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At least 919 records · Page 51Linked to original sources
PubMed1999

A review of worldwide experience with sparfloxacin in the treatment of community-acquired pneumonia and acute bacterial exacerbations of chronic bronchitis.

The worldwide occurrence of community-acquired pneumonia (CAP) shows an undiminished prevalence of this serious illness and hospitalisation is common in those patients with severe illness. The diversity of bacterial pathogens that can act as aetiologic agents presents a challenge to initial empiric antimicrobial management. In recent years, treatment has been further complicated by an increased incidence of antibiotic resistance in pathogens such as Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. The newly available fluoroquinolones including sparfloxacin offer an alternative approach to empiric management. Sparfloxacin is active against many typical and atypical pathogens, as well as strains resistant to conventional agents. In comparative studies, the in vitro potency of sparfloxacin and its pharmacokinetic profile have been confirmed. The clinical trial efficacy and safety data suggest it might be a useful empiric therapy for both CAP and acute bacterial exacerbation of chronic bronchitis.

Acute Disease↗
PubMed2006

Identifying sites under positive selection with uncertain parameter estimates.

Codon-based substitution models are routinely used to measure selective pressures acting on protein-coding genes. To this effect, the nonsynonymous to synonymous rate ratio (dN/dS = omega) is estimated. The proportion of amino-acid sites potentially under positive selection, as indicated by omega > 1, is inferred by fitting a probability distribution where some sites are permitted to have omega > 1. These sites are then inferred by means of an empirical Bayes or by a Bayes empirical Bayes approach that, respectively, ignores or accounts for sampling errors in maximum-likelihood estimates of the distribution used to infer the proportion of sites with omega > 1. Here, we extend a previous full-Bayes approach to include models with high power and low false-positive rates when inferring sites under positive selection. We propose some heuristics to alleviate the computational burden, and show that (i) full Bayes can be superior to empirical Bayes when analyzing a small data set or small simulated data, (ii) full Bayes has only a small advantage over Bayes empirical Bayes with our small test data, and (iii) Bayesian methods appear relatively insensitive to mild misspecifications of the random process generating adaptive evolution in our simulations, but in practice can prove extremely sensitive to model specification. We suggest that the codon model used to detect amino acids under selection should be carefully selected, for instance using Akaike information criterion (AIC).

Amino Acids↗
PubMed1998

Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. transplant centers.

BACKGROUND: Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated. METHODS: To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States. RESULTS: All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs. CONCLUSIONS: The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.

HIV Infections↗
PubMed2003

Nurse supervisors' actions in relation to their decision-making style and ethical approach to clinical supervision.

AIM: The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process. BACKGROUND: Clinical supervision promotes ethical awareness and behaviour in the nursing profession. METHODS: A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis. FINDINGS: The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings. CONCLUSION: Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

Decision Making↗
PubMedDate not supplied

Cancer patients' perceptions of do not resuscitate orders.

Patients' perceptions of do not resuscitate (DNR) orders and how and when to present the information were sought to aid in framing DNR policy. Semi-structured interviews of 23 patients being treated for cancer, were conducted by a clinical psychologist. The interviews were transcribed and analysed with the aid of a qualitative software package. Discourse analysis enabled hypotheses to be formed based on consistencies and variations of the language used. Most patients understood what DNR meant and preferred DNR orders to 'good palliative care' orders. They saw it as their autonomous right and responsibility to make such decisions. They would seek information on the likely medical outcomes of resuscitation but also would use non-rational criteria based on emotional and social factors to make their decisions. Family considerations suggest that personal autonomy is not the overriding basis of the decision. Patients were unsure of the best timing of a DNR discussion and were prepared to defer to doctors' intuition. Most advocated written DNR orders but few had them. Families were construed as advocates but also seen as constraining individual autonomy. When considering DNR orders, patients recognise the diversity of preferences likely to exist that belie a one policy fits all approach.

Family↗
PubMed1994

Informed consent: questionnaire survey of British otolaryngologists.

This postal questionnaire of British otolaryngologists has shown that most strive to obtain true informed consent when recommending surgery. The consent form is usually signed on the ward or at a pre-admission clinic and witnessed by a house officer. One-third of house officers received no instructions about what to discuss at this time, however, most consultants keep some record of what was discussed. A quarter of surgeons use information sheets, those not using them are more likely to anticipate problems with their use. An assessment of which complications are usually discussed is given. Comparison with a similar study shows increased disclosure of complications, perhaps a more defensive approach in surgical practice is developing.

Consent Forms↗
PubMed2005

Interactions between pharmaceutical representatives and doctors in training. A thematic review.

