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A web-based system for managing and co-ordinating multiple multisite studies.

Efficient and secure collection and management of information is essential in any modern biomedical study. Data management and coordination of multisite studies is a complex process. It involves development of systems for data collection, data cleaning with quality assurance checks, and specimen tracking, as well as development of procedures for conducting the study, training clinical sites, and communicating with sites to answer study questions and resolve and track data inquiries and resolutions. We developed a secure web-based system that is designed to automate evaluation of eligibility criteria and data collection, track specimens, serve as a resource for study-specific information, facilitate communication across sites in multisite studies, track data queries and resolutions, and allow administrative management of studies. The system combines a common framework across studies that defines the internal structure for all the web pages, with a study-specific one that defines the content of each page via a relational database. This combination creates a flexible and efficient environment enabling several multisite studies to be simultaneously or consecutively implemented and managed in a timely manner. We describe the development process, the system and its evaluation, current status, lessons learned, and future development plans.

Biomarkers, Tumor↗

Mobile software agents for Web-based medical image retrieval.

Mobile software agents are a new tool which may assist rural and remote physicians to obtain medical data from digital medical libraries on the Internet. Mobile agents are autonomous software objects that can move from digital library to digital library, analysing data to determine their usefulness to the user. A proof-of-concept system applied to mammography is proposed and a simplified prototype for this system is reported. Enhancement and development plans for the complete proof-of-concept system are suggested.

Information Storage and Retrieval↗

An analysis of why telehealth systems in Australia have not always succeeded.

Telehealth programmes are rather similar to humans in the way that they are planned, develop, grow and ultimately die or disappear. To achieve good life expectancy for a telehealth programme there appear to be three major needs: nurturing, which includes the provision of money, ideas, education, training and innovation; experience, which involves an integrated management process, the achievement of long and wide patterns of usage, the development of updated policies and procedures and the involvement of multiple disciplines; success, which involves evidence of outcomes, evaluation and research, and, most important, the sharing of information through scientific and popular press publications, and conferences and collaborations with internal and external groups. The future of telehealth in Australia is at a watershed. There are now a substantial number of programmes, and there has been a large amount of financial and human investment in telehealth around the nation. There is, however, no forum for national leadership, no national association and little support at federal government level.

Australia↗

Chicago area methyl parathion response.

The Illinois Department of Public Health participated in the Chicago, Illinois, area methyl parathion (MP) response with several other federal, state, and local government agencies beginning in April 1997. This response was initiated on evidence that hundreds of homes in the Chicago area were illegally treated for cockroaches with MP over a period of several years. Through applicator receipt books and information reported by property owners and tenants, 968 homes were identified as having been treated with MP. Upon implementation of a response plan developed by the Methyl Parathion Health Sciences Steering Committee, environmental sampling and urine monitoring were provided for eligible households. Environmental sampling was conducted in 903 homes, with MP detected above levels of concern in 596 residences. Residents of these homes were offered urine sampling to determine the extent of exposure to MP. Urine samples were collected and analyzed for p-nitrophenol in 1,913 individuals. Implementation of the protocol resulted in 550 residents being relocated during the remediation of 100 households.

Adolescent↗

An alternative health delivery system for the chronically ill elderly.

The present health care system is fragmented, uncoordinated, and too costly for the chronically ill, elderly patient. Project OPEN provides preventive health and social services in order to reduce costs and provide more effective care. This alternative delivery system is based on a consortium brokerage model which provides functional assessment, care plan development and service coordination. A randomized sample of 338 elderly individuals participated in a time series experiment. Client functional status, service utilization, and all health costs were collected for six months. The results indicated a maintenance in functioning levels, a decrease in acute hospitalizations, and a 20% reduction in health care costs for the demonstration participants as compared to the control group. Project OPEN provided more effective care while simultaneously reducing health expenditures to the chronically ill elderly.

Activities of Daily Living↗

Impact of a pharmaceutical care program in a community pharmacy on patients with dyslipidemia.

