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PubMed2002

Noninvasive measurement of iron: report of an NIDDK workshop.

An international workshop on the noninvasive measurement of iron was conducted by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) on April 17, 2001, to assess the current state of the science and to identify areas needing further investigation. The workshop concluded that a clear clinical need is evident for quantitative, noninvasive, safe, accurate, and readily available means of measuring body storage iron to improve the diagnosis and management of patients with iron overload from such disorders as hereditary hemochromatosis, thalassemia major, sickle cell disease, aplastic anemia, and myelodysplasia, among others. Magnetic resonance imaging (MRI) potentially provides the best available technique for examining the 3-dimensional distribution of excess iron in the body, but further research is needed to develop means of making measurements quantitative. Biomagnetic susceptometry provides the only noninvasive method to measure tissue iron stores that has been calibrated, validated, and used in clinical studies, but the complexity, cost, and technical demands of the liquid-helium-cooled superconducting instruments required at present have restricted clinical access to the method. The workshop identified basic and clinical research opportunities for deepening our understanding of the physical properties of iron and iron toxicity, for further investigation of MRI as a method for quantitative determinations of tissue iron, especially in liver, heart and brain, and for development of improved methods and more widely available instrumentation for biomagnetic susceptometry.

Diagnostic Imaging↗
PubMed1997

Access to bone marrow transplantation for leukemia and lymphoma: the role of sociodemographic factors.

PURPOSE: Use of bone marrow transplantation (BMT), a complex, costly treatment for many forms of cancers, has increased significantly in recent years. The increasingly competitive health care marketplace raises concerns about patient access to costly medical procedures such as BMT. We attempted to evaluate patient access to BMT for the treatment of leukemias and lymphomas. METHODS: We analyzed inpatient hospital discharge data from four states (California, Maryland, Massachusetts, and New York) for 2 years (1988 and 1991) to examine whether the use of BMT for patients with either leukemia or lymphoma varies by sociodemographic characteristics and insurance coverage. We developed a sorting algorithm to collapse the discharge data into patient level records. We used logistic regression to analyze the odds of receiving a BMT stratified by disease type (leukemia or lymphoma). RESULTS: After controlling for other factors, black patients with leukemia are 51% to 53% as likely as whites, while black patients with lymphoma are 34% to 45% as likely as white patients to undergo a BMT (P < .05). Medicaid, self-pay patients, and Health Maintenance Organization (HMO) enrollees with either leukemia or lymphoma are significantly less likely to undergo a BMT compared with patients with private insurance. Younger patients are significantly more predisposed to undergo a BMT than older patients. The odds of receiving a BMT have increased over time, but the rates of increase vary by state. Consistent with clinical expectations, the relative odds of BMT vary significantly by type of leukemia or lymphoma. CONCLUSION: Substantial variation exists in access to BMT for patients with either leukemia or lymphoma. Black patients, those enrolled in HMOs, those covered by Medicaid, and self-pay patients were less likely to receive a BMT when admitted for either leukemia or lymphoma. These findings raise concerns about access to cancer treatments for patients in the current health care system.

Black or African American↗
PubMed2004

Our once-in-a-lifetime opportunity.

Longitudinal studies of the determinants of children's health are complex, costly, infrequent, and incredibly valuable. It has become clear in recent years that the periconceptional environment plays a surprisingly large role in the health of the resulting child. This short introduction to this mini-monograph briefly recaps the articles included herein and reminds us that adequate forethought and planning will result in a study that could shed new light on the earliest determinants of children's health and thereby fill critical data gaps.

Child↗
PubMed1978

Plants as bioassay systems for monitoring atmospheric pollutants.

Plant species act as natural bioindicators of atmospheric pollutants. Plants can be used as bioassay systems for monitoring atmospheric pollutants. Plant injury symptoms, altered growth and reproductive pattern, changes in yield and/or productivity, and changes in species distribution can be used singly or in combination as monitoring devices. The results must be accepted as semiquantitative, but within that constraint, air quality can be sufficiently well defined to enable the setting of air quality standards. Genetic variability of higher plant species has yielded cultivars which display a range of tolerance to gaseous and particulate atmospheric pollutants. Asexual propagation of these cultivars provides pollutant-sensitive and pollutant-tolerant plant material which can be grown on selected sites for observation. Gymnosperm and Angiosperm species as well as species of lichens and mosses have been used to establish field monitoring networks in Europe, Canada, and the United States. White pine, shade tobacco, mosses, and lichens have proven particularly useful as bioassay tools. Pollen from pollutant-sensitive and pollutant-tolerant plant cultivars has also been used as a sensitive laboratory bioassay tool for studying air quality. Epiphytic mosses are particularly efficient as monitors of particulate pollutants, especially heavy metals, some of which may act as chemical mutagens. The cost, complexity, and lack of reliability of instrumented systems for air quality monitoring make imperative the need to develop successful plant bioassay systems for monitoring air quality.

