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PubMedDate not supplied

Endovascular aortic aneurysm repair by a multidisciplinary team: lessons learned and six-year clinical update.

BACKGROUND: Endovascular aneurysm repair (EVAR) (using an Federal Drug Association-approved AneuRx device) compared to conventional surgical repair of abdominal aortic aneurysm (AAA) previously rendered favourable outcomes regarding post-operative pain, avoidance of laparotomy, and rapid rehabilitation and hospital discharge in high-risk patients, including octagenarians. OBJECTIVES: To assess the safety, reduction in aneurysm-related deaths, and interim survival data up to 72 months after AAA exclusion by endoluminal endografts (EVAR). DESIGN: We carried out an open, controlled, prospective, multidisciplinary EVAR study for the period 1998 to 2003 (six years). In the earlier part of the study, EVAR was compared with previously published results of conventional open aneurysmectomy surgery. SETTING: Heart Unit, Panorama Medi-Clinic, Parow, South Africa. PARTICIPANTS: We recruited adult male and female patients presenting with AAA and fulfilling the inclusion criteria for endovascular repair, as recommended by the consensus 2003 meeting of the Vascular Association of South Africa (VASSA). All patients were offered open surgery as an alternative and were entered into the VASSA EVAR trial registry. Pre-operatively, AAA anatomy was assessed by spiral-computed tomography (CT), and selectively with conventional angiography and intravascular ultrasound (IVUS). Informed consent was obtained in accordance with the recommendations of the Senate of Surgery Paper 2, Ethical Guidelines, Great Britain and Ireland. Patients underwent EVAR by a multidisciplinary interventional team. INTERVENTIONS: Two hundred and seven adult patients with AAA were assessed. Forty-four of the 207 (21.2%) were excluded from EVAR because of irreversible comorbid factors and complex aneurysm morphology. One hundred and sixty-three patients (78%), with a mean age of 70.7 years (range 60-91 years), underwent EVAR (1998-2003). Five patients were lost to follow-up (3%). Median AAA diameter was 56.9 mm and ASA ratings were I, 1.2%; II, 15.9%; III, 57%; IV, 22.6%; and V, 2.4%. EVAR was performed in high- and low-risk categories of both sexes. Most patients were in ASA groups III and IV. DEVICES DEPLOYED: EVAR was performed using a selection of endografts over 72 months- AneuRx (Medtronic) 47; Talent (Medtronic) 49; Vanguard three; Zenith (Cook) one; Powerlink (Endologix) 62; and other, one. RESULTS: Thirty-day outcome: successful deployment 99%, primary stent patency 97%, surgical conversion 0.6%, procedural or intra-operative mortality 1.2%, 30-day mortality 4.3%, endoleaks 1.84%, and secondary intraprocedural endovascular interventions 24.5%. Perioperative mortality was 3.1% (one aneurysm related). One patient had suspected endograft infection. Late mortality was 21.4% (35 patients due to co-morbidities, and one was aneurysm related). Follow-up was a median of 28.3 months (range 1-69 months). In 163 patients, two persisting endoleaks (1.2%) were detected. Endotension was detected in 3/163 (1.8%) with average sac increase of 0.8 cm. Conversion to open surgery was needed in one patient (0.6%). Co-morbidities that contributed to late mortality included multi-organ failure, ischaemic heart disease (IHD), cardiomyopathy, renal failure, stroke and cancer. One procedural rupture was fatal (0.6%). Two late ruptures occurred; one was successfully endostented and the other patient died after a failed surgical intervention (0.6%). Endovascular repair of AAA is more expensive than conventional surgery. Introduction of the Endologix stent has reduced operative time from 120 to 60 minutes in un complicated patients. Newer-generation aortic stents allow better control of negative remodeling and stent migration. CONCLUSION: A multidisciplinary team can safely perform EVAR, with a low 30-day mortality rate in selected patients graded ASA II-IV and with favourable aortic aneurysm morphology. About 22% of patients with AAA are not suited for EVAR. Persisting late endoleaks occurred in 1.2% of the cohort study and were not device specific. Life-long follow-up post EVAR is a prerequisite to detect late device failure, endoleaks and aneurysm-sac enlargement, and to assure the durability of these midterm results. Short-term aneurysm rupture prevention is a predictable outcome in high-risk groups.

Aged↗
PubMed2006

Assessing clinical competence: a pilot project to evaluate the feasibility of a standardized patient -- based practical examination as a component of the Swiss certification process.

