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PubMed2006

The goals of health work: Quality of life, health and welfare.

Health-related quality of life is the ultimate general goal for medicine, health care and public health, including health promotion and health education. The other important general goal is health-related welfare. The aim of the paper is to explain what this means and what the consequences of these assumptions are for health work. This involves defining the central terms "health", "quality of life" and "welfare" and showing what their conceptual relations are. Health-related quality of life has two central meanings: health-related well-being, which constitutes quality of life, and health as ability, which contributes causally to quality of life. Four meanings of health-related welfare are put forward: general well-being, health as ability, other inner properties of the individual, and external factors. States and processes covered by these categories contribute causally to health-related quality of life. Finally, using these distinctions, some more specific goals for medicine and health care, on the one hand, and for public health and health promotion, on the other, are outlined. In the former fields work is primarily directed towards changing the health-related quality of life of the individual through direct measures, "manipulating" the individual, whereas public health work and health promotion primarily use indirect measures and further health through various sorts of health-related welfare changes, e.g. through changing the environment.

Health↗
PubMed2005

Secondary prevention in coronary heart disease: goal achievement and drug prescribing.

OBJECTIVE: To provide an overview of the degree of treatment goal achievement and drug prescribing in patients with coronary heart disease (CHD) in clinical practice. METHOD: Patients undergoing planned or acute percutaneous coronary intervention (PCI) were included. Patients' medical records and the hospital's database on clinical chemistry analyses were studied retrospectively. MAIN OUTCOME MEASURE: Goal achievement and drug prescription relative to published therapeutic guidelines. RESULTS: A total of 200 patients aged 66 +/- 11 years were included. Blood pressure <140/90 mmHg was achieved in 36% of patients 3 months after PCI and total cholesterol <5 mmol/l was achieved in 29% at the time of PCI. Three months after PCI the patients were on 1.4 (range 0-4) drugs with antihypertensive effect (including diuretics). Seventy eight percent were on a statin, 92% were on low-dose aspirin, and 23% had a diuretic in their drug regimen. Five out of 16 patients with diabetes mellitus included in the study were prescribed an angiotensin converting enzyme-inhibitor (ACE-I). CONCLUSION: There is probably a potential for increased degree of goal achievement and for improved drug prescribing in patients with CHD undergoing PCI at our hospital.

Adrenergic beta-Antagonists↗
PubMed2003

Are low target blood pressure goals justified in persons with diabetes mellitus?

Hypertension is common in patients with diabetes and is a major risk factor for development and progression of the macro- and microvascular complications seen in diabetes. The Joint National Committee VI recommendation for goal blood pressure is less than 130/85 mm Hg in diabetics--a more aggressive target than in nondiabetic patients. Data over the past decade support these aggressive goals, especially for cardiovascular and renal outcomes and overall mortality. In addition, in diabetics, blood pressure appears to be a continuous risk factor for these outcomes without evidence of a J-point effect. While these goals are rarely obtained in diabetic patients, studies demonstrate that they are achievable with attention to detail and use of multiple antihypertensive agents.

Antihypertensive Agents↗
PubMed1987

Therapeutic goals and treatment options for prevention of stress ulcer syndrome.

Stress ulcer syndrome, the occurrence of acute upper gastrointestinal bleeding or perforation from stress-related mucosal damage, is a significant cause of morbidity and mortality in critically ill patients. The mortality rate in critically ill patients who have bled from stress ulcers ranges from 50 to 77 percent, whereas the mortality rate for similar patients without stress ulcer bleeding ranges from 9 to 22 percent. The mortality rate may be as high as 90 percent in patients with clinically overt bleeding; as many as one-third of these deaths can be directly related to bleeding. Prophylactic therapy for prevention of stress ulcer bleeding is based on three premises: (1) morbidity and mortality related to stress ulcer syndrome are significant; (2) the population at risk can be identified prior to bleeding; and (3) therapy that decreases gastric acidity or improves gastric mucosal defense mechanisms will prevent ulcer formation or progression to bleeding. A review of prospective clinical studies utilizing prophylactic therapy in critically ill patients and patients undergoing surgery revealed a 17 percent overall bleeding rate for placebo groups compared with lower bleeding rates for antacid- and histamine (H2)-receptor-antagonist-treated groups (4 and 7 percent, respectively). Studies varied greatly in definition of bleeding, dosage regimens, and gastric pH goals. The need to measure gastric pH during treatment is controversial, and the optimal pH goal and the length of time for which it must be maintained remain unknown. Controversy exists as to the best therapeutic option for prophylaxis of stress ulcer syndrome, but when prevention of clinically significant bleeding is the therapeutic goal, antacids and H2-receptor antagonists appear to be equally efficacious.