Air Pollutants↗
PubMed1995

The E-SCREEN assay as a tool to identify estrogens: an update on estrogenic environmental pollutants.

Estrogens are defined by their ability to induce the proliferation of cells of the female genital tract. The wide chemical diversity of estrogenic compounds precludes an accurate prediction of estrogenic activity on the basis of chemical structure. Rodent bioassays are not suited for the large-scale screening of chemicals before their release into the environment because of their cost, complexity, and ethical concerns. The E-SCREEN assay was developed to assess the estrogenicity of environmental chemicals using the proliferative effect of estrogens on their target cells as an end point. This quantitative assay compares the cell number achieved by similar inocula of MCF-7 cells in the absence of estrogens (negative control) and in the presence of 17 beta-estradiol (positive control) and a range of concentrations of chemicals suspected to be estrogenic. Among the compounds tested, several "new" estrogens were found; alkylphenols, phthalates, some PCB congeners and hydroxylated PCBs, and the insecticides dieldrin, endosulfan, and toxaphene were estrogenic by the E-SCREEN assay. In addition, these compounds competed with estradiol for binding to the estrogen receptor and increased the levels of progesterone receptor and pS2 in MCF-7 cells, as expected from estrogen mimics. Recombinant human growth factors (bFGF, EGF, IGF-1) and insulin did not increase in cell yields. The aims of the work summarized in this paper were a) to validate the E-SCREEN assay; b) to screen a variety of chemicals present in the environment to identify those that may be causing reproductive effects in wildlife and humans; c) to assess whether environmental estrogens may act cumulatively; and finally d) to discuss the reliability of this and other assays to screen chemicals for their estrogenicity before they are released into the environment.

Animals↗
PubMedDate not supplied

Body composition measurement: a hierarchy of methods.

The range of methods now available to estimate body composition is extensive. In most cases there is a relationship between cost, complexity and information content. The consequence is that choices can still be made depending on the finances available and the needs of the health professional. This paper reviews four methods ranging in availability and clinical detail. The alternatives are use of skinfolds, electrical impedance, underwater weighing and dual energy X-ray absorptiometry. These should provide the practitioner with viable options to consider in the assessment of body composition. Although no method has been designed specifically for children, reference is made throughout to studies on paediatric subjects of the major issues involved in these methods, which will assist paediatric endocrinologists in making informed decisions.

Adipose Tissue↗
PubMed1992

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 5. General discussion and conclusions.

Part 5 is the final part of a series of five articles reporting on an international, multicenter clinical audit of treatment outcome for complete UCLP. A number of recommendations for the methodology of future studies is made especially with respect to entry criteria, sample size, assumptions of homogeneity, and the reproducibility and validity of outcome measures. The findings of the present study regarding clinical procedures are presented tentatively, and improvement and extension of the methodology are required. It appears, however, that acceptable results can be achieved by different programs and ultimately clinical choices may be based on factors such as complexity, costs, and demands of treatment. Standardization, centralization, and the participation of high volume operators were associated with good outcomes, and nonstandardization and the participation of low volume operators with poor outcomes. Therapeutic factors associated with good outcomes were the employment of a vomer flap to close the anterior palate, and poor outcomes with primary bone grafting and with active presurgical orthopedics.

Bone Transplantation↗
PubMed2005

Antedrugs: an approach to safer drugs.