PURPOSE: advances in the assessment of clinical competence have prompted medical schools and licensing authorities to complement written and oral tests with practical ones. The purposes of this project were to (1) determine how clinical competencies not effectively addressed on the present Swiss federal examinations can be assessed adequately on a standardised patient-based practical examination (SCE) and (2) evaluate the SCE validity, reliability and feasibility. METHOD: a bilingual, three-hour standardised patient-based clinical examination was pilot tested in 2003 with 48 volunteered fifth and sixth-year students from the five Swiss medical schools. All students took the same eight 15-minute patient cases. To ensure the test content validity, test cases were selected by a multi-disciplinary and -institutional committee of clinical faculty on the basis of predefined exam blueprint criteria and in reference to the Swiss catalogue of learning objectives. RESULTS: moderate correlations between the SCE and the existing Federal final written examinations (0.46) and the newly pilot-tested structured oral examination or SOE (0.56) [3] suggested that they were complementary to one another and that each might emphasise aspects of the clinical competence which others might not. The reliability (a coefficient) of the SCE scores ranged from 0.73 to 0.77. CONCLUSIONS: limited experiences gathered throughout the SCE pilot project demonstrated its feasibility. Preliminary results suggested that SCE scores had a good level of construct validity and reliability and seemed to complement scores obtained on the final certification written examinations and the newly tested SOE. These results, however, need to be further confirmed with larger samples studies.

Certification↗
PubMed1996

An extensible network query unification system for biological databases.

Database federation enables biological researchers to utilize resources more effectively, creating an environment in which the researcher can query multiple data sources without spending time learning new query mechanisms or issuing redundant queries which need to be integrated. Several mechanisms exist to federate databases. The ENQUire system is a network database federation system which uses a World-Wide-Web (WWW) interface to connect the users to various databases. Generic queries entered via a query generator form are sent in parallel to multiple databases, and the results are presented to the user in a unified format. All forms building, query generation, and results translation is done on the fly, and individual database translation modules can be added dynamically. ENQUire is a flexible answer to the problems of database federation on the WWW.

Computer Communication Networks↗
PubMedDate not supplied

Nurses and Public Law 102-119: a family-centered continuing education program.

The passage of Part H of the Education of the Handicapped Act, Public Law 99-457, and the reauthorization of the law in 1991, as Public Law 102-119, mandates a family-centered approach to the provision of services to infants and young children with handicaps. Nurses are named as providers in this federal legislation. The authors conducted a survey to assess the learning needs of nurses who may wish to serve as providers under the law. The survey results were used to develop a family-centered continuing education curriculum that pairs parents and nurse faculty as partners in delivering the curriculum.

Attitude of Health Personnel↗
PubMed2004

Cultural competency as it intersects with racial/ethnic, linguistic, and class disparities in managed healthcare organizations.

Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, limited proficiency in English, culture-specific values regarding the authority of the physician, and poor assertiveness skills. These dimensions require attention in Medicaid managed care settings. However, the promise of better-coordinated and higher quality care for low-income and working-poor racial/ethnic populations--at a lower cost to government--has yet to be fully realized. This paper identifies strategies to reduce disparities in access to healthcare that call for partnerships across government agencies and between federal and state governments, provider institutions, and community organizations. Lessons learned from successful precedents must drive the development of new programs in Medicaid managed care organizations (MCOs) to reduce disparities. Collection of population-based data and analyses by race, ethnicity, education level, and patient's primary language are critical steps for MCOs to better understand their patients' healthcare status and improve their care. Research and experience have shown that by acknowledging the unique healthcare conditions of low-income racial and ethnic minority populations and by recruiting and hiring primary care providers who have a commitment to treat underserved populations, costs are reduced and patients are more satisfied with the quality of care.

Cost Control↗
PubMed2006

Establishing and refining hurricane response systems for long-term care facilities.

In February 2006 the John A. Hartford Foundation funded a long-term care "Hurricane Summit," sponsored by the Florida Health Care Association. Representatives from five Gulf Coast states that sustained hurricane damage during 2005 and from Georgia, a receiving state for hurricane evacuees, attended. Summit participants evaluated disaster preparedness, response, and recovery for long-term care provider networks and identified gaps that impeded safe resident evacuation and disaster response. The meeting identified emergency response system issues that require coordination between long-term care providers and state and federal emergency operations centers. Five areas warranting further attention are presented as lessons learned and potential areas for grant making.

