, the importance of regarding all of the above mentioned concepts as an integral part of healthcare improvement efforts is emphasized.

Economics, Nursing↗

Diabetes in adults is now a Third World problem. World Health Organization Ad Hoc Diabetes Reporting Group.

Since 1988, the World Health Organization has been collecting standardized information on the prevalence of diabetes mellitus and impaired glucose tolerance in adult communities worldwide. Within the age range 30 to 64 years, diabetes and impaired glucose tolerance were found to be absent or rare in some traditional communities in Melanesia, East Africa, and South America. In communities of European origin, the prevalences of diabetes and impaired glucose tolerance were in the range of 3% to 10% and 3% to 15%, respectively, but migrant Indian, Chinese, and Hispanic American groups were at higher risk (15% to 20%). The highest risk was found among the Pima Indians of Arizona and the urbanized Micronesians of Nauru, where up to half of the population aged 30 to 64 years had diabetes. The prevalence of total glucose intolerance (diabetes and impaired glucose tolerance combined) was greater than 10% in almost all populations, and was within the 11% to 20% range for European and US white populations. However, the prevalence of total glucose intolerance reached almost 30% in Arab Omanis and US blacks and affected one third of all adult Chinese Mauritians, migrant Indians, urban Micronesians, and lower-income urban US Hispanics. In Nauruans and Pima Indians, approximately two thirds of all adults aged 30 to 64 years were affected. These results lead to three important conclusions. (1) An apparent epidemic of diabetes has occurred--or is occurring--in adults through the world. (2) This trend appears to be strongly related to life-style and socioeconomic change.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Tactile discrimination capacity in relation to size and organization of somatic sensory cortex in primates: I. Old-World prosimian, Galago; II. New-World anthropoids, Saimiri and Cebus.

Living primates vary considerably in brain organization, in sensorimotor and cognitive abilities, and in natural behavioral repertoires. Comparative studies of primary (SI) and secondary (SII) somatic sensory cortex of primates reveal major differences in the size and in the complexity of topographic projection patterns. The separate projections of the glabrous hand to SI cytoarchitectonic areas 3b and 1 described in the Old World (OW) anthropoid Macaca and in New World (NW) anthropoids Cebus, Saimiri, and Aotus are lacking in NW Saguinus and in the prosimian Galago. The relationship between the size and complexity of SI organization and tactile abilities is explored in this study of four species of primates--Galago, Macaca, Cebus, and Saimiri. These species were trained to discriminate between pairs of objects differing either in cross-sectional diameter (size) or surface roughness (texture). The course of acquisition of such tactile discrimination in normal Macaca and the nature of deficits following SI or SII removals are known. Selective lesions of either cytoarchitectonic area 1 or 2 in Macaca affect only texture or size discriminations, respectively. Removal of area 3b in SI, or of SII, in Macaca affects both size and texture capacities. The single projection of the glabrous hand to area 3b-1 of Galago led to our expectation that the capacity of Galago to discriminate textures would be more similar to an area 1-lesioned than to a normal Macaca. The substantial and persistent differences between Macaca and Galago on texture, but not size, tasks lend support to the view that the evolution of a second projection of the glabrous hand to area 1 in Macaca contributes to increased texture discrimination capacity. The similarity in multiple projection patterns of the glabrous hand to areas 3b and 1 in Macaca, Saimiri, and Cebus led us to expect greater correspondence in texture discrimination capacity between these three anthropoids than to Galago. Contrary to expectations, Saimiri and Cebus showed a tactile capacity more similar to Galago than to Macaca. Furthermore, the texture discrimination capacity of Cebus actually improved substantially after removal of area 1. This provides further evidence, together with the single SI hand area in NW Saguinus and Galago, that the separate cutaneous projections to area 1 in OW and NW primates are not homologous but evolved independently and possibly serve different tactile functions.

Animals↗

New Zealand military nurses fight for recognition: World War One-World War Two.

