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PubMedDate not supplied

A framework for evaluating activities to reduce the demand for drugs in Europe.

This paper describes a provisional framework that could be used to help compare and evaluate activities concerned with reducing the demand for illicit drugs in the European Community. It provides a background to European concern in this field, and comments on some methodological problems that arise regarding evaluation. The overall goal of demand reduction may be attempted through a diverse range of activities--treatment and rehabilitation, reduction of secondary harm arising from drug use, primary prevention, and suppression of drug availability and use--each of which may involve different interventions at different levels of generality and with different subsidiary objectives. Thus it is essential that data for evaluation are collected in terms of a framework where demand reduction activities and their objectives are clearly specified, together with criteria for success or failure, appropriate measures for those criteria and suitable methods to obtain those measures. The paper provides some examples of how this framework could be applied to evaluating attempts to reduce demand for drug through treating addicts, and comments on the use of global measures (indicators) of trends in the demand for drugs. A possible administrative structure for comparing drug demand activities in different countries through a European network on health data is suggested.

Europe↗
PubMed2002

Response of old-growth conifers to reduction in stand density in western Oregon forests.

The positive growth response of healthy young trees to density reduction is well known. In contrast, large old trees are usually thought to be intrinsically limited in their ability to respond to increased growing space; therefore, density reduction is seldom used in stands of old-growth trees. We tested the null hypothesis that old-growth trees are incapable of responding with increased growth following density reduction. The diameter growth response of 271 Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco), ponderosa pine (Pinus ponderosa Dougl. ex Laws) and sugar pine (Pinus lambertiana Dougl.) trees ranging in age from 158 to 650 years was examined 20 to 50 years after density reduction. Density reduction involved either light thinning with removal of less vigorous trees, or shelterwood treatments in which overstory trees were not removed. Ratios of basal area growth after treatment to basal area growth before treatment, and several other measures of growth, all indicated that the old trees sometimes benefited and were not harmed by density reduction. Growth increased by 10% or more for 68% of the trees in treated stands, and nearly 30% of trees increased growth by over 50%. This growth response persisted for at least 20 years. During this 20-year period, only three trees in treated stands (1.5%) exhibited a rapid decrease in growth, whereas growth decreased in 64% of trees in untreated stands. The length of time before a growth response to density reduction occurred varied from 5 to 25 years, with the greatest growth response often occurring 20 to 25 years after treatment. These results have important implications both for the basic biology of aging in woody plants as well as for silvicultural practices in forests with old-growth trees.

Forestry↗
PubMed1988

Microsurgical procedures in the peripheral nerves and the dorsal root entry zone for the treatment of spasticity.

When spasticity becomes severe and harmful, in spite of physical and medical therapy, neurosurgery can give functional improvement. This paper deals with the long term results of Selective Peripheral Neurotomies of the Tibial Nerve and Selective Posterior Rhizotomies in the Dorsal Root Entry Zone, in 123 patients with spastic disorders localized to the limbs. The micro-techniques and intra-operative electro-stimulation for identification of the nervous structures responsible for the spastic components, can give a substantial reduction of the harmful spasticity, without suppressing the useful muscle tone and impairing the residual motor and sensory functions. The results were effective, with a 1 to 13 year follow-up (5 on average), in 89% of 47 Selective Peripheral Neurotomies of the tibial nerve for spastic foot, in 92% of 53 Selective Posterior Rhizotomies for paraplegia and in 87% of 23 Selective Posterior Rhizotomies for hemiplegia. In the most severe situations ("comfort" indications), correction of the abnormal postures and relief of pain facilitated nursing and physiotherapy. Sometimes there was reappearance of some useful voluntary movements. In the less affected patients ("functional" indications), the suppression of the harmful spastic components made the persistant capacities more effective.

Adolescent↗
PubMed2002

Smoking reduction practices among African American smokers.

