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PubMed1967

Ovarian cancer at the Ontario Cancer Foundation Clinics, 1938-1958.

In Ontario, ovarian cancer causes 7% of female cancer deaths, exceeding cancer of the uterine cervix or corpus in women aged 50 years and over. For 1722 patients with ovarian cancer registered at the Ontario Cancer Foundation Clinics in 1938-1958, who received some or all of their treatment at the clinics or were untreated anywhere, the crude survival rate at five years was 28%. Survival was greatly influenced by extent of disease and by histological type; survival rates remained constant or rose slightly over successive periods although an increasing proportion of advanced cases were registered. The method of choice for initial treatment was panhysterectomy with bilateral salpingo-oophorectomy and radiotherapy. Agreement on classification by histological type and extent is urgently needed.

Adolescent↗
PubMed1977

[Noise generated from driving-in foundation piles].

Results of sound pressure measurements during driving-in of foundation piles are reported. The results are then compared with latest recommendation from the standpoint of hearing impairment due to continuous or impulsive noise.

Construction Materials↗
PubMed1983

Statistical procedures in clinical pharmacology: decision-theorectic foundations.

The function of statistical analysis is to reach optimal decisions in situations of principal uncertainty. The foundations of statistical procedures are experiments X, whose distributions PX are characterised by random samples. Within given classes of distributions (distribution hypothesis) mathematical statistics make optimal procedures available, which allow conclusions on the real properties of PX. The use of optimal procedures minimises the risk of incorrect decisions made on the basis of random samples (principle of greatest chance). Statistics, however, refrain from any statement on the quality of the decision to which a procedure in a certain situation leads. Against a decision-theoretic background of statistical decisions the growing complexity of clinical-pharmacological test models leads to the necessity of using descriptive-statistical methods on an even larger scale. The aim should be to reduce the number of individual parameters to a few important factors, so that the relation between the number of trial subjects on the one hand and the number of parameters on the other remains valid for meaningful statistical statements.

Clinical Trials as Topic↗
PubMed1984

Healthy roots: a solid foundation for the future.

Advances in endodontic instrumentation, materials and technique have enabled the basic principles of endodontic therapy to be more readily and predictably achieved. This allows endodontic therapy to enjoy one of the highest success rates of all forms of dental treatment. A better appreciation of the responses following traumatic injury to the teeth, together with advances in management, have provided such teeth with an optimum prognosis enabling them to be retained as useful members of the dentition. Endodontic procedures in conjunction with periodontic, orthodontic and restorative techniques have enabled severely compromised teeth to be salvaged and returned to function. Teeth endodontically treated in a proper manner provide a solid foundation for correct restoration and the long term maintenance of a healthy dentition.

Dental Pulp Cavity↗
PubMed1994

The foundations of Judaism: psychoanalytic interpretations.

The psychological foundations of Judaism are a major challenge to psychoanalytic theory. This (selective) literature review focuses on post-Freudian work on this question. Freud described Judaism as a father religion, within the Oedipal framework of all religions and cultures. Over the years other notions have become dominant, and we can observe the changes from the Oedipal to the pre-Oedipal and towards more attention to maternal projections. Jewish mythology is a major topic, and the attention given to it bears no relation to its role in living Judaism. Many psychoanalytic contributions which aim at interpreting Judaic mythology demonstrate mostly their authors' inability to separate mythological narratives and history, as they accept without criticism the biblical account of supposedly ancient events, and then continue with speculations about mythological personages and events. The literature we have reviewed is certainly psychoanalytic, but one question is its relationship to Freud's work on religion. What emerges is that in many cases there is no attempt to follow Freud in the sense of accepting his assertions, but there is continuity in terms of interpretive temperament. Freud's writings have served as stimulus and inspiration, not as dogma to be upheld.

Bible↗
PubMed1995

[Problem-based learning--documented effects and theoretical foundations].

Since problem-based learning is becoming more popular in medical education, the interest in the effects of and theoretical foundations for, such educational strategies is increasing. This article reviews research on the effects of problem-based learning, and relevant research on the development of knowledge and learning. In conclusion it is shown that the learning effects are contingent on how problem-based learning is implemented in the curriculum.

Clinical Competence↗
PubMed1996

Failure of implementation of the National Heart Foundation of New Zealand guidelines for the management of dyslipidaemia.