BACKGROUND: Inappropriate use of medications is a significant problem in health care today. A possible solution to this problem may be achieved through better control of patients' drug therapy. OBJECTIVE: To design a pharmaceutical care program for dyslipidemic patients within a community pharmacy setting that provides education in the areas of medication compliance and lifestyle modifications, while emphasizing the importance of achieving cholesterol goals to ensure improvement in quality of life. METHODS: Patients at an outpatient pharmacy volunteered to be surveyed for 16 weeks. Although both the intervention and control groups were surveyed, the randomly selected intervention group was interviewed more frequently and more comprehensively. Cholesterol, triglycerides, glucose, weight, risk factors, drug-related problems (DRPs), and quality of life were measured via a survey at the onset of the study and continually measured until the study's conclusion. RESULTS: In the intervention group, 26 DRPs were detected, of which 24 were resolved; in the control group, 26 DRPs were detected, of which 5 were resolved. When comparing initial and final blood cholesterol levels in the intervention group, the mean decrease was 27.0 +/- 41.1 mg/dL (p = 0.0266); in the control group, the average blood cholesterol level decreased by a mean of 1.4 +/- 37.2 mg/dL (p = 0.6624). In the intervention group, the triglyceride level decreased an average of 50.5 +/- 80.3 mg/dL (p = 0.0169), while the control group experienced a mean triglyceride level increase of 29.6 +/- 118.5 mg/dL (p = 0.1435). As a result of the intervention, the quality of life in the intervention group was improved. CONCLUSIONS: Short-term pharmaceutical care plans developed in a retail pharmacy within the proper setting may contribute to improved blood lipid values, cardiovascular disease risk factors, and patients' quality of life.

Aged↗

Tooth whitening today.

BACKGROUND: Methods to improve the esthetics of the dentition by tooth whitening are of interest to dentists, their patients and the public. In the past 20 years, research on bleaching and other methods of removing tooth discolorations has dramatically increased. Dentist-supervised and over-the-counter products now are available to solve a variety of tooth discoloration problems without restorative intervention. The indications for appropriate use of tooth-whitening methods and products are dependent on correct diagnosis of the discoloration. OVERVIEW: Tooth-whitening methods include the use of peroxide bleaching agents to remove internal discolorations or abrasive products to remove external stains. Peroxide bleaching procedures are completed by the dentist in single or multiple appointments, or by the patient over a period of weeks to months using custom trays loaded with a bleaching agent. Both methods are safe and effective when supervised by the dentist. Microabrasion is indicated for the removal of isolated discolorations that often are associated with fluorosis. Whitening toothpastes remove surface stains only through the polishing effect of the abrasives they contain. CONCLUSIONS AND PRACTICE IMPLICATIONS: Tooth whitening is a form of dental treatment and should be completed as part of a comprehensive treatment plan developed by a dentist after an oral examination. When used appropriately, tooth-whitening methods are safe and effective.

Dental Devices, Home Care↗

The evolution of the CEREC system.

BACKGROUND AND OVERVIEW: Early in 1980, the author anticipated the attraction of restoring posterior teeth with tooth-colored material. He conducted studies and developed the clinical concept of bonded ceramic inlays, at the same time raising the issue of the fast fabrication of the ceramic restorations. The author developed plans for in-office computer-aided design/computer-aided manufacturing (CAD/CAM) fabrication of ceramic restorations specifically to enable the dentist to complete one or multiple ceramic restorations chairside, in a single appointment. The initial concept comprised a small mobile CAD/CAM unit integrating a computer, keyboard, trackball, foot pedal and optoelectronic mouth camera as input devices, a monitor and a machining compartment. CEREC 3 (Sirona Dental Systems GmbH, Bensheim, Germany) divided the system into an acquisition/design unit and a separate machining unit. Three-dimensional software makes the handling illustrative and easy both in the office and in the laboratory. CONCLUSIONS: It appears that the CEREC CAD/CAM concept is becoming a significant part of dentistry. CLINICAL IMPLICATIONS: Sound knowledge of adhesive bonding and diligent planning are essential for the successful integration of CAD/CAM into clinical dental offices.

Ceramics↗

Evaluation of a learning collaborative to improve the delivery of preventive services by pediatric practices.

