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Mortality and morbidity transition in Kuwait: the role of health and development policies.

Kuwait has, in recent years, achieved a marked improvement in the health status of its population, as measured by a variety of mortality and morbidity indicators. This can be attributed to the implementation of two sets of policies that impact upon health, namely the health and socio-economic development plans of the Kuwaiti government. This article seeks to outline these recent changes in mortality and morbidity levels, and traces out the key policies considered to be the major determinants for these changes. Data is presented on health status, and on patterns and trends of health services' utilization. These trends suggest strongly that, for Kuwait, the health goals set for the year 2000 are achievable.

Health Policy↗

Application of physiologically based pharmacokinetic models for assessing drug disposition in space.

Exposure to weightlessness induces physiologic changes that may lead to pharmacokinetic and pharmacodynamic alterations of drugs administered to crew members in flight. Preliminary data from flight and ground-based studies indicate that pharmacologically significant changes occur in the kinetics of medications given in weightlessness and in simulated microgravity (head-down bed rest). Conducting flight studies on all available medications to identify the changes in their pharmacokinetic behavior in weightlessness is not feasible. An alternative approach for obtaining such information is to use computer simulations employing physiologically based pharmacokinetic (PBPK) models. Information thus obtained would be helpful in predicting the therapeutic effectiveness of medications in space, and also in developing plans for flight studies. This paper presents a brief review of relevant physiologic factors and pharmacokinetic implications of space flight, and includes a preliminary PBPK model for estimating plasma concentration-time profiles of acetaminophen under different experimental conditions.

Acetaminophen↗

Modeling the relationship between land use and surface water quality.

It is widely known that watershed hydrology is dependent on many factors, including land use, climate, and soil conditions. But the relative impacts of different types of land use on the surface water are yet to be ascertained and quantified. This research attempted to use a comprehensive approach to examine the hydrologic effects of land use at both a regional and a local scale. Statistical and spatial analyses were employed to examine the statistical and spatial relationships of land use and the flow and water quality in receiving waters on a regional scale in the State of Ohio. Besides, a widely accepted watershed-based water quality assessment tool, the Better Assessment Science Integrating Point and Nonpoint Sources (BASINS), was adopted to model the plausible effects of land use on water quality in a local watershed in the East Fork Little Miami River Basin. The results from the statistical analyses revealed that there was a significant relationship between land use and in-stream water quality, especially for nitrogen, phosphorus and Fecal coliform. The geographic information systems (GIS) spatial analyses identified the watersheds that have high levels of contaminants and percentages of agricultural and urban lands. Furthermore, the hydrologic and water quality modeling showed that agricultural and impervious urban lands produced a much higher level of nitrogen and phosphorus than other land surfaces. From this research, it seems that the approach adopted in this study is comprehensive, covering both the regional and local scales. It also reveals that BASINS is a very useful and reliable tool, capable of characterizing the flow and water quality conditions for the study area under different watershed scales. With little modification, these models should be able to adapt to other watersheds or to simulate other contaminants. They also can be used to study the plausible impacts of global environmental change. In addition, the information on the hydrologic effects of land use is very useful. It can provide guidelines not only for resource managers in restoring our aquatic ecosystems, but also for local planners in devising viable and ecologically-sound watershed development plans, as well as for policy makers in evaluating alternate land management decisions.

Agriculture↗

Clinical trial designs for therapeutic cancer vaccines.

Therapeutic cancer vaccines have characteristics that require a new paradigm for phase I and phase II clinical development. Effective development plans may take advantage of some of the following observations: Dose ranging safety trials are not appropriate for many cancer vaccines. Dose ranging trials to establish an optimal biologic dose are often not practical. We have presented an efficient design of Korn et al. (4) to identify an immunogenic dose. Vaccine efficacy can be efficiently evaluated with tumor response as endpoint utilizing a two stage design with only 9 patients in the first stage. If no partial or complete responses are observed in the initial 9 patients, accrual to the trial is terminated. Optimization of vaccine delivery by comparing results of single arm phase II studies using immunological response as endpoint is problematic because of assay variation and potential non-comparability of patients in different studies. Randomized screening studies can be used to efficiently optimize vaccine immunogenicity. Efficiency in use of patients depends on having assay variation and inter-patient variability small relative to the difference in immunogenicity to be detected. Phase II studies using time to progression as endpoint are most interpretable if they employ randomized designs with a no-vaccine control group. Such designs may use an inflated type 1 error rate, and need not be prohibitively large if patients with rapidly progressive disease are studied. Interim monitoring plans may effectively limit the size of the trials by terminating accrual early when results are not consistent with the targeted improvement.