This article examines the battle undertaken by New Zealand's military nurses to gain recognition as officers. The fight to win this battle took from just prior to World War One to mid-way through World War Two-twenty seven years. Issues such as male domination of the military and the government, the generally accepted work of women in war and the lack of knowledge concerning nursing's professionalism combined to create a situation whereby practical recognition of the nurses did not take place until visual alterations were made to uniforms in 1941.

Career Mobility↗

The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization.

This paper describes the World Health Organization's project to develop a quality of life instrument (the WHOQOL). It outlines the reasons that the project was undertaken, the thinking that underlies the project, the method that has been followed in its development and the current status of the project. The WHOQOL assesses individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It has been developed collaboratively in several culturally diverse centres over four years. Piloting of the WHOQOL on some 4500 respondents in 15 cultural settings has been completed. On the basis of this data the revised WHOQOL Field Trial Form has been finalized, and field testing is currently in progress. The WHOQOL produces a multi-dimensional profile of scores across six domains and 24 sub-domains of quality of life.

Culture↗

The World Health Report 2000: World Health Organization health policy steering off course-changed values, poor evidence, and lack of accountability.

The World Health Report 2000 on health systems has raised concerns about its political biases, its methods and indicators, and its lack of reliable data. Tracing the origins of the Report, this article argues that it counteracts many of the concerns that gave rise to preparation of the Report in the first place. The mutually agreed-upon value-base, expressed in the Health for All strategy, has been largely abandoned. The Report includes contradictory messages, and many of its recommendations are not evidence-based. Furthermore, the ranking of countries according to their health systems' performance is not useful for health-policy-making, even if the methods and data could be improved. Because the member states and governing bodies of the WHO were not consulted during the production of the Report, the WHO secretariat has not received a mandate to change the value-base of the WHO's health policy or the aims of the Report. The WHO should return to its mandate as a normative intergovernmental U.N. agency on health.

Communicable Disease Control↗

"The worst of both worlds": the management reform of the World Health Organization.

The governance and management of global health institutions, such as the World Health Organization (WHO), are under increasing critical scrutiny. This management case study explores the first year of transformation at the WHO under Director-General Dr. Gro Harlem Brundtland, focusing on the key stakeholders and the role of complexity in institutional change. This is a story about transition in a difficult, politically fraught, and management-resource-constrained environment. In the search for appropriate management paradigms, organizations such as the WHO may believe that the answers lie in harsh reengineering and the search for high-profile "success stories." Ironically, global business has moved away from such approaches and is far more focused on collaboration, empowerment, and knowledge sharing.

Budgets↗

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization.

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.

Adult↗

World Health organization (WHO) and the World Heart Federation (WHF) pathobiological determinants of atherosclerosis in youth study (WHO/WHF PBDAY Study) 1986-1996. Histomorphometry and histochemistry of atherosclerotic lesions in coronary arteries and the aorta in a young population.

BACKGROUND AND AIM: The present work is a chapter in an investigation directed by the World Health Organization on the Pathobiological Determinants of Atherosclerosis In Youth (WHO-PBDAY). Our aim was to study the development of atherosclerotic lesions in a young population. METHODS AND RESULTS: Samples of left anterior descending coronary artery (LDC) and thoracic (TA) and abdominal aorta (AA) from five Collaborating Centres (Budapest/Hungary, Havana/Cuba, Heidelberg/Germany, Mexico City/Mexico, Peradeniya/Sri Lanka) of 214 subjects who died aged 15 and 34 were analysed at the Budapest Reference Centre. Slides stained with haematoxylin-eosin and with stains for extracellular matrix were quantitatively and qualitatively evaluated. Mean intima/media (I/M) ratio and the prevalence of type III-IV lesions (preatheroma; atheroma; calcified and fibrous atheroma) were determined and compared in different risk factor (high blood pressure, smoking) groups. High I/M ratio was found in the LDC and type III-IV lesions were frequently found both in the LDC and in the AA. I/M ratio and the occurrence of type III-IV lesions increased in all arteries by age. Atherosclerotic lesions in men were more severe, particularly in the LDC. Geographic origin had a limited effect on the histologic lesion parameters. Appearance of type III-IV lesions was associated with substantially different extracellular matrix changes. Myoelastic layer formation was found in each artery in both early and type III-IV lesions. Hypertension was associated with higher prevalence of type III-IV lesions in all arteries, in particular, in the TA; smoking showed a significant effect on the AA only. CONCLUSIONS: Atherosclerotic lesions were found in many of these young subjects. The effect of hypertension and smoking on their development suggests that control of risk factors, beginning in early adolescence, could help to prevent cardiovascular diseases.