Acute Disease↗
PubMed1993

Analytical quality goals and assessment to ensure transferability of laboratory results.

About 3 years ago NORDKEM started a project entitled 'Medical Need for Quality Specifications in Clinical Laboratories'. This communication describes the general approach of this project and a subproject oriented towards problems of transferability of clinical laboratory data. Attempts are made to estimate clinical goals for analytical measurements--either used alone or in combinations with other measurements or observations--in defined clinical situations. Various methodologies are used for the assessment of the clinical goals, starting, e.g., from clinical situations or biological reference data. The analytical quality specifications are expressed as total allowable errors. It is necessary to complement specifications of 'clinical goals' with data describing characteristics of the measurement procedure, preanalytical errors and internal and external quality assurance procedures in order to establish the laboratory quality specification guaranteed by the laboratory. Problems of transferability of clinical laboratory results occur both within a laboratory/hospital and between laboratories/hospitals/health care units, problems that sometimes make communication of laboratory results difficult or even meaningless. In order to study the transferability of clinical laboratory data within a health care region, so called 'transformation functions' could be used to characterize each laboratory in a strict quality assessment/proficiency testing procedure on the basis of analytical quality specifications. Under certain conditions, e.g. for analytical procedures with high specificity and documented stable analytical performance, numerical correction of analytical bias could be performed to decrease interlaboratory variation to a level specified by medical needs.

Cholesterol↗
PubMed1983

Interim recruitment goals in clinical trials.

The recruitment rate or duration of a clinical trial must be so determined that the required number of patients may be assured within the given design frame. Establishing interim recruitment goals in clinical trials will not only help keep the clinical investigator from falling too far behind in recruitment but will also enable the sponsor of the study to decide in the early stages of the study whether the investigator can achieve the final recruitment goal. We propose statistical methods for determining a proper recruitment rate, duration and interim recruitment goals. A method of projecting the final recruitment at interims and a method of adjusting the recruitment duration at interims are discussed. Seasonal adjustment methods are also noted.

Clinical Trials as Topic↗
PubMed1995

Kinetics: our window into the goals and strategies of the central nervous system.

The goal of this chapter is to demonstrate the role of integrated biomechanical analyses in complex movements such as gait in alerting researchers of the goals and synergies of the CNS. Because of the large number of segments involved and the potential for the CNS to take advantage of inter-limb coupling it is only through appropriate biomechanical analyses that such collaboration can be identified. Examples from normal, perturbed, elderly and pathological gait are presented to demonstrate the principles of total limb and total body analysis to pinpoint the goals of the CNS and to identify total limb or body synergies and adaptations in the elderly and in gait pathologies. Such findings reinforce the generalizations made many years ago by Bernstein [2] when he postulated several simplifying principles of CNS control. Also, evident from these analyses are the precision and accuracy of biomechanical variables that make these measures particularly sensitive to small changes within an individual or across a population group.

Adult↗
PubMed1995

Ontogenesis of goal-directed behavior: anatomo-functional considerations.

Recent neuroanatomical and neurophysiological studies in man have revealed ontogenetic events which coincide with broadly defined phases of behavioral and cognitive development. During the early fetal period, early produced neurons make initial synapses which form the basis for the earliest electrical activity of the human brain. The overall immaturity of neuronal connections, in particularly in cortical areas, correlates with the absence of any behavioral pattern or goal-directed movements. In the late fetus and preterm infant, transient accumulation of major afferent pathways, the presence of transient layers (subplate zone) and transient pattern of transmitter-related organization form the neurological basis of cortical electric responses as well as transient behavioral states and sleep patterns. Parallel to the profound structural and chemical reorganization of the human cerebrum during the first 6 postnatal months there is a disappearance of transient behavioral and motor patterns. The previously close spatio-temporal correlation between these events becomes progressively looser. The overproduction of circuitry elements during the subsequent period peaks in associative cortex between 1 and 2 years of age, corresponding to the emergence of skilled actions and cognitive functions. After the elimination of some circuitry elements after the second year of life, the prolonged maturation of goal-directed behavior and the protracted emergence of different cognitive functions correlates with the development plateau of synapse production which can be seen up to 16 years of age. Parallel to the prolonged maturation of postsynaptic elements, there are well defined maturational changes in the chemical properties of associative pyramidal neurons of cortical layer III. These findings correspond to the prolonged maturation of movement-related brain macropotentials as well as other cognition-related potentials, where the last prominent changes were seen after 10 years of age. Although the coincidence of the developmental events does not necessarily mean a causal relationship, the combination of structural and physiological data opens new vistas for the further investigation of the neurobiological basis of goal-directed movement and cognitive behavior.