The antedrug concept was introduced by Lee and Soliman in 1982 in designing potent, yet safer locally active anti-inflammatory steroids. Antedrug is defined as an active synthetic derivative that is designed to undergo biotransformation to the readily excretable inactive form upon entry in the systemic circulation. Thus, are minimizing systemic side effects and are increasing the therapeutic indices. Steroid-21-oate esters have been developed as the first of this kind, which quickly hydrolyzed to the corresponding inactive steroid acids thereby exerting minimal systemic side effects. Later, other steroidal and nonsteroidal antedrugs have also been developed. The cost, complexity and length in development of a new therapeutic drug, in addition to the adverse drug reactions, the potential risk factors causing the withdrawal of the drugs from the market, have made the approach of antedrug design unique and attractive to the scientists involved in drug design. Considering these factors, the concept which strictly designed to eliminate the deleterious adverse systemic effects, is becoming an affordable approach in drug development arena. This review is not intended to be comprehensive; instead the focus will be on the recent advances in steroidal as well as nonsteroidal antedrugs, which appear to offer new leverage to the development of safer and more efficacious therapeutic agents.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

Physiologic evaluation of coronary flow: the role of positron emission tomography.

As the complexity, cost, and risks of cardiac interventions direct attention to careful selection of patients, the ability of diagnostic imaging techniques to provide quantitative documentation of the hemodynamic severity of coronary artery disease will assume greater importance. Among the various techniques currently in use, positron emission tomography yields superior spatial resolution and attenuation correction and has high sensitivity and specificity. The correlation of positron emission tomography results with coronary stenosis severity and the possibility of making quantitative flow measurements using oxygen-15 water suggest that cardiac positron emission tomography may be the best noninvasive approach for diagnostic purposes.

Coronary Angiography↗
PubMed1999

Going the distance: the influence of practice location on the Ontario Maternal Serum Screening Program.

BACKGROUND: The Ontario Maternal Serum Screening (MSS) Program was introduced by the Ontario Ministry of Health as a province-wide pilot project in 1993. The objective of this study was to determine the influence of practice location on Ontario health care providers' use of and opinions regarding MSS, access to follow-up services and recommendations about the program. METHODS: A questionnaire was mailed to a random sample of 2000 family physicians, all 565 obstetricians and all 62 registered midwives in Ontario between November 1994 and March 1995. RESULTS: Among providers who were eligible (those providing antenatal care or attending births) the response rates were 91.4% (778/851), 76.0% (273/359) and 78.0% (46/59) respectively. Fewer respondents in the Northwest region (71.4%) and in rural areas (81.9%) stated that they routinely offer MSS to all pregnant women in their practices compared with respondents in other regions (84.4%-91.5%) and urban centres (90.1%). Fewer respondents in the northern regions (Northeast 49.2%, Northwest 25.0%) than in the Central East region (includes Toronto) (76.6%) felt that follow-up services were readily available. Respondents in the northern regions had less favourable opinions of MSS than those in the other regions in terms of its complexity, cost, the time involved in counselling and the high false-positive rate. More respondents in the Central East region (64.6%) and in urban centres (52.9%) recommended not changing the MSS program than did those in the Northwest (7.1%) and rural areas (39.8%). After provider characteristics were controlled for in a logistic regression analysis, practice location was not the most important factor. Instead, the model showed that respondents who cared for 50 or more pregnant women in the previous year were more likely to offer MSS routinely (OR 2.00, 95% CI 1.21-3.27) and that those who felt that patient characteristics affect the offering of MSS (OR 0.42, 95% CI 0.26-0.67) or that follow-up services were not readily available (OR 0.33, 95% CI 0.20-0.55) were less likely to offer it. INTERPRETATION: Health care providers in northern and rural Ontario were less likely to offer MSS routinely than those in other regions and were more likely to recommend changing or eliminating the program. Providers' concerns about the social and cultural sensitivity of MSS and the availability of follow-up services affected use.

Abnormalities, Multiple↗
PubMed2001

Sharing the IT pain.

Outsourcing info tech is too appealing a temptation for many hospitals to pass up. Information technology is costly, complex, prone to breakdowns and ever-changing. Many hospitals already outsource part of their IT operation, but there appears to be a trend toward outsourcing entire departments. Recently, a number of deals worth hundreds of millions of dollars were announced by some of the nation's largest systems and outsourcing companies. While outsourcing is the best alternative for certain operations, for others it may just be a trade-off between a short-term headache and long-term pain.

Database Management Systems↗
PubMedDate not supplied

Pathophysiology, clinical manifestations and supportive care of metastatic brain cancer.

