National security and the health of people: human needs and the allocation of scarce resources.
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Delivery of Health Care↗
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Economic constraints and quality assurance in mental health services: sensitive indicators.
Clinicians in the field of mental health are met with the dual challenge of increased accountability and shrinking resources. Funds are often allocated through the use of crude administrative monitors. This is of little solace to the clinician faced with unmet patients' wants and needs. A set of clinical monitors is outlined requiring the practitioner's cooperation. The presentation of an accurate composite picture is a must in the process of resource allocation. Such clinical monitors include the analysis of characteristics of patients such as the repeaters at emergency, "the revolving door" pool of patients and those falling in between networks. Reviews of waiting lists and lengths of stay, an evaluation of nursing care variables, the auditing of the choice of therapeutic modalities and the use of restraints are other suggested contributors to the assessment of service needs.
Canada↗
Placebo-associated blood pressure response and adverse effects in the treatment of hypertension: observations from a Department of Veterans Affairs Cooperative Study.
BACKGROUND: The use of placebo in clinical trials has been vigorously debated. Placebo control may be useful in disease states, such as stage 1 and stage 2 hypertension as defined by the Sixth Report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC VI), in which response rates for placebo are high or close to response rates for effective therapies, or when established interventions have significant adverse effects. OBJECTIVE: To compare rates for the control of blood pressure and adverse effects of placebo vs active treatment in patients with stage 1 and stage 2 hypertension. METHODS: This study is a randomized controlled trial evaluating the blood pressure response and adverse effects of placebo vs 6 active treatments administered in 15 Veterans Affairs hypertension centers. The 1292 subjects of the Veterans Affairs Cooperative Study receiving single-drug therapy for hypertension were randomly allocated to receive treatment with 1 of 6 active drugs (n= 1105) or placebo (n=187). Treatment success was defined as maintaining a diastolic blood pressure of less than 95 mm Hg for at least 1 year. We compared treatment success rates for the control of blood pressure and adverse effects of placebo vs active treatment. Using the Kaplan-Meier method, we also compared rates of discontinuation from placebo vs active drug treatment over time as a result of adverse drug effects and blood pressure exceeding safety limits. RESULTS: At the end of the titration phase, 58 patients who were treated with placebo (31%) achieved a goal diastolic blood pressure lower than 90 mm Hg and 57 (30%) achieved success at 1 year. Older white patients who received placebo had a success rate of 38% vs 23% to 27% for the other age-race subgroups. The rates of discontinuation as a result of adverse drug effects were 13% for patients receiving placebo vs 12% for patients receiving active treatment (P=.40). The rates of discontinuation for blood pressure being too high were 14% for patients receiving placebo vs 7% for patients receiving active treatment (P=.01). CONCLUSIONS: Placebo control provides an important benchmark for both efficacy and adverse effects. It continues to have an appropriate place in certain therapeutic trials, particularly those involving the treatment of stage 1 and stage 2 hypertension.
Adult↗
Psychiatrists' duties in discharging sicker and potentially violent inpatients in the managed care era.
Psychiatrists have certain clinical responsibilities and legal duties to patients treated in managed care settings. They include disclosure of all treatment options, the exercise of rights of appeal for any care they believe will materially benefit patients regardless of allocation guidelines or gatekeeper directives, continuance of emergency treatment, and reasonable cooperation with utilization reviewers. An additional duty--to warn and protect endangered third parties--will likely increase as cost-containment measures curtail the length of hospitalization. The author discusses these duties in the context of sicker and potentially violent patients. He cautions psychiatrists to be careful not to prematurely discharge these patients because of pressures from managed care organizations. The policies of such organizations can place psychiatrists and patients in a precarious position by limiting the time and resources for diagnosis and the assessment of the risk of potential violence. These responsibilities and duties often can be turned into clinical opportunities that enhance the therapeutic alliance with patients.
Disclosure↗
Chemotherapy versus tamoxifen versus chemotherapy plus tamoxifen in node-positive, oestrogen-receptor positive breast cancer patients. An update at 7 years of the 1st GROCTA (Breast Cancer Adjuvant Chemo-Hormone Therapy Cooperative Group) trial.