AIMS: We examined the outcome of patients at high absolute risk of coronary events who had been discharged from the Green Lane Hospital risk factor clinic before publication of the 1993 National Heart Foundation of New Zealand (NHF) guidelines for management of dyslipidaemia. METHODS: Consecutive patients who had been discharged >12 months previously were followed up by general practitioner and patient questionnaires. Patients were categorised according to risk of a coronary event over 10 years. Ideal lipid levels (cholesterol <5.2 mmol/L, high-density lipoprotein (HDL) cholesterol >1 mmol/L, total:HDL cholesterol ratio <5) and 'acceptable' lipid levels (cholesterol <6.5 mmol/L for high risk, <7.5 for moderate risk, <8 in men and <8.5 in women at mild or low risk) were defined according to the NHF guidelines. RESULTS: Of the 270 patients, 55.6% were at very high risk, 25.5% at high risk, 10.4% at moderate risk, 3.8% at mild risk and 0.7% at low risk. Twenty-four percent of patients were managed on diet alone at clinic discharge and 18% at follow up of 32+/-12 months. Total cholesterol (6.39 mmol/L), HDL cholesterol (1.22 mmol/L) and the total:HDL cholesterol ratio (5.71) were unchanged from discharge. In the very high risk group ideal lipid levels were achieved in only 12% at discharge and 7% at follow up. The corresponding figures for achievement of acceptable lipids at discharge compared with follow up were 48% and 39% for the high risk group, 88% and 79% for the moderate risk group and 93% and 93% for the mild risk group. The corresponding figures for achievement of ideal lipids were 4% and 8% for the high risk group, 0% and 5% for the moderate risk group and 7% and 7% for the mild risk group. CONCLUSIONS: Lipid levels achieved during clinic visits were maintained long term, but there were no improvements following publication of the NHF guidelines. Continued efforts are needed to increase awareness and implementation of the guidelines, particularly in patients at high risk. Removal of the restrictions on prescription of lipid modifying agents by general practitioners and improved interchange between general practitioners and specialists should greatly improve these outcomes.

Family Practice↗
PubMed1996

[Kidney transplant from living donor. Experience at the Jiménez Díaz Foundation].

OBJECTIVES: To discuss the organizational and surgical aspects, results, remarkable events and some ethical considerations of the renal transplantation program with grafts from living donors at our institution over a 25-year period. METHODS: The renal transplant program of the Jiménez Diaz Foundation began in 1964 and the first kidney graft from a living donor was transplanted in 1968. Since then and until December 1993, 157 renal grafts from living donors have been transplanted. The donors were parents in 94, siblings in 55 and the spouse in 4 occasions. Moreover, two free kidneys and two grafts from nonrelated donors were transplanted. The surgical procedure was also similar; i.e., right nephrectomy through a supracostal lumbotomy to remove the kidney and transplantation in the right iliac fosa with anatomosis to cava and common iliac or hypogastric artery. Changes in the surgical technique warranted by the intraoperative findings were infrequent. The ureter was anastomosed to the bladder using an extra- or transvesical technique depending on the surgeon's experience. Harvesting and transplantation of the kidney graft were performed simultaneously by two surgical teams. RESULTS: There were no major complications in the donors or technical difficulties or errors during harvesting that might have compromised graft viability, although complications such as hemorrhage, urinary fistula, thrombosis and prolonged anuria were observed early postoperatively. The incidence of grafts lost specifically related with the technique was less than 3%. Nineteen recipients had died early postoperatively from acute rejection and sepsis. Recipient and graft survival were basically related with the degree of histocompatibility and the changing therapeutic strategy over the 25-year period. The best results were found in 33 transplants involving HLA identical siblings, with a five-year actuarial survival rate of 89%, a 10- and 15-year survival of 70% and a 22-year survival of 22%, followed by those who were haploidentical who had donor-specific transfusions and the haploidentical cases treated with cyclosporine. The poorest results were seen in the historical group of 52 transplant procedures performed between 1968 and 1981 who were treated with the classical medication. CONCLUSIONS: The good results achieved and the minimal risk to donors demonstrated by our experience over a period of 25 years support continuation of the renal transplantation program with grafts from living donors, as well as our approach of having two surgical teams working simultaneously.

Adult↗
PubMed1996

Perspectives of tumour radiotherapy in the Czech Republic and "Oncology 2000" Foundation.