OBJECTIVE: Effective delivery of preventive services is an essential component of high-quality pediatric health care. However, both variation in and deviation from accepted guidelines have been reported. Learning collaboratives (LCs) have been shown to result in improvement in several aspects of pediatric care. The objective of this study was to determine whether pediatric practices that participated in a preventive services LC would improve their delivery of preventive services. METHODS: After conducting an initial audit of the medical records of twenty 2-year-olds and twenty 4-year-olds for documentation of preventive services on the basis of national standards, practice teams attended a quality improvement workshop. They were presented with evidence to support the value of preventive services and the results of their audits and taught quality improvement methods, eg, rapid cycles of change. Each team developed plans to improve 1 or more services. Brief audits with feedback and monthly conference calls were used to support practices to conduct rapid cycles of change, to discuss barriers and solutions, and to monitor progress. The results of final chart audits of twenty 2-year-olds and 4-year-olds were compared with the initial chart audits. A Preventive Service Score (PSS) was assigned to each practice on the basis of the number of services provided, and initial to final comparisons were made. RESULTS: Fourteen practices participated. PSSs improved for all practices after the LC. Mean PSS for 2-year-olds increased from 4.0 +/- 1.1 to 4.9 +/- 1.2 and for 4-year-olds increased from 3.8 +/- 1.8 to 5.6 +/- 1.9. The proportions of children who received 9 of the 10 individual preventive services also improved significantly. CONCLUSION: LCs are a potentially effective method of improving the quality of care that is delivered by pediatric practices.

Child, Preschool↗

Tegumentary and visceral leishmaniases in Brazil: emerging anthropozoonosis and possibilities for their control.

The existence of a number of different species of Leishmania, the persistent increase in the infection rate of diseases caused by this parasite (tegumentary and visceral forms), the different epidemiological situations found in regions of both recent and older colonization, and the trend towards urbanization have led to the adoption of different strategies to control leishmaniases in Brazil. The control measures involve studies related to the parasite, vectors, sources of infection (animal and human), clinical aspects, geographical distribution, historical and socioeconomic factors, integration of health services, and adequate technologies for diagnosis, treatment, and immunoprophylaxis. Finally, successful control requires work with human communities, involving education, provision of information, health promotion, and participation of these communities in the planning, development, and maintenance of control programs.

Journal Article↗

Dialysis in Barbados: the cost of hemodialysis provision at the Queen Elizabeth Hospital.

OBJECTIVE: The purpose of this study was to assess the health service cost of hemodialysis delivered at the Queen Elizabeth Hospital in St. Michael, Barbados. METHODS: A cost analysis was performed from the viewpoint of the tertiary hospital studied here, using treatment protocols based on current practice for establishing vascular access sites (surgical set-up) and dialysis maintenance. Cost and patient data were collected for the period from 1 April 1998 to 31 March 1999. Sixty-four patients were studied and a total of 7 488 hemodialysis sessions were performed in the study period. The costs analyzed were personnel, drug expenditure, supplies (dialysis and nondialysis), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as engineering, housekeeping, laundry and administration. RESULTS: The cost per hemodialysis treatment was calculated as US$ 156.64 in the first year and US$ 145.55 in subsequent years. The total cost per patient per year was US$ 18 327.22 in the first year of dialysis including surgical set-up, and US$ 17 029.54 thereafter. Direct costs (determined by patients' utilization of resources and labor costs for physicians and nurses) contributed to 80.7% of the total cost. The main expenditures were dialysis-related supplies, labor and overheads. CONCLUSION: These findings are important in the light of limited economic resources available to health services in Caribbean countries coupled with the spiraling prevalence of kidney failure in these countries. Further analyses are recommended to review the provision of renal replacement therapy services in Barbados and to develop plans to expand and optimize services.

Barbados↗

[Environmental sustainability of water resources in the city of Rio de Janeiro, Brazil].

OBJECTIVE: To propose an urban water sustainability index based on indicators that may serve as a foundation for developing planned actions concerning water resources. METHODS: Eleven indicators (covering aspects of water and sewage) were selected based on the parameters of Brazil's National Water and Sanitation Information System (Sistema Nacional de Informação sobre Saneamento) for the years 2000 and 2001. A score and a weight were assigned to each indicator. Based on that, the urban water sustainability index (UWSI) was calculated, using the formula UWSI = product (I(i)(pi)), where I(i) is the score attributed to each indicator i, ranging from 0 to 100, and p(i) is the weight for each indicator sigma(i=1)(n) p(i) = 1, where n is the number of indicators considered). The lowest water quality is indicated by an index value of 0, and the best by an index value of 100. RESULTS: The urban water sustainability index for the city of Rio de Janeiro was 58.99 in 2000, and it rose to 59.57 in 2001, indicating water of good quality in both those years. CONCLUSIONS: The improvement in the quality of the water resources between 2000 and 2001 in the city of Rio de Janeiro is possibly the result of the implementation, in the 1990s, of an environmental management program in the Rio de Janeiro region. Environmental planning that includes rational use of water resources and methods to prevent their destruction is crucial to sustaining society.

Brazil↗

Endoscopic sex determination and gonadal manipulation in Gulf of Mexico sturgeon (Acipenser oxyrinchus desotoi).