Adolescent↗
PubMed1995

Diabetes service management training and the need for a patient perspective: a 10-year evolution of training strategies and goals.

In 1977, the Swedish National Board of Health and Welfare published guidelines for comprehensive care of patients with diabetes. The Stockholm County (1.6 million inhabitants) responded and opened a Diabetes Education and Training Centre, LUCD, in 1979. The goal was to reduce the impact of long-term complications. The centre should translate available knowledge about diabetes care into clinical practice, promoting a shift of patients and resources to the primary health care sector. Follow-up studies and new knowledge have changed the short-term training strategies; the long-term goal has remained unchanged. Current work is concentrated on training of staff, improving methods to support better patient learning, aiding organisational changes, and supporting large-scale interventions aimed at both patients, staff and the public. The patient can realize the goals. Knowledge and demands expressed by persons with diabetes are necessary for improvements of diabetes care. The skilled patient is also a guarantee for continuity of care. Regular follow-up of diabetes services was an important impetus for progressive change of short-term training strategies.

Area Health Education Centers↗
PubMed2005

The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment.

Each year, pelvic floor dysfunction affects between 300,000 and 400,000 American women so severely that they require surgery. Approximately 30% of the operations performed are re-operations. The high prevalence of this problem indicates the need for preventive strategies, and the common occurrence of re-operation indicates the need for treatment improvement. Efforts at prevention and treatment improvement will only be possible if research clarifies causative mechanisms and scientifically valid studies discover why operations fail. By reaching a goal of 25% prevention we could save 90,000 women from experiencing pelvic floor dysfunction and with 25% treatment improvement we could avoid 30,000 women from needing a second operation. To achieve these goals we must discover specific events or behaviors in a woman's life that lead to these problems and that are amenable to preventive strategies. In addition, we must define specific biologic and behavioral factors that explain why certain women have recurrence after surgery. Because the pelvic organ support system is comprised of muscles, ligaments, and nerves arranged in a complex tension-based apparatus, the basic nature of this work must include biomechanical analyses of the overall mechanism and targeted research into the biology of muscle, ligament, nerve, and their complex interactions in normal pelvic floor function and in symptomatic patient. Each of these scientific disciplines is well developed so that engaging scientists in the effort to move forward will bring predictably important results. With an integrated approach to this problem over the next 20 years, it should be possible to achieve these goals and reduce the suffering for more than 100,000 afflicted women.

Delivery, Obstetric↗
PubMed2006

Nicotine does not produce state-dependent effects on learning in a Pavlovian appetitive goal tracking task with rats.

Past research has shown that when rats received 0.4mg base/kg nicotine paired reliably with intermittent sucrose delivery that anticipatory sucrose-seeking behavior (i.e., goal tracking) was differentially displayed in the nicotine state relative to intermixed saline sessions in which no sucrose was delivered. The present research extended this observation to a lower dose of nicotine (i.e., 0.2mg base/kg) and tested a state-dependent learning account of differential conditioned responding. According to this account, the increase in goal tracking on nicotine sessions reflects a chamber-sucrose association that is only recalled when in the nicotine state. We used a 2x2 factorial design in which rats received sucrose deliveries in one drug state (nicotine or saline) and were then tested in the same state (Nic-->Nic or Sal-->Sal) or a different state (Nic-->Sal or Sal-->Nic) after acquiring the conditioned response. A state-dependency account predicts disruption in conditioned goal tracking for rats that receive a shift in drug state on the test day. This disruption did not occur suggesting that differential control of conditioned responding by nicotine is more likely due to a direct excitatory association between the interoceptive cueing effects of nicotine and the appetitive qualities of sucrose.