Despite smoking fewer cigarettes per day than Caucasians, African Americans bear a disproportionate share of health consequences of smoking. Because the risk of many tobacco-related diseases is dose-dependent, smoking reduction has been suggested as a method to reduce harm for smokers. Little information exists about behavioral smoking-reduction strategies and whether such strategies result in smoking fewer cigarettes. We conducted a survey of 484 African American smokers classified as occasional, light, moderate, and heavy smokers. The survey examined sociodemography, smoking characteristics, and eight smoking reduction strategies, including intentional limiting of smoking, smoking less than half of a cigarette, setting a daily limit for smoking, changing cigarette brand, reducing number of cigarettes, smoking only on some days, switching to a lighter tar cigarette, and not inhaling deeply. Compared to moderate and heavy smokers, occasional and light smokers were more likely to have engaged in most of these strategies. Smokers who used >or= 4 strategies on average smoked 11 cigarettes per day (cpd), compared to 14 cpd and 18 cpd for those who used 1 to 3 strategies and no strategies respectively (p <.0001). After analyses controlled for age, gender, and education, the number of smoking reduction strategies utilized was a significant predictor of smoking 10 or fewer cigarettes per day. This study provides evidence that African American smokers who engaged in multiple smoking reduction strategies smoked fewer cigarettes per day. Smokers not interested in quitting but willing to reduce their smoking should be encouraged to utilize a variety of smoking reduction strategies.

Adult↗
PubMed1996

[Evaluation of a stay and care center for drug addicts in Lucerne].

UNLABELLED: Between April 1992 and March 1994 a low threshold centre named "Aufenthalts- und Betreuungsraum für Drogenabhängige (ABfD)" ("Common Care Room for Drug Addicts") was run in the city of Lucerne which intended to help drug addicts to live and survive in terms of harm and risk reduction. The evaluation of the ABfD was conducted by the Institute for Social and Preventive Medicine on behalf of the Federal Office of Health. Combining qualitative and quantitative research methods its structure was evaluated regarding the realization of its own objectives. THE RESULTS: the ABfD was frequented beyond expectation by an average of about 65 male and female drug addicts per evening. All of its facilities were used and appreciated. The clientele of the ABfD was characterized by a great diversity of sociodemographic factors such as age, sex and income as well as housing conditions. The majority were residents of the city (approx. 54%) and the canton of Lucerne (approx. 28%). In general, the ABfD had a positive effect on the physical condition of its user insofar as the distribution of sterile injecting material enabled them to behave more risk consciously. Also, it gave many drug addicts something like a home and the opportunity to experience an atmosphere of solidarity. In spite of isolated criticism the ABfD generally enjoyed great esteem. The evaluation has shown that there is a need for a care center for drug addicts such as the ABfD, that it had been widely made use of, realized many of its objectives and it had no attractive effect on other regions. The researchers concluded by recommending the establishment of an analogous institution within a sensible period of time since with the closing of the ABfD in the Lucerne area the help to live and survive, an important pillar of the drug policy was no longer warranted for.

Adult↗
PubMed1996

[Evaluation of street facilities I, II and III in Basel].

In June 1991 the city of Basel established the first low threshold centre (LTC) subsidized by the government after various private initiatives of "Live & Survive" aids. This low threshold facility which was supplemented in 1992 by two additional LTCs aimed at harm and risk reduction. The evaluation of LTCs was conducted by the institute for Social and Preventive Medicine of the University of Basel on behalf of the Federal Office of Health. Combining qualitative and quantitative research methods its structure was evaluated regarding the realization of its own objectives. The LTCs reached a great variety of drug addicts which were characterized by a remarkable heterogeneity. The majority of users were aged between 20 and 30, a quarter of them were female. Differences were found in housing conditions, subsistence and the degree of social integration. The facilities of the institutions were extensively used. In 1993 and 1994 a daily average of 250 to 300 visits was recorded in the injecting rooms only. the clientele were mainly residents of the Basel area. This lead to the conclusion that there was no attractive effect on more remote regions. As a consequence of the extensive use of the facilities a movement of the drug scene away from the street into the LTCs could be observed. In general, a stabilization or even an improvement of the physical condition of its users could be noticed. Another important feature was the improvement of the drug addicts' social integration. The main reason for this was the relationship between users and staff. Due to the shortage of personnel this promising base for further psychosocial work could not be adequately developed. The investigators not only concluded that there is a need for continuing maintenance of these facilities but also that additional efforts to improve the psychosocial services would be justified.