504 evaluable node positive oestrogen receptor (ER) positive breast cancer patients were randomly allocated to receive either 5 years tamoxifen treatment or chemotherapy [six courses of cyclophosphamide, methotrexate and 5-fluorouracil (CMF) followed by 4 courses of epirubicin] or a combination of both treatments. At a median follow-up of 5 years tamoxifen appeared to be more effective than chemotherapy, the difference being highly significant in postmenopausal women. The addition of chemotherapy to tamoxifen was not able to significantly improve the results achieved by tamoxifen alone, irrespective of menopausal status. Trends were similar even after stratification for the number of involved nodes. The protective effect of tamoxifen in terms of reduction of the odds of death increased with time and no rebound phenomena on recurrence or death has occurred so far after the completion of tamoxifen treatment. Overall, the prognostic value of number of involved nodes and of progesterone receptor (PgR) status was confirmed by multivariate analysis. However, the predictive value of PgR was lost in patients receiving tamoxifen alone. Similarly, the degree of ER positivity was not predictive of the response to tamoxifen. Tamoxifen treatment should still be regarded as the gold standard for postmenopausal ER positive patients. In younger women the antioestrogen proved to be safe and at least as effective as chemotherapy. However, the analysis of the annual risks suggests that the concurrent or the sequential use of chemotherapy and tamoxifen might represent a more appropriate treatment for this patient subset, particularly for those with four or more involved nodes. Different cut-offs of ER and PgR assays from those we have arbitrarily employed in the present analysis should probably be used to select more properly the patients who can benefit from endocrine therapy.
Adult↗
Preparedness and response to terrorism: a framework for public health action.
UNLABELLED: Political group violence in the form of terrorist actions has become a reality worldwide, affecting the health and economies of populations. As a consequence, preparedness and response are becoming an integral part of public health action. Risk appraisal, preservation of human and civil rights and communications within and between countries are all issues to be considered in the process. The combination of the natural history of terrorist actions and the epidemiological triangle model has been adapted in this paper and suggested as a comprehensive approach for preparedness and action. It covers preparedness (pre-event), response (event) and the consequences (post-event) of a terrorist attack. It takes into account the human factor, vectors and environment involved in each one of the phases. KEY POINTS: Terrorism is a global reality with varying underlying causes, manifestations and impact on the health of the public. Preparedness, response and rehabilitation are an integral part of public health action. Consideration of the pre-event, event and post-event phases in terrorist actions, together with the human factor, vector/agent and environment in each of these phases, offers a framework for public health preparedness, response and rehabilitation. Planning should consider risk assessment, risk communication, inter-sectorial cooperation, enactment of laws and regulations which consider protection of the public's health and civil liberties. Allocation of resources would need to make allowance for maintenance and development of ongoing public health activities.
Civil Rights↗
retrospective analysis of topoisomerase IIa amplifications and deletions as predictive markers in primary breast cancer patients randomly assigned to cyclophosphamide, methotrexate, and fluorouracil or cyclophosphamide, epirubicin, and fluorouracil: Danish Breast Cancer Cooperative Group.
PURPOSE: The aim of the study was to evaluate the predictive value of HER2 and topoisomerase IIalpha gene (TOP2A) for the efficacy of epirubicin in the adjuvant setting of breast cancer patients. PATIENTS AND METHODS: In the Danish Breast Cancer Cooperative Group trial 89D, 980 pre- and postmenopausal primary patients were randomly allocated to either CMF (cyclophosphamide, methotrexate, and fluorouracil; n = 500) or CEF (cyclophosphamide, epirubicin, and fluorouracil; n = 480) times 9, between January 1990 and November 1999. Tumor tissue was retrospectively identified from 805 patients and was analyzed for HER2-positivity and for TOP2A-amplifications and deletions. RESULTS: HER2-positivity was found in 33% of the 805 investigated tumors and was not a predictive marker for epirubicin sensitivity. TOP2A changes were identified in 23% of the 773 investigated tumors: 12% had TOP2A amplifications and 11% had TOP2A deletions. We found that patients with TOP2A amplification had an increased recurrence-free (RFS; hazard ratio [HR], 0.43; 95% CI, 0.24 to 0.78) and overall survival (OS; HR, 0.57; 95% CI, 0.29 to 1.13), respectively if treated with CEF compared with CMF, and that patients with TOP2A deletions had an almost identical hazard ratio (RFS: HR, 0.63; 95% CI, 0.36 to 1.11; OS: HR, 0.56; 95% CI, 0.30 to 1.04). This is in contrast to patients with a normal TOP2A genotype for whom similar outcome was observed in both treatment arms (RFS: HR, 0.90; 95% CI, 0.70 to 1.17; OS: HR, 0.88; 95% CI, 0.66 to 1.17). CONCLUSION: TOP2A amplification-and possibly deletion-seems to be predictive markers for the effect of adjuvant epirubicin containing therapy in primary breast cancer, but a final conclusion has to await a confirmative study or a meta-analysis.