Analysis of Variance↗
PubMed2004

Inpatient care for elderly cancer patients: the role for Geriatric Evaluation and Management Units in fulfilling goals for care.

PURPOSE: To describe patterns of functional status, symptoms, therapeutic goals and outcomes among older adults with cancer diagnoses hospitalized on a Geriatric Evaluation and Management Unit (GEMU). DESIGN AND METHODS: Retrospective chart review of veterans with a cancer diagnosis consecutively admitted to a Department of Veterans Affairs GEMU between 1996 and 1999. RESULTS: Thirty-six veterans with cancer diagnoses, average age of 80+/-5.0 years, 100% men, 50% white, 39% married were admitted during the target period. Comorbid illness was common (mean +/- S.D. = 4.6+/-2.0) as were associated symptoms (mean = 2.5+/-1.9). Average Karnofsky performance status was 55+/-7. Goals were accomplished 78% of the time for diagnosis, 73% for symptom management, 79% for functional improvement, and 100% for disposition/caregiver support. IMPLICATIONS: Elderly oncology patients admitted to a GEMU display diverse needs and goals that are realistic and attainable in this context. In-patient GEMU services represent a promising approach to care for older cancer patients, and deserve further evaluation of benefits and risks.

Activities of Daily Living↗
PubMed2004

Target selection and the superior colliculus: goals, choices and hypotheses.

The intermediate and deep layers of the superior colliculus (SC) compose a retinotopically organized motor map and are known to be important for the control of saccadic eye movements. However, recent studies have shown that the functions of the SC are not restricted to the motor control of saccades. The pattern of activity observed during multi-saccade movements, combined eye-head movements, and pursuit eye movements argue that activity in the SC indicates the location of the goal, but does not specify the particular movements that will be used to acquire the goal. Prior to the onset of a movement, the SC is involved in representing possible targets, as has been shown by the effects of manipulating target probability and the changes in pre-motor activity found during visual search tasks. A major unresolved issue is how target-related activity in the SC is transformed into the signal that triggers the movement. One possibility is that the levels of activity across the SC motor map correspond to the likelihood of the possible targets, and that the movement decision is based on the neural equivalent of hypothesis testing. In one version of this mechanism, the decision to select a new goal would occur each time the null hypothesis, represented by neurons in the rostral SC, was rejected in favor of an alternative represented elsewhere in the SC.

Attention↗
PubMed2005

Update on the National Patient Safety Goals--changes for 2005.

Each year sice 2003, the Joint Commission on Accreditation of Healthcare Organizations has established National Patient Safety Goals for accredited health care organizations. The goals are developed to promote improvement in patient safety by helping health care organizations address specific safety concerns. This article discusses the current goals and highlights new information for 2005.

Accidental Falls↗
PubMed2001

Achieving and maintaining National Cholesterol Education Program low-density lipoprotein cholesterol goals with five statins.

PURPOSE: Most patients fail to achieve and maintain low-density lipoprotein (LDL) cholesterol goals established by the National Cholesterol Education Program (NCEP). The Atorvastatin Comparative Cholesterol Efficacy and Safety Study (ACCESS) was a randomized study comparing the efficacy and safety of five statins and their ability reduce LDL cholesterol to the NCEP target level. SUBJECTS AND METHODS: Of 7542 patients screened, 3916 hypercholesterolemic patients were randomly assigned to treatment with a statin, beginning with the lowest recommended dose (atorvastatin, pravastatin, and simvastatin, 10 mg; fluvastatin and lovastatin, 20 mg). If the NCEP target was not achieved, the dose was titrated up to the recommended maximum (atorvastatin, fluvastatin, and lovastatin, 80 mg; pravastatin and simvastatin, 40 mg). The total duration of treatment was 54 weeks. RESULTS: Atorvastatin achieved the greatest mean reduction in LDL cholesterol: 36% +/- 11% at 6 weeks (initial dose) and 42% +/- 13% at 54 weeks. More patients receiving atorvastatin at its initial dose (53%, 997 of 1888) achieved their NCEP target levels than patients receiving simvastatin (38%, 174 of 462), lovastatin (28%, 134 of 472), pravastatin (15%, 71 of 461), or fluvastatin (15%, 69 of 474) at the initial dose. Atorvastatin-treated patients were more likely to maintain their target levels from week 6 to week 54. The percent reduction in LDL cholesterol achieved at the initial dose correlated strongly with the proportion of patients who maintained their goals at 54 weeks (r = -0.84). CONCLUSION: For patients treated with statins, providing a greater margin between the NCEP target level and the achieved LDL cholesterol level enhances the likelihood of maintaining NCEP goal levels.