Adult↗
PubMed2001

Drugs and the dance music scene: a survey of current drug use patterns among a sample of dance music enthusiasts in the UK.

This study explores the utility of a self-completion survey method to quickly and cheaply generate information on patterns and trends among regular "recreational" drug consumers. Data is reported here from 1151 subjects accessed through a dance music publication. In keeping with previous studies of drug use within the dance scene polysubstance use was the norm. Many of those reporting use of "ecstasy" were regularly using multiple tablets often consumed in combination with other substances thus exposing themselves to serious health risks, in particular the risk of dose related neurotoxic effects. Seventy percent were drinking alcohol at hazardous levels. Subjects' patterns of drug purchasing also put them at risk of severe criminal sanction. Data supported evidence that cocaine use had become increasing popular in the UK, but contrasted with some commentators' views that ecstasy use was in decline. The utility of this method and how the results should be interpreted is discussed, as are the data's implications for harm and risk reduction activities.

Adult↗
PubMed2002

Risks and benefits of early treatment of acute myocardial infarction with an angiotensin-converting enzyme inhibitor in patients with a history of arterial hypertension: analysis of the GISSI-3 database.

BACKGROUND: Many trials have proved the benefits of early systematic treatment with angiotensin-converting enzyme inhibitors in patients with acute myocardial infarction (AMI). Pathophysiological studies, however, suggest potential harm in excessive reduction of blood pressure (BP) in hypertensive patients with ischemic heart disease. METHODS: We analyzed data from the GISSI-3 (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico) trial to assess the effects of early treatment with angiotensin-converting enzyme inhibitors during AMI in patients with a history of hypertension compared with normotensive patients. The trial randomly assigned 19,394 patients to 6 weeks of lisinopril treatment or control, starting treatment within 24 hours of AMI onset. RESULTS: In the 10,661 normotensive patients, lisinopril significantly reduced lethal events, but in the 7362 hypertensive patients, a higher rate of lethal events was reported the first day of treatment, and the benefits only appeared subsequently. These results may be attributable to the subgroup of 1165 hypertensive patients with low baseline systolic BP (lower quintile, BP <120 mm Hg), in whom critical hypotension was more prone to develop after lisinopril treatment. In fact, these patients showed a higher mortality rate as the result of an excess of cardiogenic shock during the first day of lisinopril treatment (odds ratio 3.07, 95% CI 1.39-6.77) and a persistent, unfavorable death trend after 6 weeks. CONCLUSIONS: These data suggest that caution should be exercised when using lisinopril in the acute phase of a myocardial infarction in patients with a history of hypertension but low systolic BP at presentation.

Aged↗
PubMed1986

Recent developments in chemotherapy of ocular diseases.

The profile of organisms responsible for ocular infections has changed over the past few decades. Although nonresistant and resistant staphylococci still lead the list, gram-negative, mixed infections and anaerobic organisms have become more evident. In spite of more potent and broader spectra antibiotics, resistant organisms still emerge. The therapy of intraocular infections requires an awareness of the latest antibiotics, particularly their advantages, limitations, toxicities, and administration. Iontophoresis through the sclera overlying the pars planum area with small diameter applicators may offer another route of administration which may reduce or eliminate the value of direct intravitreal injections of antibiotics. Reduction of the harmful effects of endotoxins of organismal origin might minimize the adverse effects of intraocular infection, particularly after gram-negative invasion. The choice of antibiotic may influence the quantities of endotoxins released.

Anti-Bacterial Agents↗
PubMed2006

The future of tobacco regulation: a response to a proposal for fundamental institutional change.