Antigens, Neoplasm↗
Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly.
OBJECTIVE: To investigate the relation between mortality and treated systolic and diastolic blood pressures. DESIGN: Randomised double blind placebo controlled trial. Mortality in the two treatment groups was examined in thirds of treated systolic and diastolic blood pressures. PATIENTS: 339 And 352 patients allocated to placebo and active treatment, respectively. The groups were similar at randomisation in sex ratio (70% women), mean age (71.5 years), blood pressure (182/101 mm Hg), and proportion of patients with cardiovascular complications (35%). MEASUREMENTS AND MAIN RESULTS: In the placebo group total mortality rose with increasing systolic pressure whereas it had a U shaped relation with diastolic pressure, the total lowest mortality being in patients in the middle third of the distribution of diastolic pressure. In the group given active treatment total mortality showed a U shaped relation with systolic pressure and an inverse association with treated diastolic pressure. In both groups cardiovascular and non-cardiovascular mortality followed the same trends as total mortality. The increased mortality in the lowest thirds of pressure was not associated with an increased proportion of patients with cardiovascular complications at randomisation or with a fall in diastolic pressure exceeding the median fall in pressure in each group. In contrast, patients in the lowest thirds of pressure showed greater decreases in body weight and haemoglobin concentration than those in the middle and upper thirds of pressure. CONCLUSIONS: In patients taking active treatment total mortality was increased in the lowest thirds of treated systolic and diastolic blood pressures. This increased mortality is not necessarily explained by an exaggerated reduction in pressure induced by drugs as for diastolic pressure a U shaped relation also existed during treatment with placebo. In addition, patients in the lowest thirds of systolic and diastolic pressures were characterised by decreases in body weight and haemoglobin concentration, and the patients in the lowest thirds of diastolic pressure taking active treatment also by an increased non-cardiovascular mortality, suggesting some deterioration of general health.
Aged↗
Begging and sibling competition: how should offspring respond to their rivals?
Godfray's influential model of competitive begging predicted that offspring should respond to each other's behavior, displaying more intensely when competing with needier rivals. Empirical tests of this prediction have, however, yielded equivocal results. Here, I develop a series of evolutionarily stable strategy models of begging as a signal of need, which show that this prediction holds only for competitive aspects of display that influence the division of food among the brood. No such response is expected for cooperative begging (which influences the total level of provisioning by the parent), and the models even predict the opposite trend under some circumstances (where the indirect costs of extracting additional resources from the parent are high). These contrasting sets of predictions may help to explain the varying empirical results obtained by studies of sibling interaction. Cooperative (as opposed to competitive) begging is likely to be of greater significance in cases where dominant young can gain direct control of allocation (or enjoy some competitive advantage). Dominants are then predicted to parasitize the efforts of their weaker rivals and reduce their own investment in cooperative signaling while continuing to claim a disproportionately large share of the resources provided by the parent.
Animal Communication↗
[Allocation of responsibility for positioning patients for surgery and liability for damages consequent on faulty positioning].
The cooperation of surgeon and anaesthetist in positioning of the patient is subject to the principles of horizontal division of labour recognized in the interdisciplinary agreement and confirmed by the legislature: anaesthetist and surgeon carry out their respective tasks independently of each other, each bearing full responsibility for their own work (principle of strict separation of functions), they tailor their procedures to fit in with each other (duty of coordination), and each is entitled to expect and rely on due care in the other (principle of trust). In the case of conflict--when the best position for the specific intervention leads to a higher anaesthesiological risk--the principle of predominance of the actual requirements applies. If no agreement is reached it is incumbent on the surgeon to make the decision; this means that the surgeon bears the medical and legal responsibility for appropriate deliberation. Faults in organization are regarded under the law as faulty treatment. Anaesthetist and surgeon are each responsible for their own errors. According to the interdisciplinary agreements, positioning and checks on position are the task of the surgeon, while the anaesthetist is responsible for the "infusion arm". This does not exclude the possibility that anaesthetist and surgeon may agree on a different division of labour in the operating room. The patient bears the burden of proof that errors were committed in a case for damages. The doctor does, however, have to prove that the patient was correctly positioned. The demands of jurisdiction in terms of documentation of the positioning and of presentation of evidence are practically oriented and can basically be met. The same is true of the information supplied to the patient on the risk that positioning can cause harm. The doctor is obliged to supply evidence of the patient's substantive consent and the provision of information that this implies.