Cancer Vaccines↗

Pesticide residues in foods imported into the United States.

Interest in pesticide residues in foods has increased, and the issue of residues in imported foods has been raised as a potential public health problem. Three U.S. government agencies, EPA, FDA, and USDA, are responsible for regulating pesticides. EPA sets tolerances, and FDA and USDA enforce those tolerances. As part of its regulatory activities, FDA conducts a regulatory monitoring program that samples and analyzes each year approximately 20,000 food shipments, about 60% of which are imports. Samples of imported foods are collected at ports of entry, and are chosen on the basis of several factors rather than on a completely random basis. Raw agricultural products are emphasized. Most analyses are performed using MRMs, to make best use of FDA's resources. Using five MRMs, about half of the 300 pesticides with U.S. tolerances can be determined. Results from monitoring over the past several years have shown that nearly 60% of the imported foods sampled had no pesticide residues detected. Of those samples that were violative, 5% contained residues for which there was no U.S. tolerance, and less than 1% had over-tolerance residues. Examples are given of the various pesticide/commodity combinations that have been found to be violative. FDA is often criticized for the scope of its pesticide coverage, particularly with regard to imported foods. Some critics have promoted the idea of a 'circle of poison,' which is based on the premise that pesticides banned in the U.S. are exported and used on foods in foreign countries; then the food containing these residues is imported into the U.S. and consumed. However, FDA's testing of imported foods has shown that residues of EPA-banned pesticides are not occurring from currently purposeful uses. The violation rates for imports also have not been significantly different from those for domestic foods. This indicates that foreign producers, as well as domestic growers, generally use pesticides in a manner consistent with EPA requirements. FDA continues to broaden its information-gathering capabilities. As mandated by the PMIA of 1988, FDA will attempt to obtain pesticide use information from countries that are major food exporters to the United States. An improved data management system will also be in place, and a long-range analytical method development plan instituted. Several international organizations address the issue of pesticide residues in foods. Attempts at harmonization of national tolerances for pesticide residues have not been successful, i.e., a number of individual nations have not accepted Codex MRLs.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

The impact of treatment on survival roles of a person with a traumatic brain injury.

Over 250 survivors of brain injury were clinically evaluated and a long term care plan developed for each of them. 105 survivors were located and a follow-up questionnaire was administered at least two years later to the survivors and families to evaluate the predictions that were made regarding long-term needs. The study looked at the impact on eight survival roles as defined by WHO and attempted to determine the effectiveness of services, correlating various treatment modalities and services with changes, adjustments, accommodations, achievements, and future goals. Results showed that there is a correlation between some non-traditional therapies (Recreational and Cognitive) and for individuals' future goals in physical independence, mobility, community reintergration and self care. These future goals were not significant for occupational and physical therapies. Also, a less significant correlation was made between paid attendant care and level of outside activities.

Brain Injuries↗

Clergy consultation as a community mental health program.

The authors describe the planning, development, implementation, and results of a consultation program to the clergy as part of an agency's community mental health service. The paper focuses on the four main program goals of (1) revitalizing a local association for the clergy, (2) developing the clergy's pastoral skills, (3) increasing community supports for mental health, and (4) developing a counseling service sponsored by the local clergy for community residents.

Clergy↗

The use of videotape in internal medicine training.

By paying attention to the power of the medium and the method of feedback, videotaping programs can be a remarkably successful teaching and research tool. Learners can view their performance, review feedback on their own behavior, knowledge, and displayed attitudes, and develop plans to change behavior that can be followed up on subsequent tappings. In addition, trainees can share important experiences with each other and valued teachers. Interviewing skills can be documented and preserved, creating a video library that allows trainees to actually visualize improvements in their own performances over time. An archive of many such performances allows trainees, faculty, and researchers alike comparative access to the complex challenges of the medical interview.

Decision Making↗

Caring for the frail older patient: the doctor-patient-family caregiver relationship.

Much has been written about the complexities of the doctor-patient relationship and the myriad ways that both parties communicate. When patients become more frail, this relationship must expand to include their family caregivers. This addition of a third person complicates the situation in more than an additive fashion. It requires more time and energy on the part of physicians that are not without costs. Balancing both patient and caregiver needs in a time-driven and increasingly competitive world is not easy. Physicians not only need better preparation to meet the challenges of caring for frail older patients, but they also need changes in reimbursement policies so that they can afford to spend the time needed to manage the complexities inherent in the doctor-patient-family caregiver relationship. Although there is uncertainty about timing of these changes, there is no uncertainty about the complexity of the doctor-patient-family caregiver relationship. To make its management easier, the following rules are worth remembering: 1. Carefully assess problems in all domains of patient function and develop plans for managing and monitoring these problems. 2. Recognize that the effects of patient disabilities cycle between patient and caregiver. 3. Pay attention to the needs and concerns of patients and of their caregivers. 4. Provide caregivers with as much information as possible and educate them about "when to worry." 5. Assure caregivers that you are available to answer questions and help them with handling problems that arise in the care of their elders.