There is much debate about the future of tobacco regulation. Some have argued that to achieve maximum possible reduction in the harm tobacco causes, new regulatory models that involve fundamental institutional change must be adopted. The tobacco industry will continue to undermine tobacco control, and, so it is argued, we must change the way in which it operates if we are to be able to make the necessary progress. Such proposals may have an immediate appeal, especially for those frustrated that progress in tobacco control is not as rapid as they would hope--with all the avoidable loss of life and livelihoods that that entails--but they need to be carefully analysed and assessed, and much thought must be applied before spending time and resources advocating for them. One such proposal, advanced by Borland, involves the establishment of a monopsonistic statutory purchasing agency and wholesale distributor of tobacco products. Borland argues the relative benefits of such a model as compared to a more "conventional" model. On close examination, the benefits of the Borland proposal, as compared to the conventional model, appear overstated, and the Borland proposal introduces significant regulatory problems. There is still much that can be achieved in tobacco regulation through more conventional approaches, and within the "existing system". We should be wary of allowing the understandable allure of new or radical approaches to distract us from this reality.

Government Regulation↗
PubMed1985

Microsurgical selective procedures in peripheral nerves and the posterior root-spinal cord junction for spasticity.

This review deals with the long-term results of selective peripheral neurotomy (SPN) of the tibial nerve and selective posterior rhizotomy (SPR) in 123 cases of severe spastic syndromes in the limbs. The microtechniques and preoperative electrostimulation for identification of the nervous structures responsible for the spastic components give to these methods an advantage of a substantial reduction of the harmful spasticity, without suppressing the useful muscle tone and impairing the residual motor and sensory functions. The results were effective, with a 1- to 13-year follow-up, in 89% of 47 SPN of the tibial nerve for spastic foot, in 92% of 53 SPR for paraplegia and in 87% of 23 SPR for hemiplegia.

Adolescent↗
PubMed1996

Medical therapy can improve the biological properties of the chronically failing heart. A new era in the treatment of heart failure.

Myocardial failure has been considered to be an irreversible and progressive process characterized by ventricular enlargement, chamber geometric alterations, and diminished pump performance. However, more recent evidence has suggested that certain types of medical therapy may lead to retardation and even reversal of the cardiomyopathic process. In the failing heart, long-term neurohormonal/autocrine-paracrine activation results in abnormalities in myocyte growth, energy production and utilization, calcium flux, and receptor regulation that produce a progressively dysfunctional, mechanically inefficient heart. Interventions such as ACE inhibition and beta-blockade result in a reduction in the harmful long-term consequences of neurohormonal/autocrine-paracrine effects and retard the progression of left ventricular dysfunction or ventricular remodeling. Furthermore, in subjects with idiopathic dilated or ischemic cardiomyopathy, antiadrenergic therapy with beta-blocking agents appears to be able to partially reverse systolic dysfunction and ventricular remodeling. Although the precise mechanisms underlying this latter effect have not yet been elucidated, the general mechanism appears to be via improvement in the biological function of the cardiac myocyte. Such an improvement in the intrinsic defect(s) responsible for myocardial failure will likely translate into important clinical benefits.

Cardiomyopathies↗
PubMed2005

The interpretation and application of the three Rs by animal ethics committee members.

The Three Rs form the basis of review of animal-use protocols by Animal Ethics Committees (AECs), but little research has examined how AECs actually interpret and implement the Three Rs. This topic was explored through in-depth, open-ended interviews with 28 members of AECs at four Canadian universities. In describing protocol review, AEC members rarely mentioned the Three Rs, but most reported applying some aspects of the basic concepts. Comments identified several factors that could impede full application of the Three Rs: incomplete understanding of the Three Rs (especially Refinement), trust that researchers implement Replacement and Reduction themselves, belief by some members that granting agency review covers the Three Rs, focus on sample size rather than experimental design to achieve Reduction, focus on harm caused by procedures to the exclusion of housing and husbandry, and lack of consensus on key issues, notably on the nature and moral significance of animal pain and suffering, and on whether AECs should minimise overall harm to animals. The study suggests ways to achieve more consistent application of the Three Rs, by providing AECs with up-to-date information on the Three Rs and with access to statistical expertise, by consensus-building on divisive issues, and by training on the scope and implementation of the Three Rs.