Brain metastases (BrM) are tumours that originate in tissues outside the central nervous system and spread secondarily to involve mainly the brain. The management of patients with cerebral metastases is complex, costly, and in some instances controversial. Furthermore, even in patients with widespread systemic cancer, the symptoms of the disease are often controllable while the symptoms of the BrM may be disabling. The treatment of BrM is one of the few areas of neuro-oncology where real progress has been made in the last twenty years. Moreover, the costs of managing this disease are rising, as therapies become more intensive and the number of patients with BrM increases. Modern neuroradiological imaging techniques, which are able to discover BrM earlier in the course of systemic cancer, and the greater efficacy of specific treatments, which lengthens survival, have increased the prevalence. The aggressive treatment of BrM may add some benefits to the patient, but its excessive cost leads to the necessity for accurate cost-effectiveness analysis. The latter begins with a complete understanding of the disease: its diagnosis, natural history and results of various modalities of treatment. While the development of BrM usually indicates a poor prognosis for the patient, advances in supportive care have made it possible to reverse most of the neurological symptoms and to give patients a meaningful extension of useful life.

Brain Neoplasms↗
PubMedDate not supplied

Estimating true burden of disease detected by screening tests of varying validity.

Timely and accurate information on disease load is essential for planning health programs. Unfortunately, complexity, cost and need of skilled personnel limit the use of screening tools of high validity in developing countries. The disease load estimated with tools of low validity differs considerably from true disease load, particularly for diseases of extreme levels of prevalence/incidence. A tool of 70% sensitivity and specificity may yield a prevalence/incidence rate of 34% (CI: 32.23-35.67%) for a disease whose true rate is only 10.0% (CI: 8.94-11.06%). We proposed a procedure to derive the true estimate in such cases, based on the concepts of sensitivity and specificity of a diagnostic/screening test. It is applied on two sets of real data--one pertaining to incidence rate of low birth weight (LBW) and the other to prevalence rate of obesity--where multiple screening tests of varying validity were used to estimate the magnitude. Different screening tests yielded widely varying incidence/prevalence rates of LBW/obesity. The prevalence/incidence rates derived by using the proposed estimation procedure are similar and close to the true estimate obtained by screening tests considered as gold standard. Further, sample size determined on the basis of the results of a tool of low validity may be either larger or smaller than the required sample size. Estimation of true disease load enables determination of correct sample size, thus improving the precision of the estimate and, in some instances, reducing the cost of investigation.

Cost of Illness↗
PubMed2002

A new approach to assessing skill needs of senior managers.

Management of health care organizations must improve to meet the well-documented challenges of quality improvement and cost control. Other industries have developed the tools--entry education, mentoring, planned mid-career formal education and experience, and special programs for senior management. The purpose of this paper is to pilot test an alternative method to identify competencies and performance of health care executives. We propose using formal lists of technical, interpersonal, and strategic competencies and specific real events chosen by the respondent to identify and prioritize competencies. Results of a trial with 30 large health care system CEOs and 15 early careerists demonstrate that the method reveals useful depth and detail about managers' educational needs. The results suggest that current thinking about managerial education and learning patterns may be seriously inadequate in several respects. The continued improvement of U.S. health care is a pressing national concern. Quality of care is highly variable and substantially deficient in many institutions (Chassin and Galvin 1998; Committee on Quality of Health Care in America 2001). "Quality improvement should be the essential business strategy for healthcare in the 21st century (Kizer 2001)." Productivity improvements will be essential to balance cost pressures from an aging population and growing technology (Heffler, et al. 2002). Skillful management is necessary to improve quality and productivity. Teams of dozens of caregivers are often required to improve a patient's health. The organizations that provide care have grown larger in response to the greater cost, complexity of operation and finance, and evidence of the success of scale in other industries. While many small professional practices, hospitals, and nursing homes remain, consolidation has created a few dozen provider and intermediary organizations exceeding a billion dollars a year in expenditures. These large health care organizations are, or should be, modern corporate organizations at least as effective as their counterparts in manufacturing, retailing, or finance. To achieve that goal, they will require managers with comparable ability, motivation, and preparation. The National Summit on The Future Of Health Management and Policy Education emphasized the development of "evidence-based management education" by identifying, prioritizing, and measuring mastery of specific skills, knowledge, and abilities (Griffith 2001). Faculty of Association of University Programs in Health Administration (AUPHA) are working with practitioners to identify and prioritize specific learning competencies at the graduate degree level. Their effort focuses on skills teachable in the classroom, and it is expected to lead to measured performance of graduate school cohorts (Griffith 2001). The purpose of this paper is to pilot test an alternative method to identify competencies and performance of health care executives. Although it deliberately draws competency elements from academic sources, it supplements the teachable skills approach with a questionnaire that asks practitioner respondents to identify the skills and knowledge necessary to manage a specific management event and to evaluate the performance of an anonymous colleague against these skills and knowledge.