OBJECTIVE: Medical school and residency are formative years in establishing patterns of prescribing. We aimed to review the literature regarding the extent of pharmaceutical industry contact with trainees, attitudes about these interactions, and effects on trainee prescribing behavior, with an emphasis on points of potential intervention and policy formation. DESIGN: We searched MEDLINE from 1966 until May 2004 for English language articles. All original articles were included if the abstract reported content relevant to medical training and the pharmaceutical industry. Editorials, guidelines, and policy recommendations were excluded. MEASUREMENTS AND MAIN RESULTS: Contact with pharmaceutical representatives was common among residents. The majority of trainees felt that the interactions were appropriate. A minority felt that their own prescribing could be influenced by contact or gifts, but were more likely to believe that others' prescribing could be influenced. Resident prescribing was associated with pharmaceutical representative visits and the availability of samples. A variety of policy and educational interventions appear to influence resident attitudes toward interactions with industry, although data on the long-term effects of these interventions are limited. Overall, residents reported insufficient training in this area. CONCLUSIONS: The pharmaceutical industry has a significant presence during residency training, has gained the overall acceptance of trainees, and appears to influence prescribing behavior. Training programs can benefit from policies and curricula that teach residents about industry influence and ways in which to critically evaluate information that they are given. Recommendations for local and national approaches are discussed.

Attitude of Health Personnel↗
PubMed1991

Short-term mortality predictions for critically ill hospitalized adults: science and ethics.

Modern life-sustaining therapy often succeeds in postponing death but may be ineffective at restoring health. Decisions that influence the time and circumstances of an individual's death are now common and require an accurate and comprehensive characterization of likely outcome. Evaluation of alternative outcomes requires acknowledgement that most patients find some outcomes to be worse than death. Improved understanding of major predictors of patient outcome, combined with rapidly expanding technical abilities to collect and manipulate large amounts of detailed clinical data, have created a new intellectual and technical basis for estimating outcomes from intensive medical care. Such objective probability estimates, such as the system described here, can reduce uncertainty about difficult clinical decisions and can be used by physicians, patients, and society to reorient health care toward more scientifically and ethically defensible approaches.

Adult↗
PubMed1984

"The high cost of dying": what do the data show?

Assertions that we now spend too much of our medical dollar on the dying often imply a ready target for cost-containment efforts: frequency and intensity of expenditures at the end of life, especially for the aged. But available, although meager data suggest there has been neither a dramatic rise in the last 20 years in the use of the hospital as a place to die, nor of widespread use of "heroic" interventions on behalf of those who die. Rather, very sick patients receive intensive and expensive care; our ability to project rates of survival vs. terminal patient status warrants caution in approaches to medical economy.

Adult↗
PubMed1998

Ethical dilemmas in the use of donor gametes.

Current ethical debate is about the processes of reproductive medicine; the moral status of the embryo. Within a societal acceptance of the expansion of reproductive medicine worldwide, donated gametes are increasingly being used. Medical practice favours anonymity of donors and confidentiality for participants. These apparently legitimate concerns are to protect the adults involved. They do not address the implications for any children thus created. This paper aims to shift the debate and to address specifically the rights and needs of the children following gamete donations. How far do they need to know about their birth origins? How do they fare as future adults with no knowledge of 50% of their genetic family histories? Data is now available about how children themselves view this and, in accord with international declarations about the rights of the child, a radical new approach is urgently needed both in reproductive medicine and legal provisions.

Adult↗
PubMed2006

A simple implementation of a normal mixture approach to differential gene expression in multiclass microarrays.

MOTIVATION: An important problem in microarray experiments is the detection of genes that are differentially expressed in a given number of classes. We provide a straightforward and easily implemented method for estimating the posterior probability that an individual gene is null. The problem can be expressed in a two-component mixture framework, using an empirical Bayes approach. Current methods of implementing this approach either have some limitations due to the minimal assumptions made or with more specific assumptions are computationally intensive. RESULTS: By converting to a z-score the value of the test statistic used to test the significance of each gene, we propose a simple two-component normal mixture that models adequately the distribution of this score. The usefulness of our approach is demonstrated on three real datasets.

Algorithms↗
PubMed1979

The questionnaire to parents of children with the Down syndrome: how to inform the parents and psychological responses to counseling.

This study determined the experience of 137 sets of parents when they were informed that their child had Down syndrome and how they would have preferred this matter to have been handled. The survey revealed that the majority of parents would have preferred being told as soon as possible, with both of them present, and that they had suspected something wrong at the birth of the child. This information prompted us to analyze critically the parental experiences and to formulate a positive approach, with sensitive, supportive, and progressive counseling.

Adaptation, Psychological↗
PubMed1996

Attitudes of emergency nurses toward organ and tissue donation.