Animal Experimentation↗
PubMed2003

Teaching students the repair of resin-based composite restorations: a survey of North American dental schools.

BACKGROUND: The purpose of this study was to evaluate whether North American dental schools teach students to repair resin-based composite, or RBC, restorations and to compare the findings with those from similar European surveys. MATERIALS AND METHODS: The authors mailed a 15-item questionnaire to 64 dental schools in the United States, Canada and Puerto Rico. The survey asked whether the school taught repair of RBC restorations and inquired about the respondent's experience with such procedures. Questions also elicited reasons why schools taught or did not teach repair, information in regard to relevant decision-making processes, criteria for deciding whether to perform repairs and the nature of the instruction (theoretical, practical, preclinical or clinical). RESULTS: Fifty-two (81 percent) of 64 schools participated in the survey. Thirty-seven (71 percent) of the respondents reported that they taught undergraduate students repair techniques as an alternative to replacing failing RBC restorations. Twenty-seven (73 percent) of these 37 schools reported that such teaching was at the clinical level, while only three schools (8 percent) reported that it was included in formal lectures as part of preclinical courses. The major reasons given for teaching students how to repair RBC restorations were tooth structure preservation and reduction of potentially harmful effects on the pulp. Indications included the correction of marginal defect and marginal discoloration. CONCLUSIONS: More than one-half of the respondents reported that they taught repair of RBC restorations and that patients were willing to accept such treatment. Most schools considered the repair of RBC restorations to be a definitive measure and reported that, on average, expected a repaired RBC restoration to have a longevity of four years.

Canada↗
PubMed1998

Comparative tolerability profile of hypertensive crisis treatments.

Hypertensive crisis is defined as a severe elevation in BP and is classified as either urgency or emergency. In hypertensive urgency there is no end-organ injury and no evidence that acute BP lowering is beneficial. Indeed, rapid uncontrolled pressure reduction may be harmful. Therefore, in hypertensive urgencies BP should be lowered gradually over 24 to 48 hours using oral antihypertensives. When the cause of transient BP elevations is easily identified, appropriate treatment should be given. When the cause is unknown, an oral antihypertensive should be given. The efficacy of available treatments appear similar; however, the underlying pathophysiological and clinical findings, mechanism of action and potential for adverse effects should guide choice. Captopril should be avoided in patients with bilateral renal artery stenosis or unilateral renal artery stenosis in patients with a solitary kidney. Nifedipine and other dihydropyridines increase heart rate whereas clonidine, beta-blockers and labetalol tend to decrease it. This is particularly important in patients with ischaemic heart disease. Labetalol and beta-blockers are contraindicated in patients with bronchospasm and bradycardia or heart blocks. Clonidine should be avoided if mental acuity is desired. In hypertensive emergency there is an immediate threat to the integrity of the cardiovascular system. BP should be immediately reduced to avoid further end organ damage. Sodium nitroprusside is the most popular agent. Nitroglycerin (glyceryl trinitrate) is preferred when there is acute coronary insufficiency. A beta-blocker may be added in some patients. Loop diuretics, nitroglycerin and sodium nitroprusside are effective in patients with concomitant pulmonary oedema. Enalaprilat is also theoretically helpful, especially when the renin system might be activated. Initial treatment of aortic dissection involves rapid, controlled titration of arterial pressure to normal levels using intravenous sodium nitroprusside and a beta-blocker. If beta-blockers are contraindicated, urapidil or trimetaphan camsilate are alternatives. Hydralazine is the drug of choice for patients with eclampsia. Labetalol, urapidil or calcium antagonists are possible alternatives if hydralazine fails or is contraindicated. For patients with catecholamine-induced crises, an alpha-blocker such as phentolamine should be given; labetalol or sodium nitroprusside with beta-blockers are alternatives. There are few, if any, comparative or randomised trials providing definitive conclusions about the efficacy and safety of comparative agents. Some investigators recommend decreasing the diastolic BP to no less than 100 to 110 mm Hg. A reasonable approach for most patients with hypertensive emergencies is to lower the mean arterial pressure by 25% over the initial 2 to 4 hours with the most specific antihypertensive regimen.