Adaptation, Psychological↗

Opinion: a prototype for a computerized national mammography registry and tracking system using telecommunications and the Internet.

In this report, we analyze the feasability and discuss the potential benefits of using currently available technology for the wide-area registration and tracking of mammography patients. In our prototype, three dissimilar computer systems transmitted mammographic data (demographics and the results of mammograms) in a standardized format to a central data repository. Two of the three systems were dedicated computerized mammography systems and one was a general-purpose radiology information system. High-speed modems and the Internet were used to connect with the central repository, which could be queried in real time by remote users. Our results indicated that a busy mammography practice, using the slowest transmission method we tested (14-kilobaud modem), could transmit several days of mammographic data to a central repository in a matter of minutes. To implement systems that provide nation-wide mammographic tracking and follow up, more in-depth planning, development, and testing are necessary.

Computer Communication Networks↗

Perspectives on local environmental security, exemplified by a rural South African village.

This paper analyzes the human-nature interaction in a village in rural South Africa. It discusses preconditions, perceptions, and consequences of natural resource use, and places these findings into a regional and historical context. Applying an interdisciplinary perspective, the study uses interviews, questionnaires, remote sensing, and participatory mapping to analyze land cover changes and local perceptions of the environment. The study area is located in a former homeland (Transkei), a setting where well-recorded conflicts in the human-nature sphere have previously been triggered by population pressure, apartheid policies, and other historical, political, and social reasons. A small-scale and subjective conceptualization of environmental security is used as an approach to analyze local livelihood strategies in a selected village. The results indicate that the environment is not the highest priority in local survival strategies. Instead, formal and informal jobs and governmental grants are the most important security strategies. There are thus no major conflicts resulting from the interaction between the local population and the natural resources in this specific area. Explanations to this pattern can partly be found in historical contexts, which include apartheid policies, re-localizations, and a system of migrant labor. The study also suggests that general truths about a region such as Transkei might be misleading in specific localities. For relevant and successful environmental management and development planning however, it is crucial that decision-makers be able to get a clear picture of local situations and adjust their plans accordingly.

Conservation of Natural Resources↗

Integrating dictation with PACS to eliminate paper.

Five years ago our department migrated from a film-based imaging environment to a PACS-based environment. We discovered that our reliance on paper tracking forms for clinical history and dictation information was hindering our practice. Integrating dictation with PACS was one of three key components we needed to free ourselves from the tyranny of paper, the other two being an online worklist and an online patient history. We discuss our evolution to a (mostly) paperless reading room environment, our implementation, general performance, and future development plans, focusing on integrated dictation.

Humans↗

Preparation and validation of gridded emission inventory of criteria air pollutants and identification of emission hotspots for megacity Delhi.

Delhi is one of the many megacities struggling with punishing levels of pollution from industrial, residential, and transportation sources. Over the years, pollution abatement in Delhi has become an important constituent of state policies. In the past one decade a lot of policies and regulations have been implemented which have had a noticeable effect on pollution levels. In this context, air quality models provide a powerful tool to study the impact of development plans on the expected air pollution levels and thus aid the regulating and planning authorities in decision-making process. In air quality modeling, emissions in the modeling domain at regular interval are one of the most important inputs. From the annual emission data of over a decade (1990-2000), emission inventory is prepared for the megacity Delhi. Four criteria pollutants namely, CO, SO(2), PM, and NO(x) are considered and a gridded emission inventory over Delhi has been prepared taking into account land use pattern, population density, traffic density, industrial areas, etc. A top down approach is used for this purpose. Emission isopleths are drawn and annual emission patterns are discussed mainly for the years 1990, 1996 and 2000. Primary and secondary areas of emission hotspots are identified and emission variations discussed during the study period. Validation of estimated values is desired from the available data. There is a direct relationship of pollution levels and emission strength in a given area. Hence, an attempt has been made to validate the emission inventory for all criteria pollutants by analyzing emissions in various sampling zones with the ambient pollution levels. For validation purpose, the geographical region encompassing the study area (Delhi) has been divided into seven emission zones as per the air quality monitoring stations using Voronoi polygon concept. Dispersion modeling is also used for continuous elevated sources to have the contributing emissions at the ground level to facilitate validation. A good correlation between emission estimates and concentration has been found. Correlation coefficient of 0.82, 0.77, 0.58 and 0.68 for CO, SO(2), PM and NO(x) respectively shows a reasonably satisfactory performance of the present estimates.