Congresses as Topic↗
PubMed2003

Learning through public involvement in environmental assessment hearings.

This research examined the opportunities for critical education available to participants of a federal environmental assessment (EA) that includes hearings. The Sable Gas Panel Review, an assessment of a natural gas project situated in the Maritimes, was undertaken between 1996 and 1997. This study documented what participants learned through their experiences and how that learning was facilitated. Primary data collection emphasized the use of semi-structured interviews to record the experientially based observations of panel participants. Primary data were supported by a review of material submitted by hearing participants for consideration by the panel, and complemented with literature related to EA, environmental education, and transformational learning theories. Evidence was considered in terms of assessment-specific operational definitions, developed from Shor (1993) [Education is politics: Paulo Freire's Critical Pedagogy. In: McLaren, P., Leonard, P. (Eds.), Paulo Freire : A critical Encounter, Routledge, New York, pp. 25-35] ten indicators of critical education. The study revealed that participants of the Sable Gas panel review had an opportunity to engage in critical education. While it is important to acknowledge that the panel did not set out to engage participants in a 'critical educational' experience, each of the 10 operational definitions of critical education used in the study were addressed to varying degrees through activities undertaken by the panel secretariat. Results illustrate the types of educational opportunities, such as a class on how to participate in a quasi-judicial hearing, and the importance of participant-led research that can arise out of the panel review process. The findings of this research contribute to the evolving literature regarding the role of critical education in EA and environmental management. Understanding the existing scope of critical education within a panel review provides the foundation for identifying opportunities for expanding the capacity of the existing EA process to facilitate learning by participants.

Community Participation↗
PubMed2004

Ethics, regulation, and biomedical research.

Controversy has surrounded the institutions that facilitate discussion and regulation of American biomedical research for years. Recent challenges to the legitimacy of the President's Council on Bioethics have been focused on stem cell research. These arguments represent an opportunity to reconsider the legislation under which stem cell research is regulated, as well as to consider preexisting bodies like the Recombinant DNA Advisory Committee and National Bioethics Advisory Commission. This paper proposes a Federal Life Sciences Policy Commission, a novel commission with advisory and regulatory powers that would benefit from the positive and negative lessons learned under the legislation that currently shapes the formation and institutional characteristics of advisory bodies in the United States. The Federal Life Sciences Policy Commission would have institutional independence not present in previous advisory bodies, while maintaining the tradition of broad societal representation and thoughtful discourse that has developed in the United States.

Advisory Committees↗
PubMed2000

Variability in mammography screening legislation across the states.

Before passage of the Federal legislation, National Breast and Cervical Cancer Screening Act (NBCCSA) in 1991, over half the states (65%) had preexisting laws requiring health insurers, for example, Blue Cross/Blue Shield and HMOs, to provide services beyond the federal coverage for mammography screening and care following breast cancer. This study examined mammography screening legislation across the states. Data were derived from telephone interviews with six NBCCSA program directors or coordinators from July 1999 to October 1999. A review of existing documents from the Institute for Women's Policy Research, online data from the Centers for Disease Control and Prevention, and state laws provided by the Governmental Affairs Division of the American Cancer Society was undertaken. There was considerable variability in relation to factors potentially related to the extent of state laws. The states with the lowest age-adjusted breast cancer mortality rates among black women had the least comprehensive state legislation. Several states with the least percent of women above the federal poverty threshold also had the least comprehensive legislation. Some states had a wide gap between the provision of health insurance coverage and scope of legislation to ensure care following breast cancer. Some states were more aggressive in their efforts to ensure care following breast malignancy at diagnosis. Lessons could be learned by states that enacted the least comprehensive legislation. With the passage of the federal legislation nearly a decade ago, more women are receiving timely and available mammography screening, resulting in earlier diagnosis of breast cancer. Greater efforts must be undertaken by all states to provide the full array of breast cancer treatment for women in the millennium.

Adult↗
PubMedDate not supplied

Survey results of reduced-fee and free-of-charge dental services by the membership of the Federation of Special Care Organizations in Dentistry.