The incidence of tumours has still an increasing tendency. A great effort is being devoted to prevention as well as to improving early diagnosis and treatment. It is the radiotherapy which seems to bring new treatment possibilities at the present. Its goal consists in destroying all tumour cells in the target volume while all normal cells being damaged unsubstantially only. That is being achieved with standard available means only with rather great difficulties. However, in the last time two radiotherapy methods have been developed which are based on the use of the so called hadrons (i.e. particles exhibiting strong mutual interactions) and come nearer to the mentioned ideal goal of any tumour therapy. The first method consists in the application of beams of charged hadrons having a suitable characteristic of energy transfer; the most energy being transferred to the matter in the end of hadron tracks. Thus, by a suitable choice of initial energy of beam particles this maximum may lie in a tumour volume, while all other tissues obtain a smaller dose, the difference being greater when a multiple-field technique is used. The other approach (neutron capture therapy-NCT) makes use of epithermal (or thermal) neutrons captured by special isotopes accumulated in tumour cells with the help of suitable chemical carriers. Both the methods are now being introduced into clinical use in many countries. The "Oncology 2000" Foundation was grounded to introduce these methods into clinical use also in the Czech Republic. It proceeds with activities started by an interdisciplinary group of specialists formed approximately 20 years ago and having prepared some necessary conditions. As to the NCT a corresponding facility is now being finished and clinical tests are expected to be started in 1997. The main attention is now devoted to building up an oncology center based on the use of hadron beams.

Czech Republic↗
PubMed1996

Guidelines for the early detection of osteoporosis and prediction of fracture risk. Council of the National Osteoporosis Foundation.

OBJECTIVE: To assess methods available in clinical practice for the early detection of osteoporosis and prediction of fracture risk, and to set guidelines for their use. To make recommendations regarding cost-effective screening of asymptomatic subjects by physicians. OPTIONS: Three methods to predict fracture risk are considered: (i) clinical risk factor analysis; (ii) biochemical tests; and (iii) techniques to measure bone mass. Mass (unselected) screening is compared with screening only those at risk of sustaining a fracture. The optimal age/time of screening and therapeutic intervention thresholds are also considered. OUTCOMES: The main potential outcomes considered are the morbidity and mortality of advanced osteoporosis and fracture; the accuracy, precision, safety and costs of screening tests; and treatment for those at risk. EVIDENCE: Based on the results of published recommendations of international osteoporosis societies, World Health Organisation guidelines and expert opinion. VALUES: The guidelines were developed by the National Osteoporosis Foundation in conjunction with other specialists and societies. A workshop attended by all the osteodensitometrists in the country was held in August 1994 to obtain consensus on recommendations. There were no major disputes about the content. The guidelines are intended to optimise health care of society as a whole and are not geared to individual patients. BENEFITS, HARMS AND COSTS: Up to 20% of victims of hip fracture die within 1 year and less than 50% ever regain the functional capability to lead an independent life. The cost of acute fracture care in the USA exceeded $10 billion in 1990. Early intervention has been shown to reduce the rate of vertebral and hip fractures by 50 - 70%. The cost of fracture care and of selected screening has not been measured in this country. Measurement of bone mass is safe, accurate and precise. RECOMMENDATIONS: (i) Measurement of bone mass employing dual-energy X-ray absorptiometry (DEXA) is at present the method of choice to predict hip and vertebral fracture risk. A single measurement can correctly identify the majority of those at risk. (ii) Densitometric screening of all (asymptomatic) women cannot be recommended, and selective screening according to specific indications is suggested. Densitometry is indicated at any age if the indication is valid. (iii) Guidelines for the interpretation of bone mass data, including therapeutic intervention thresholds, are suggested.

Bone Density↗
PubMed1996

Repeated HLA mismatches and second renal graft survival in centers of the South-Eastern Organ Procurement Foundation.