Air Pollutants↗

Discovery and development of flecainide.

The flecainide discovery and development process started in 1966 with the broad goal of investigating the effects of fluorine substitution in potential drug molecules. The overall process evolved slowly. The original goals of the project were translated into the 3 major phases: (1) the synthesis and evaluation of 2 major chemical series through the efforts of chemists who incorporated fluorine atoms into new compounds; (2) a change in focus from local anesthetic programs to the antiarrhythmic project through the efforts and advisement of pharmacologists; and (3) commitment to a flecainide development plan culminating in the new drug application for approval of flecainide in the suppression and prevention of ventricular arrhythmias.

Anesthetics, Local↗

Crossover from polytherapy to monotherapy in primary generalized epilepsy.

Patients with primary generalized tonic-clonic seizures can obtain equal or superior seizure control and fewer side effects when managed with valproate than when taking multiple antiepileptic drugs. The conversion from polytherapy to valproate monotherapy must be done carefully if side effects and seizure exacerbation are to be avoided. A gradual crossover, often requiring several months, is usually necessary. A well-developed plan and understanding by the patient, coupled with close follow-up, are essential. The major improvement in quality of life that results for the majority of patients after completing such a conversion fully warrants the extra time and effort required.

Adult↗

Stimulability: a useful clinical tool.

Although difficult to define, stimulability is an easily measured skill that can provide valuable information for clinicians treating children with phonological disorders. In this article, we review changing trends in the definition of stimulability, standardized and nonstandardized approaches to its measurement, and clinical implications of stimulability for prognosis and treatment plan development as they have evolved over a 40-year period. Clinical application of stimulability information in caseload management and intervention is emphasized.

Child↗

Clinical studies with the new anxiolytic alpidem in anxious patients: an overview of the European experiences.

Alpidem is a new imidazopyridine compound which has been selected in animal pharmacology for its anxiolytic and anticonvulsant activity, and for its high therapeutic index. In healthy volunteers, alpidem was well tolerated up to doses of 300 mg and appeared to be devoid of CNS toxic effects. An extensive clinical development plan has been carried out in Europe to test its efficacy and safety in anxious patients. In a series of 5 double-blind placebo controlled parallel group studies, alpidem was administered as a single dose in a situation of stress induced anxiety where the stress was represented by diagnostic investigations such as gastroscopy, cardiac catheterisation or minor surgical operations. In these studies, 188 patients received placebo and 188 received alpidem; their anxiety was assessed before and after the drug administration by means of visual analogue scales and state anxiety inventories. Alpidem at 50 and 75 mg was significantly better than placebo in reducing stress induced anxiety. Alpidem was then administered to patients suffering from severe generalized anxiety in doses from 50 to 150 mg/day for 3-4 weeks in 3 double-blind placebo controlled studies: 127 patients received alpidem and 80 received placebo. Patients were assessed by means of rating scales and visual analogue scales. Alpidem did show an anxiolytic activity in this patient population and was well tolerated especially with regard to CNS side-effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Anxiety Agents↗

Predictors of legal intervention in child maltreatment cases.

Using information extracted from child protective services and criminal court records, this research examines the extent and nature of dependency and criminal filings in 833 substantiated intrafamilial child abuse and neglect cases reported in Denver (CO), Los Angeles (CA), and Newcastle (DE) Counties in 1985-1986. Techniques of chi-square and discriminant analyses were used to identify factors associated with dependency and criminal filings. Results indicate that legal intervention is rare: Dependency filings and prosecutions occur in just 21% and 4% of the sample, respectively, although treatment plan development and out-of-home placement of the child occur in approximately 75% and 50% of the sample, respectively. Eighty percent of cases with criminal filings proceed to trial or plea bargaining, with 92% resulting in conviction. Bivariate analyses indicate cases involving abandonment, sexual abuse, frequent maltreatment, and severe maltreatment are most likely to result in an initial dependency filing, while cases involving sexual abuse, severe maltreatment, a nonparent perpetrator, an ethnic minority perpetrator, a female victim, and a victim aged 7-12 years are most likely to result in a criminal filing. The multivariate analyses show the primary predictor of both dependency and criminal filings is whether the case involved sexual abuse. This finding reflects the widespread public and professional attention child sexual abuse has received in recent years.

Adolescent↗