Acute Disease↗
PubMed2005

Gene therapy for the prevention of ischemia/reperfusion injury in organ transplantation.

Introduction of gene therapy into molecular medicine has been gaining increasing interest. Although treatment of various diseases e.g. monogenetic defects or cancer by using gene transfer technologies has been extensively probed, the clinical success has been limited. However, recent experimental data suggest that gene therapy may represent an attractive and powerful approach in preventing ischemia/reperfusion injury as well as organ rejection in transplant recipients. Easy and selective access to the donor organ facilitates the reduction of potentially harmful systemic side effects of gene therapy vectors. By introducing anti-apoptotic or cytoprotective genes, these studies focused on the protection of the transplant from the apoptotic cell death. In addition, down-regulation of adhesion molecules and/or blockade of gene expression in the graft itself also ameliorated ischemia/reperfusion injury. This review summarizes the current progress on gene therapy application in combating ischemia-reperfusion injury in organ transplantation. Although the use of viral vectors is emphasized, non-viral gene transfer techniques are also discussed. Future development of novel, low-immunogenic vectors should further contribute to the minimization of ischemia/reperfusion injury, and thus to the overall success of organ transplantation.

Adenoviridae↗
PubMed1999

A computer based intervention to reduce unnecessary serologic testing.

OBJECTIVE: Laboratory testing is important in the evaluation of patients with possible systemic rheumatic disease, but uncritical use of any test may result in misleading information and unnecessary costs. We attempted to reduce the number of unnecessary antinuclear antibody, rheumatoid factor, and complement level tests ordered by house officers at a large teaching hospital, where inpatient orders are written through a computer based order entry system. METHODS: We conducted a prospective cohort study of an interactive test ordering program. The intervention consisted of displaying post-test probability estimates during the usual physician order entry session. These estimates were based on pretest probabilities entered by the ordering physician and sensitivities and specificities derived from a literature review. Another group of test orders did not prompt the intervention and were considered controls. The outcome of interest was the percentage of tests canceled in the intervention group versus the control group. RESULTS: Eleven percent (11/99) of intervention orders were canceled, versus only one order among 236 controls (p = 0.001). However, there was no association between the physicians' pretest probability estimates and whether test orders were canceled (p = 0.59). Additionally, 43 of the 335 orders (13%) yielded positive tests, but only 4 patients (1%) were given new diagnoses of rheumatic disease. CONCLUSION: The computer based intervention significantly reduced orders for antinuclear antibody and rheumatoid factor levels by 10%. Further reductions without clinical harm are probably possible, since the yield of testing for new rheumatic diseases was low.

Adult↗
PubMed2000

[Prevention in pulmonology].

In the fight against respiratory diseases the well established most effective strategy is their prevention. Mainly the field of screening-caring--so called the second and third levels in prevention--belongs to the competency of the pulmonology specialty, while the key-issue of primary prevention consisting of the reduction of environmental harm and health education is not--or at least not only--the responsibility of the health care system. In the light of national epidemiological data BCG vaccination of the new-born is necessary, however, the system of revaccination of school-age children needs revision. The system of chest screening by rtg nowadays is adapted to the local prevalence of tuberculosis; it is needed to concentrate to high-risk subjects. The effectivity of radiological screening now is recognised internationally and this perspective partly based on our national results. In the care of patients with chronic obstructive pulmonary diseases (COPD) the key-issue is the identification and regular follow-up, care of high-risk subjects with rapid decrease in lung function by effective screening. The most important issue in this work is smoking cessation. Of course, if we could prevent smoking addiction, we could significantly reduce the number of several other widespread diseases, not only lung cancer.

BCG Vaccine↗