Adolescent↗

The delicate balance of world health. Emerging plagues & resurrected pestilence. A report from the World Health Forum 1998.

The Health Industry Council and the International Hospital Federation welcomed an international audience of 21 participants from 13 countries to the third biannual World Health Forum (WHF). Participants in the WHF 1998 were nominated by their peers because of a distinguished professional record in their respective fields in their own nations. Countries represented included Belgium, Brazil, Chile, Greece, Hungary, India, Israel, Mexico, Nigeria, Sweden, Switzerland, Thailand, and the United States. The purpose of the event was to examine emerging and re-emerging infectious diseases from an international perspective, and to develop a set of guidelines and recommendations for proactively managing potential and recurring infectious disease outbreaks. This topic was chosen to provide an opportunity for different nations to come together and respond to the growing international public health threat posed by the increased proliferation of antibiotic-drug-resistant micro-organisms, food-borne illnesses, and emerging and re-emerging outbreaks of infectious diseases.

Communicable Diseases, Emerging↗

Guidelines for the management of hypertension: the World Health Organization/International Society of Hypertension view. World Health Organization. International Society of Hypertension.

ORGANIZATIONS PRODUCING GUIDELINES: Guidelines or recommendations for the management of hypertension have periodically been produced by various organizations or specialized scientific societies, in particular the United States Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure and the World Health Organization/International Society of Hypertension Guidelines Sub-Committee. SIMILARITIES, DIFFERENCES AND EVALUATION OF GUIDELINES: There are many similarities between the different guidelines and any dissimilarities are mainly related to the choice of first-line drugs for treatment and the goal of treatment. In formulating guidelines it is important to avoid placing rigid constraints on practising doctors' decisions while helping them to exert the most careful and informed judgement in individual cases.

Antihypertensive Agents↗

Anatomical brain asymmetries in New World and Old World monkeys: stages of temporal lobe development in primate evolution.

Relatively large (n = 20-30) samples of formalin-fixed brain specimens from five Old and New World monkey species were examined in a study measuring anatomical temporal-lobe asymmetries. Linear measurements of the length of the Sylvian fissure were taken on each cerebral hemisphere to evaluate lateral differences related to development of auditory association cortex. The results indicate significantly greater Sylvian fissure length on the left hemisphere than on the right hemisphere in four of these species. Measurements of a different parameter on Saimiri sciureus brain specimens (length of anterior portion of the Sylvian fissure) also suggested temporal-lobe asymmetry favoring the left hemisphere. Other measurements (length of the Sylvian fissure lying posterior to the central sulcus, and dorso-ventral position of the Sylvian point) in Macaca mulatta and M. fascicularis did not reveal significant right/left-hemisphere differences. Sylvian-fissure length determined from photographs of M. mulatta hemispheres in contrast to results of direct measurements did not yield significant right/left-hemisphere asymmetry. We mention possible reasons why previous anatomical studies of brains from monkeys did not discern temporal-lobe asymmetry, and we also discuss whether or not certain of these asymmetries in monkeys foreshadowed the evolution of language-processing areas of the cerebral cortex in hominids.

Animals↗

Environmental management in resource-rich Alberta, Canada: first world jurisdiction, Third World analogue?