Anesthesia↗
Compliance of Victorian dairy farmers with current calf rearing recommendations for control of Johne's disease.
Questionnaires were posted to 800 randomly selected registered Victorian dairy farmers in 1996. Five hundred and thirty-four responses were received and analysed. Johne's disease (JD) had been diagnosed on the farm of 13.2% of respondents in the last 5 years. JD was rated second only to neonatal diarrhoea in importance as a disease of calves, even though other diseases occurred more frequently. However, there was a low level of compliance with JD control recommendations by the respondents. There was no significant difference in the number of JD control recommendations adopted by farmers between the three major Victorian regions. There was a significant difference in compliance between farms having had a diagnosed case of JD and those that had not. Although there is awareness among dairy farmers of the importance of JD, there appears to be a poor implementation of measures by farmers to prevent the spread of the disease. Current JD control recommendations and the method of information transfer to Victorian dairy farms should be reassessed to ensure that dairy heifers are reared with minimal risk of transmission of JD.
Animals↗
The team halo effect: why teams are not blamed for their failures.
In this study, the existence of the team halo effect, the phenomenon that teams tend not to be blamed for their failures, is documented. With 2 studies using both real teams and controlled scenarios, the authors found evidence that the nature of the causal attribution processes used to diagnose failure scenarios leads to individuals being more likely to be identified as the cause of team failure than the team as a collective. Team schema development, as indexed by team experience, influences this effect, with individuals who have more team experience being less likely to show the team halo effect
Cooperative Behavior↗
Engaging men as social justice allies in ending violence against women: evidence for a social norms approach.
The field of sexual assault prevention is shifting attention to educational interventions that address the role of men in ending violence against women. Recent studies document the often-misperceived norms men hold about other men's endorsement of rape-supportive attitudes and behaviors. The authors provide further evidence supporting the design of population-based social norms interventions to prevent sexual assault. Data from this study suggest that men underestimate the importance that most men and women place on consent and willingness of most men to intervene against sexual violence. In addition, men's personal adherence to only consensual activity and their willingness to act as women's allies are strongly influenced by their perceptions of other men's and women's norms. These findings support the proposition that accurate normative data, which counters the misperception of rape-supportive environments, can be a critical part of comprehensive campus efforts to catalyze and support men's development as women's social justice allies in preventing sexual violence against women.
Cooperative Behavior↗
Co-operation not confrontation: imperative of the nuclear age. Report on the Fifth Congress of International Physicians for the Prevention of Nuclear War.
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Humans↗
A time to sequence.
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Chromosome Mapping↗
Shared impression formation in the cognitively interdependent dyad.
We examined the role of cognitive interdependence in determining how close friends form shared impressions of another person. Cognitive interdependence should provide a processing advantage, such that close friends are more efficient in forming shared impressions and are more successful at doing so. Under normal circumstances, the conversations of close friends should be marked by little necessity to make explicit requests for information, mutual recognition of who currently is controlling the flow of conversation, and willingness to express differences in opinion. Given these advantages, close friends also should be able to form complex shared impressions that go beyond mere one-sided stereotypic judgments and that instead resolve apparent discrepancies in the target's personality. However, if the cognitive interdependence system is disrupted by mutual distraction, these advantages should attenuate or even reverse. Dyads of varying degrees of closeness were mutually distracted or not while discussing their impressions of another female college student. Results supported predictions and are discussed with reference to how cognitive interdependence may help close dyads function within their mutual social networks.
Attitude↗
Product line cost estimation: a standard cost approach.
Product line managers often must make decisions based on inaccurate cost information. A method is needed to determine costs more accurately. By using a standard costing model, product line managers can better estimate the cost of intermediate and end products, and hence better estimate the costs of the product line.
Accounting↗
Health and human rights.
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Delivery of Health Care↗