OBJECTIVE: Organ and tissue transplantation has gained increased acceptance as a medical procedure. Costs for most transplantations are reimbursed by insurance companies, and the list of transplantable tissues and organs has doubled during the past 10 years. To meet this resulting increased demand, more organs and tissues need to be recovered from potential donors. The purpose of this study was to examine the relationship between emergency nurses' attitudes and their intention to ask potential donor families if they will donate their family member's organs and tissues. METHODS: Thirty hospitals were sent a letter inviting them to participate in this descriptive survey research design. Survey packets were sent to the 17 hospitals that responded positively to the request. Surveys contained a cover letter to the participants with directions and assurance that anonymity would be maintained. Completed surveys were returned directly to the researcher. RESULTS: We found a relationship between the nurses' attitudes and the frequency with which they approached families regarding donation. Further analysis revealed that nurses' attitudes about organ and tissue donation were related to their confidence in asking families about donation. The study also demonstrated that emergency nurses want educational programs that offer information on how to approach donor families. DISCUSSION: These results can be used to develop educational programs for emergency nurses to provide them information that can increase their confidence in asking families about donation and subsequently increase the number of families they approach regarding donation.

Adult↗
PubMed1995

Research on field-based services: models for reform in the delivery of mental health care to populations with complex clinical problems.

OBJECTIVE: Clinical services for psychiatrically impaired populations have only recently been studied with scientifically valid designs to explore innovations in structure, accessibility, and financing. Health systems reform in the United States has provided the impetus for better defining clinically effective and cost-sensitive models for mental health services. This article reviews assertive community treatment, used for adults with severe mental illnesses, and multisystemic therapy, used for adolescents with serious emotional disturbances, as examples of service system innovations that have been studied with controlled clinical trial designs and have demonstrated efficacy in treating difficult and costly clinical populations. METHOD: The authors reviewed the published controlled clinical trials of assertive community treatment and multisystemic therapy, focusing on the clinical and administrative elements that distinguish them from traditional service systems. RESULTS: A qualitative assessment of these two approaches suggests that they share common elements, with important implications for mental health policy. Specifically, the use of an ecological model of behavior applied to mental health patients is critical to both systems. In addition, therapeutic principles emphasizing pragmatic (outcome-oriented) treatment approaches, home-based interventions, and individualized goals are key elements of their success. Most important, both systems embody a therapeutic philosophy demanding therapist accountability, in which personnel are rewarded for clinical outcomes and therapeutic innovation rather than for following a prescribed plan. CONCLUSIONS: As empirically tested approaches, assertive community treatment and multisystemic therapy provide a scientific foundation for continued reform and serve to illustrate critical elements in designing new community treatment initiatives for behavioral as well as medical conditions.

Adolescent↗
PubMed1999

An experimental study of influences on the perceived likelihood of seeking genetic testing: "nondirectiveness" may be misleading.

It has been suggested that decision making involves the implicit weighing up of those advantages and disadvantages of possible options considered relevant at the time the decision is made. If this is so, the information that people have most readily available at the time of the decision would influence the decision outcome. The study reported here experimentally evaluates the effect of manipulating the issues on which individuals focus as a way of investigating subtle directive influences. Participants (n = 104) were interviewed about their anticipated likelihood of opting for testing for hereditary hemochromatosis. All participants were given standard information about hemochromatosis, including a description of the disorder as causing progressive damage over many years and an explanation that treatment is most effective if begun before the age of 30 years. Individuals were randomly allocated to groups according to age group (30 years and under, or over 30 years) and gender. Those allocated to the positive group were then encouraged to focus on positive aspects of the previously given information by considering the extent to which statements applied to them, whereas the negative group focused on negative aspects. The control group focused on an unrelated disease. Analyses of variance indicated that the focusing manipulation affected the likelihood of opting for testing. This effect interacted with age of respondent: in participants over 30, the positive group ratings of likelihood of testing increased, whereas in the negative group they decreased; in participants 30 and under, both the positive and negative groups showed an increased desire to be tested. The control group did not alter significantly. The relevance of these findings to "nondirective" approaches to genetic counseling is considered.

Adult↗
PubMed2002

Are we ignoring potential dangers of in vitro fertilization and related treatments?

By conventional assessments, in vitro fertilization (IVF) is one of the safest medical treatments. But producing new life brings immense responsibilities. Recently, there have been disquieting reports of foetal abnormality after these treatments and here we evaluate the potential risks associated with intracytoplasmic sperm injection (ICSI), embryo freezing and pre-implantation genetic diagnosis. In our opinion, before translating new techniques into practice, more research, particularly in animals,is desirable. In addition, better child follow-up and a fresh approach to regulation are also needed.

Chromosome Aberrations↗
PubMed1995

Consulting the public about health service priorities.

Consulting the public is an important component of commissioning health services. Somerset Health Authority has devised a method of consultation using eight focus groups meeting three times a year. Each group consists of 12 people, and together the groups are demographically representative of Somerset's population. The groups are asked about issues that are concerning the health authority, and their views have influenced health authority decisions. Each group is given some background information before the meeting, together with more information at the meeting. The discussions are tape recorded and analysed for qualitative information, but the groups are also asked to score certain priorities. The groups have been found to be representative, valid, and focused on community rather than individual values. Health authorities wanting to know the values people attach to health services should adopt this qualitative approach to consultation.

Adolescent↗