In 1996, a questionnaire was mailed to all members of the Federation of Special Care Organizations in Dentistry (FSCO) in an attempt to learn more about their professional practices. Questions focused primarily on the amount of free and reduced-fee dentistry that the membership provided to the public. The questionnaire asked respondents to identify their field of practice; estimate the amount of time, the number of patients, and the monetary value of the dentistry provided; as well as to classify the types of patients to whom they provided these dental services for free or at reduced fees. Each of the FSCO respondents reported providing an average of $14,820 in free dentistry in 1995. Not surprisingly, the respondents reported treating a significant number of special-needs patients. Members also reported spending 31.0% of their clinical time working at reduced fees and 7.4% of the time working for free. This questionnaire revealed that the Federation of Special Care member respondents are donating a significant amount of dentistry and treating a large segment of special-needs patients.

Aged↗
PubMed1999

The role of the medical examiner in mass casualty situations with special reference to the Alfred P. Murrah Building bombing.

OBJECTIVE: To describe the events that shaped the investigation by the Oklahoma Office of the Chief Medical Examiner with regard to the terrorist bombing of the Alfred P. Murrah Federal Building in Oklahoma City in 1995 and to provide lessons learned for reinforcement and future planning. STUDY POPULATION: All persons known to have been killed by the blast. METHODS: Standard forensic techniques with regard to crime scene investigation, documentation, body identification and cause of death determinations were followed. MAIN OUTCOME MEASURES: Fatality injury and related evidence documentation. RESULTS: A total of 168 people died principally from secondary and tertiary injuries caused by projectiles, victim displacement, and crushing. Emphasis is placed on the methods of operation required to find, remove, identify, and determine cause of death in these individuals. Simultaneously, evidence must be identified and preserved in a homicide investigation of this type. Close cooperation must exist among multiple varied agencies and disciplines to accomplish the task and to prepare for subsequent analysis and courtroom testimony required by the criminal justice system. CONCLUSIONS: Terrorism, both foreign and domestic, is a current fact and will be a problem in many forms in the 21st century. No one is immune. The key to success is to plan ahead and be aware of available resources. Preplanning for short comings and difficult issues, and most importantly, relying on team work will allow future participants to successfully meet and complete the challenge. The investigation developed detailed injury data and mechanisms that were available for subsequent judicial proceedings and for in-depth epidemiological studies spearheaded by the Injury Prevention Service of the Oklahoma State Department of Health.

Coroners and Medical Examiners↗
PubMedDate not supplied

Coming to terms with the "otherwise qualified" student with a learning disability.

Section 504 of the Rehabilitation Act of 1973 ensures all "otherwise qualified" individuals with handicaps the right to higher education. Federal regulations implementing the broad principles of Section 504 address only obliquely the interpretation of the construct "otherwise qualified." The determination of the qualified individual with a handicap in higher education entails unique consideration when applied to students with learning disabilities. In a setting traditionally based on academic merit and competition, the student with a learning disability requires accommodation of the learning process. Postsecondary institutions are faced with the task of determining the qualified student while maintaining academic standards. To clarify this process, existing tenets of the construct "otherwise qualified" were examined. Issues in implementing the law with students with learning disabilities were discussed, and current practice in addressing the issues was evaluated in light of legal principles. Guidelines were proposed for implementing the construct "otherwise qualified" with students with learning disabilities in higher education.

Persons with Disabilities↗
PubMed1995

The learning disabled optometry student: compliance with Section 504 of the Rehabilitation Act of 1973.

Section 504 of the Rehabilitation Act of 1973 is an antidiscrimination law that covers those persons with handicaps who are otherwise qualified to participate in and benefit from the programs or activities receiving Federal financial assistance. This article discusses the qualified handicapped applicant, especially individuals who have been identified as learning disabled, who meets the academic and technical standards requisite to admission to a school or college of optometry. The learning characteristics and handicaps that have been associated with this disability are discussed. The "reasonable accommodations" that educational institutions are expected (and not expected) to provide students are explained. Results of a survey of 15 colleges of optometry revealed that there are numerous inconsistencies in compliance with Section 504 involving reasonable accommodations in the classroom, clinic, and testing procedures involving learning disabled professional students. Recommendations to improve required services are proposed.

Persons with Disabilities↗
PubMed2004

Shriners Hospitals for Children, Honolulu's experience with telemedicine: program implementation, maintenance, growth, and lessons learned.

Shriners Hospitals for Children, Honolulu Telemedicine Program conducts real-time video consultations with remotes sites in Hawaii, Guam, Saipan, American Samoa, the Federated States of Micronesia, and the Republic of the Marshall Islands. The program began in 1999 and has provided over 240 consultations. This report is a summary of the Shriners Hospitals experience and lessons learned regarding program implementation and maintenance.