To determine if repeated HLA mismatches and other putative risk factors were predictive of second graft failure in second grafts performed at Southeastern Organ Procurement Foundation (SEOPF) members centers, we identified a cohort of 753 retransplants in which one or more HLA antigens were mismatched in primary grafts. Of this group, 158 (21.1%) received second grafts with repeated mismatches of one or more HLA-A, B, or DR antigens that were previously mismatched in the primary graft (RMMs). All regrafts were cadaveric kidneys transplanted between 1982 and 1995. Multivariate analysis of 19 covariates in 438 regrafts identified four independent factors that were predictive of graft survival frequency in second transplants. Three of the four factors were associated with a reduced risk for graft loss in retransplants: cyclosporin A (CsA) use in graft (p = 0.0001, RR = 0.26), peak PRA < 50% (p = 0.008, RR = 0.52) and white donor race (p = 0.035, RR = 0.63). One factor was associated with an increased risk of second graft failure, namely, blood transfusion prior to the first graft (p = 0.026, RR = 5.14). None of the other 15 factors exerted significant additional risk to regraft survival frequency in these SEOPF data. In multivariate analysis, RMMs were not associated with altered graft survival frequency in regrafts (p = 0.944, RR = 0.99). We than used univariate analyses to determine whether RMMs had adverse effects on GS in particular subsets of recipients that were thought to be at increased risk for the second transplant failure. Univariate analyses were performed with methods that are sensitive to early events (Wilcoxon) and late events (log-rank). The variables tested were CsA use for the regraft, duration of primary graft function, panel reactive antibody levels (PRA), immunopathologic cause of first graft failure, and HLA mismatch of the second graft. These analyses indicated that repeated HLA mismatches were not an associated risk factor in any of these subgroups. These SEOPF data indicate that RMMs are not predictive of increased frequency of graft loss in cadaveric donor second transplants. We conclude that our results do not support a policy of routine avoidance of RMMs, which may result in increased waiting time for a second donor without providing an improved graft survival rate. The available literature suggests that HLA antibody identification, the use of sensitive flow cytometric and antiglobulin-augmented cross-match tests, together with appropriate donor selection, optimal immunosuppression and patient management may be sufficient to avoid the early loss of second grafts.

Adult↗
PubMed1996

CREG matching for first cadaveric kidney transplants (TNX) performed by SEOPF centers between October 1987 and September 1995. Southeastern Organ Procurement Foundation.

The Southeastern Organ Procurement Foundation (SEOPF) data base from October 1987 to September 1995 included 12,536 first cadaveric kidney transplants, of which 39.5% were placed into non-white recipients (N-WR). Consequently, the SEOPF data offered an excellent sample in which to examine the effect of a number of conventional HLA-A, B versus public (crossreactive group, CREG) matching schemes on access and graft survival (GS). The standard applied was that 3-yr GS had to be greater than that of the mean GS of the racial group. Because of the excellent 1- and 3-yr GS of 0 A, B, DR mismatched kidneys in both white recipients (WR) = 87.9% and 82.8% and N-WR = 86.9% and 80.9%, these transplants were excluded from further analysis. Thereafter, the mean 1- and 3-yr GS of the remaining 7011 WR and 4862 N-WR, transplants used for all subsequent comparisons were 82.5% and 72.4% for WR versus 80.9% and 63.0% for N-WR. Four different matching schemes were compared: 1) Class I A, B versus CREG hierarchical effect disregarding DR; 2) 0, 1, 2B, DR versus 0-2 CREG, DR mismatching; 3) DR mismatching disregarding Class I A, B or CREG mismatching and 4) Class I A, B versus CREG mismatching stratified for DR. Two and possibly three CREG, DR mismatched groups were identified in which improved access and GS occurred in comparison with the 0, 1, and 2B, DR mismatched transplants currently receiving 7, 3 and 1 point in the UNOS sharing algorithm. The 1- and 3-yr GS in WR and N-WR of these groups were as follows: 0 CREG, 0 DR mismatches: 85.7% and 78.3% in WR (n = 385); 83.0% and 69.4% in N-WR (n = 157). 1-3 CREG, 0 DR mismatches: 84.5% and 74% in WR (n = 1550); 82.7% and 65.7% in N-WR (n = 1083). Based on this analysis, there may be a significant potential advantage of prospective Class I CREG over A, B matching for first cadaver kidney transplantation.

Algorithms↗
PubMed1997

The foundations of effective management of bipolar disorder.

OBJECTIVES: To understand the epidemiology and course of bipolar disorder; to outline the importance of accurate and reliable diagnosis of bipolar disorder both on a cross-sectional and longitudinal basis; and to emphasize the value of a collaborative therapeutic relationship, psychoeducation, and psychotherapy. METHODS: A brief review of relevant literature to deal with the issues of diagnosis and laying the foundations for effective treatment. RESULTS: Bipolar disorder may well be a heterogeneous group of conditions with varying forms of biphasic mood dysregulation and a changing course across a lifetime. A collaborative therapeutic relationship, psychoeducation, and psychotherapy can be the basis for effective management. CONCLUSIONS: As the concept of bipolar disorder has broadened, the condition is being identified with increasing frequency in many clinical settings. It is a relapsing and recurring condition. It is now recognized that in addition to rational pharmacotherapy, there is a need to encourage a high level of treatment adherence while providing a holistic package of interventions.

Bipolar Disorder↗
PubMed1996

Tumor heterogeneity and progression: conceptual foundations for modeling.