Economic growth is frequently touted as a cure for environmental ills, particularly for those in Third World countries. Here we examine that paradigm in a case study of Alberta, Canada, a wealthy, resource-rich province within a wealthy nation. Through provincial-scale datasets, we examine the increasing pressures of the forest, petroleum, and agricultural industries upon the ecosystems of Alberta within management, economic, and political contexts. We advance the thesis that economic activity leads to environmental degradation unless ecosystem-based management is integrated into economic decision making. Agricultural lands cover 31.7%, and forest management areas leased to industry cover 33.4% of Alberta; both continue to increase in extent. The rate of logging (focused on old-growth by government policy) continues a decades-long exponential rise. Current Alberta annual petroleum production is 52.5 million m3 crude oil and 117 billion m3 of gas. As of early 1999, there were approximately 199,025 oil and gas wells and a conservative total of approximately 1.5-1.8 million km of seismic lines in Alberta. Fire occurrence data indicate no downward trends in annual area burned by wildfire, which may be characterized as driven by climate and inherently variable. When logging and wildfire are combined, the annual allowable cut in Alberta is unsustainable, even when only timber supply is considered and the effects of expanding agriculture and oil and gas activities are ignored. Ecosystem degradation in Alberta is pervasive and contrasts prominently with a high standard of living. A wealth of ecological data exists that indicates current resource-based economic activities are non-sustainable and destructive of ecosystem health yet these data are not considered within the economic decision making process. Given the complex, compounded, and increasing ecosystem perturbations, a future of unpleasant ecological surprises is likely. We conclude with tentative predictions as to where current trends in Alberta may lead if decisions biased against ecosystems continue.

Agriculture↗

[Deafness: the right to silence or the chance to hear with a cochlear implant? Human images and medicine in the world of the deaf and in the world of the hearing].

Cochlear implantation has evolved from its experimental state into a safe and effective therapy for the treatment of profound deafness. Although not applicable to all patients, it offers an alternative to a life in silence. In particular, in early detected and treated deafness in childhood inner ear prostheses have enabled affected persons to be integrated into the world of sound. In addition to the significant impact that therapy has on the life of the individual, there is a social and cultural consequence for society. This is epitomized in the criticism by the deaf community that has resulted in the total rejection of cochlear implants. A critical analysis reveals different personal images prevailing in the deaf community. Knowledge of these differences and their relevance is important for all clinicians involved in counselling a cochlear implant candidate.

Cochlear Implants↗

Third world medicine in first world cities: capital accumulation, uneven development and public health.

This paper addresses issues of public health and access to care for the urban poor in the context of current U.S. urban, economic and industrial policy. The pathologies that threaten "inner city" neighborhoods are the result of decades of political neglect, economic exploitation and resource withdrawal, which themselves stem directly from public and corporate sector strategies to facilitate capital accumulation and consolidation. The resulting conditions of uneven development between wealthy and impoverished local sectors mirror similar relationships between First and Third World countries. These same patterns are reflected and reproduced in the health care "industry" itself, where growing corporate dominance has developed alongside a concomitant reduction in support for public sector and community-based care. These trends create and exacerbate conditions that place poor and minority populations at risk. Community development and political empowerment, as well as the overall corporate hegemony that increasingly characterizes the political economy of the U.S.A., are essential public health considerations that must be included in any meaningful health policy or health care reform proposals.

Cities↗

Worlds we have lost and worlds we may regain: two centuries of changes in the life course in Sweden.

"The article seeks to place into historical context the familial changes in ¿post-industrial' Sweden during the past two decades, by comparing them with general characterizations (based on documented life-course experiences) of the traditional Swedish agrarian society (before 1800), the transitional society (c. 1800-1870), and the industrial society (c. 1870-1980). Familial lives in traditional Swedish society tended to be stable. By contrast, during the agrarian-to-industrial society, especially since World War II, stability became once again the hallmark because of general government social policy."

Developed Countries↗