Aged↗
PubMed2004

[Blood pressure goals in diabetes. A critical appraisal].

In this article we review the evidence supporting the need to achieve a target blood pressure (BP) under 130-80 mm Hg in diabetic patients, as recent international guidelines recommend (JNC VII, ESH-ESC and ADA). We have analyzed the explicit arguments used in these guidelines, 3 clinical trials designed to determine which is the best BP in diabetics (HOT, UKPDS-38 and ABCD) as well as other potentially misleading clinical trials. In our opinion, neither these 3 specific clinical trials nor other trials quoted in the guidelines (due to results and methodology employed) can answer the question of the best goal of pharmacological treatment for hypertension in diabetics. On the other hand, international agreements are not sufficiently rigorous regarding both the sources mentioned and the direct interpretation of the data provided. We conclude that there is not enough evidence to support the goal pressure below 130/80 mm Hg in patients with diabetes. We insist in the need of individualization of therapy in patients and consider that a under 140/85 mm Hg goal pressure in diabetics is perfectly supported by current evidence.

Blood Pressure↗
PubMed1997

Kinematics of goal-directed arm movements in neglect: control of hand in space.

The present study investigated unrestrained, three-dimensional arm movements during goal-directed pointing in five patients with clinically manifest neglect to targets positioned either in the center or the left and right hemispace. Five patients with unilateral right hemispheric lesions without neglect and six healthy subjects served as controls. All subjects were able to point to these targets. Terminal accuracy of pointing did not differ between the three groups along the horizontal, vertical and anterior-posterior axis. Subjects' hand trajectories did not reveal direction-specific deviations from a straightline hand path. Our data show that deviations in the trajectories toward the ipsilesional side are not characteristic for patients with spatial neglect. We argue that exploratory and goal-directed motor behavior might not share the same egocentric, body-centered reference frame. A spatial reference frame for exploratory behavior is disturbed in patients with neglect resulting in a failure to explore the contralesional part of space by eye or limb movements. Its failure does not induce a spatial bias in hand trajectory formation during goal-directed arm movements in peripersonal space. Such deviations of reaching or pointing rather seem to be characteristic for patients with optic ataxia.

Adolescent↗
PubMed2001

Locomotion towards a goal alters the synchronous firing of neurons recorded simultaneously in the subiculum and nucleus accumbens of rats.

Rats were implanted with recording electrodes aimed at the subiculum and nucleus accumbens. They were subsequently placed in a cylindrical environment, where they searched for locations where they would receive rewarding medial forebrain bundle stimulation. At times a tone was sounded, indicating that the reward location was in the center of the environment. Animals quickly learned to switch from random running to goal directed locomotion when the tone was on. To quantify the synchronous firing between simultaneously recorded neurons in the subiculum and nucleus accumbens, a gravitational clustering algorithm was employed. Individual neurons were modeled as particles in N dimensional space. Every spike discharge of the neuron augmented the 'gravitational charge' on its model particle. Synchronous firing between two cells caused their corresponding particles to draw together over time, due to the concurrent appearance of gravitational charge. All pair-wise combinations of cells isolated in subiculum and nucleus accumbens were examined using this algorithm. The firing of nine out of 52 subicular-accumbens cell pairings was significantly more synchronous when the tone was on, and the rat was running towards the central goal. This was also seen for 15 out of 22 subicular-subicular cell pairings. Conversely, only two out of 51 accumbens-accumbens pairings displayed significant tone dependent changes in synchronous firing. Thus, synchronous interactions between subiculum and nucleus accumbens occur preferentially when the animal is required to locate a fixed goal in space, i.e., the functional connectivity is altered by the navigational demands of the spatial reward task.

Algorithms↗