A conceptual foundation for modeling tumor progression, growth, and heterogeneity is presented. The purpose of such models is to aid understanding, test ideas, formulate experiments, and to model cancer 'in machina' to address the dynamic features of tumor cell heterogeneity, progression, and growth. The descriptive capabilities of such an approach provides a consistent language for qualitatively reasoning about tumor behavior. This approach provides a schema for building conceptual models that combine three key phenomenological driving elements: growth, progression, and genetic instability. The growth element encompasses processes contributing to changes in tumor bulk and is distinct from progression per se. The progression element subsumes a broad collection of processes underlying phenotypic progression. The genetics elements represents heritable changes which potentially affect tumor character and behavior. Models, conceptual and mathematical, can be built for different tumor situations by drawing upon the interaction of these three distinct driving elements. These models can be used as tools to explore a diversity of hypotheses concerning dynamic changes in cellular populations during tumor progression, including the generation of intratumor heterogeneity. Such models can also serve to guide experimentation and to gain insight into dynamic aspects of complex tumor behavior.

Animals↗
PubMed1997

Foundations of arrhythmia interpretation.

Basic arrhythmia monitoring is being used with increasing frequency in both inpatient and outpatient care settings. Nurses are being asked to interpret cardiac rhythms and develop critical thinking skills that assist in evaluating the significance of the rhythms identified for individual patients. The foundations needed for nurses to evaluate cardiac rhythms and assess the significance of the rhythms identified are provided. Cardiac anatomy, physiology, and cardiac properties are used to provide a framework for interpreting and understanding rhythms.

Arrhythmias, Cardiac↗
PubMed1997

Effect of race on outcome following kidney and kidney-pancreas transplantation in type I diabetics: the South-Eastern Organ Procurement Foundation experience.

In this study we analyze the South-Eastern Organ Procurement Foundation (SEOPF) experience with kidney and kidney-pancreas transplantation in IDDM recipients and evaluate the impact of racial disparity on patient and graft outcome. Data obtained from 4413 kidney-alone and 884 pancreas transplants performed in White and Black type I diabetics at member institutions of SEOPF between 10/1/87 and 7/25/96 were analyzed. Survival data from 15,827 transplants performed during the same period of time in non-diabetics were available for comparison. A lesser proportion of pancreas recipients were Black compared to kidney-alone (12% vs 23%, p < 0.0005). Recipient race had no effect on patient survival in any of the groups studied. Kidney graft survival, on the other hand, was adversely affected by Black race in both non-diabetic and diabetic recipients of a kidney transplant but not in diabetics who received a combined pancreas-kidney transplant. As was the case for patient survival in diabetics, recipient race had no effect on pancreas graft survival. Cox Regression analysis showed that kidney-pancreas transplant (p = 0.034, RR = 0.49) and female recipient gender (p = 0.046, RR = 0.68) were associated with a lower risk of failure of the pancreas graft. The following factors were independent predictors of kidney graft outcome: Donor age (p = 0.0001, RR = 0.95), kidney-pancreas transplant (p = 0.0004, RR = 0.58), AB match (p = 0.001, RR = 0.86), DR match (p = 0.006, RR = 0.82), preservation time (p = 0.012, RR = 1.01), Black recipient race (p = 0.047, RR = 1.23) and living donor (p = 0.06, RR = 0.73). Our findings suggest that the effect of race on graft outcome observed in non-diabetic and, to a lesser extent, diabetic kidney-alone transplant recipients, is not present after kidney-pancreas transplantation.

ABO Blood-Group System↗
PubMed1997

Revisiting foundations of autonomy and beneficence in genetic counseling.

Respect for autonomy of clients and helping clients to achieve the good they desire are now recurring themes in genetic counseling literature. In professional discourses on the clinical encounter involving genetic counseling these ideas are frequently employed in a manner which suggests that a client enters the conversation lacking only some technical information needed to make a decision. However, decision-making autonomy is developed and sustained over a lifetime through dependencies on social partners; including with the genetic professional. In an operational sense autonomy is reflected in the capacity of a client to do informed analytical work, to engage in reality testing of alternative decisions, and to do moral testing of decisions. The counselor's role can extend to assisting the client in developing the skills needed for the tasks of moral deliberation. This work develops a theoretical framework for conceptualizing autonomy of clients and the resulting relationship between counselor and client. This framework is more foundational than current debates about the relative merits of directive versus nondirective counseling, and points toward a relationship between counselor and client which differs from that implied by either of these two traditional relational paradigms.

Beneficence↗