Attitude of Health Personnel↗
PubMed2002

[The ethical implications, guidelines, and standardization of genetic tests].

Laboratory advances in molecular genetics have resulted in numerous clinical applications for DNA analysis. Genetic tests can contribute a great deal of information to clinical diagnosis. These genetic tests including PCR, fluorescence detection, real-time PCR, and automated sequencing have developed into both simple and time-consuming laboratory techniques. Currently, DNA diagnosis is not used routinely because of cost, complexity, and resources. We have focused on the ethical implications and proper standardization in DNA diagnosis. This review is to discuss a guide to proceed genetic tests for their efficiency, accessibility and quality in laboratory.

Genetic Counseling↗
PubMed2004

Alarm-enhancement systems for ventilators.

Ventilator alarms can be crucial for safeguarding the health and even the lives of patients. Therefore, it's vital that they--like other critical alarms--be readily detected in even the busiest, noisiest hospital departments. One way to make sure that this happens is to use alarm-enhancement systems, which communicate ventilator alarms to locations where they are more likely to be detected by caregivers. There are four basic categories of ventilator alarm enhancements: (1) interfacing ventilators with networked physiologic monitors, (2) incorporating commercially available systems for centralized remote monitoring of ventilator alarms, (3) interfacing ventilators with nurse call systems, and (4) utilizing remote annunciators for ventilator alarms. These options range widely in complexity, cost, and the types of care settings for which they're likely to be suitable. In this article, we describe the ventilator alarm-enhancement systems that are currently on the market. We highlight their pluses and minuses based on information we have gained from product literature, through conversations with suppliers, and, where possible, through discussions with users. We also provide guidance to facilities on how to choose among the various options and products available.

Decision Making, Organizational↗
PubMed2004

Best face forward.

Most companies serve customers through a broad array of interfaces, from retail sales clerks to Web sites to voice-response telephone systems. But while the typical company has an impressive interface collection, it doesn't have an interface system. That is, the whole set does not add up to the sum of its parts in its ability to provide service and build customer relationships. Too many people and too many machines operating with insufficient coordination (and often at cross-purposes) mean rising complexity, costs, and customer dissatisfaction. In a world where companies compete not on what they sell but on how they sell it, turning that liability into an asset is what separates winners from losers. In this adaptation of their forthcoming book by the same title, Jeffrey Rayport and Bernard Jaworski explain how companies must reengineer their customer interface systems for optimal efficiency and effectiveness. Part of that transformation, they observe, will involve a steady encroachment by machine interfaces into areas that have long been the sacred province of humans. Managers now have opportunities unprecedented in the history of business to use machines, not just people, to credibly manage their interactions with customers. Because people and machines each have their strengths and weaknesses, company executives must identify what people do best, what machines do best, and how to deploy them separately and together. Front-office reengineering subjects every current and potential service interface to an analysis of opportunities for substitution (using machines instead of people), complementarity (using a mix of machines and people), and displacement (using networks to shift physical locations of people and machines), with the twin objectives of compressing costs and driving top-line growth through increased customer value.

Commerce↗
PubMed2005

[Free fat flap for the treatment of Parry-Romberg disease in children].

Progressive hemifacial Atrophy (PHA) or Romberg's Disease is a rare entity of unknown etiology, which most often affects only one side of the face and can include all tissue planes in different grades of severity. Of the several treatments proposed, pedicled or free flaps seem to achieve the best cosmetic results in severe cases. In mild to moderate cases, free autologous fat transplant may obtain optimal results with lower complexity, cost and morbidity. The presence of multiple adipoblasts might increase the possibilities of graft take, particularly in children. Furthermore, refinements in the processes of extraction, preparation and reintroduction of the fat have contributed to improve the results that may be long lasting. We present 2 cases of PHA in 2 girls (11 and 13 years old), that were treated by lipofilling. No complications occurred. In both cases we observed a small reduction in the volume of the initial graft. Thus the procedure was repeated 6 months later to improve facial symmetry. Results have been excellent in one year follow-up.

Adipose Tissue↗