Child↗
PubMed1996

Tobacco farmers and diversification: opportunities and barriers.

OBJECTIVE: To assess the knowledge, attitudes, and behaviours of tobacco growers and allotment owners in the southeastern United States. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Tobacco growers (n = 529) and tobacco allotment owners (n = 417) were interviewed by telephone in March 1995. SETTING: Tobacco growing states in the southeastern US. MAIN OUTCOME MEASURES: Attitudes of tobacco growers and tobacco allotment owners towards, and experience with, diversification; and attitudes towards an increase in the federal excise tax on tobacco. RESULTS: Half of the respondents had done something to learn about on-farm alternatives to tobacco, had an interest in trying other on-farm ventures to supplement tobacco income, and found alternatives that were profitable. There was a strong, negative linear trend between age and being interested in or trying alternative enterprises. Structural and economic impediments to diversification were noted by respondents (especially younger respondents), but 73% supported an increase in the federal excise tax on tobacco if the money was used to help farmers overcome these barriers. CONCLUSIONS: These data suggest that farmers and health professionals have reason to establish dialogue around diversification and using excise tax increases to fund diversification and to promote health. Tobacco companies have been successful in mobilising farmers against tax increases, but efforts must be made to show farmers that tax increases can be beneficial both to their diversification efforts and to public health. The outcome of this dialogue may well affect the economic infrastructure of thousands of rural communities, the livelihood of tens of thousands of tobacco farmers and their families, and the health of millions of tobacco users.

Adult↗
PubMed1999

Order of selection in vocational rehabilitation: implications for the transition from school to adult outcomes for youths with learning disabilities.

Interagency cooperation between special education and vocational rehabilitation (VR) is central to ensuring the continuity of services to young adults with disabilities who are in transition from school to adult living. However, the interface between special education and VR may be complicated by order of selection, an equally binding mandate in federal VR policy to provide priority services to individuals with the most severe disabilities. Because students with learning disabilities are typically perceived as having mild rather than severe disabilities, these youths are most at risk for falling through the cracks in the service landscape once they leave the school setting in states where the VR agency is implementing an order of selection procedure. This article identifies and discusses common impediments to collaborative transition planning for students with learning disabilities that may be intensified when the state VR agency is operating under an order of selection plan. Recommendations are provided to facilitate greater interagency cooperation among schools and VR agencies so that transition planning and implementation for students with learning disabilities is not subverted as a result of the order of selection mandate.

Journal Article↗
PubMed2004

Using our best judgment in conducting human research.

The federal regulations of human research were written to permit the use of discretion so that research can fit the circumstances under which it is conducted. For example, the researcher and institutional review board (IRB) could waive or alter some informed consent elements if they deem this the morally and scientifically best way to conduct the research. To do so, however, researchers and IRBs would first have to use mature moral and scientific judgment. They might also have to rely on empirical research to discover the most effective way to act on their moral sense (e.g., to discover how best to approach potential research participants and explain the nature and purpose of the research participation for which they are being recruited, to ensure comprehension and competent decision making). On discovering the most ethical way to proceed, they would then need to look to the federal regulations of human research to discover how to document their decision and justify it within that somewhat flexible regulatory structure. Unfortunately, many IRBs and researchers fail to take these sensible steps to solve ethical problems and proceed immediately to a default requirement of the regulations that places science at odds with the regulations and, ostensibly, with ethics. The following articles in this special issue are about the process of learning to engage in ethical problem solving and using the flexibility permitted by the federal regulations. These articles extricate researchers from the mindset that has gotten them into trouble, and, ideally, provoke them to use mature common sense and moral judgment.

Behavioral Research↗
PubMed2004

Lost in Translation: Obstacles to Translational Medicine.

When we launched the Journal of Translational Medicine a few months ago, we were interested primarily in exploring scientific consideration of this discipline. However, as editors of JTM, we have been contacted almost daily to discuss the problems faced by scientists and clinicians around the world who are challenging the traditional boundaries of science and medicine. Through these conversations, we have learned that translational medicine is in fact "lost in translation," inspiring much angst, many promises and some Federal appropriations. However, little has been done to substantively promote this important field. Authoritative reviews on the subject are available to the interested reader 1234567. In this article, we will address JTM's "constituency" to report what we've learned about the obstacles to translational medicine from the myriad of phone conversations and e-mail interactions.

Editorial↗