Seventeen Gulf of Mexico sturgeons (Acipenser oxyrinchus desotoi) underwent endoscopic sex determination, gonadal biopsy, and various reproductive surgeries as part of a conservation development plan. The fish were anesthetized with tricaine methanesulfonate (MS-222) buffered with sodium bicarbonate and maintained on a recirculating water anesthesia circuit. A 6-mm Ternamian EndoTip Cannula, placed through the ventral midline, midway between pectoral and pelvic fins, permitted the introduction of a 5-mm telescope. Swim bladder aspiration and CO2 insufflation of the coelomic cavity provided excellent observation. Second and third cannulae were placed under direct visual control, lateral and cranial or caudal to the telescope cannula. Sex determination was successfully performed in all fish; however, five of 17 sturgeons (29%) required endoscopic gonadal biopsy to confirm sex. Bilateral ovariectomy or orchidectomy was successfully performed in three males and four females. Unilateral ovariectomy and bilateral ligation of the müllerian ducts using an extracorporeal suturing technique was accomplished in an additional three females. No apparent morbidity was associated with the anesthesia or endoscopic surgery in any fish. The ability to safely perform minimally invasive reproductive surgery in fish may have important management and conservation benefits.

Animals↗

Gastrointestinal bleeding rates among managed care patients newly started on cox-2 inhibitors or nonselective NSAIDs.

OBJECTIVE: While cyclooxygenase-2 (COX-2) inhibitors were introduced to the U.S. market with the promise of less gastrointestinal (GI) toxicity than nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), additional research is needed to examine this outcome in the naturalistic setting. The objective of this study was to examine whether use of COX-2 inhibitors is associated with reduced risk of GI bleed in a managed care population. METHODS: Adult patients in a multistate managed care organization that were initiated on a nonselective NSAID between January 1999 and August 2002 were identified and matched using propensity scoring with patients in the same managed care organization that were initiated on a COX-2 inhibitor. Matching variables included age, gender, geographical state, comorbidity index, corticosteroid use, warfarin use, arthritis indication, and history of recent GI bleed. Patients were followed until they switched or discontinued their NSAID or COX-2 inhibitor, disenrolled from the health plan, developed a GI bleed, or reached the end of the 1-year follow-up period. A GI bleed was defined as an inpatient hospitalization for GI bleed or at least 2 medical claims with a primary diagnosis for GI bleed. The relative risk (RR) of GI bleed was calculated using proportional hazards regression. RESULTS: Overall, 35,007 pairs of COX-2 inhibitor and nonselective NSAID users were evaluated. Mean age was 63 years, and 65% were female. There were 375 cases of GI bleed among 19,201 follow-up years for COX-2 users (19.5 cases per 1,000 person-years) versus 228 cases of GI bleed among 12,680 follow-up years for NSAID users (18.0 cases per 1,000 person-years). The risk of GI bleed was not significantly different for COX-2 users compared with nonselective NSAID users (RR 1.07; 95% confidence interval [CI], 0.90-1.26). Even among high-risk patients, there was no reduction in the risk of a GI bleed among users of COX-2 inhibitors (RR 0.995; 95% CI, 0.84 -1.19). CONCLUSION: Overall, within this managed care population, COX-2 inhibitor users did not have a reduced risk of a GI bleed compared with patients with similar baseline characteristics using nonselective NSAIDs.

Adult↗

More care at home: the challenge of creating viable community alternatives to nursing home care.

Creating a national long-term care (LTC) delivery "infrastructure"--one that would make home-based care more accessible to people with extensive needs--will be a major undertaking. It will require new service organizations that have the authority to provide and coordinate an appropriate array of services. Medicaid Managed Long-Term Care (MLTC) and the Programs of All-Inclusive Care for the Elderly (PACE) offer two promising examples of what the service organizations of the future might look like. The history of how these plans developed illuminates challenges that others will encounter. Further expansion of these types of organizations requires resolution of resource, staffing, and operational issues.

Home Care Services↗

Quantifying ground water inputs along the Lower Jordan River.

The flow rate of the Lower Jordan River has changed dramatically during the second half of the 20th century. The diversion of its major natural sources reduced its flow rate and led to drying events during the drought years of 2000 and 2001. Under these conditions of low flow rates, the potential influence of external sources on the river discharge and chemical composition became significant. Our measurements show that the concentrations of chloride, calcium, and sodium in the river water decrease along the first 20-km section, while sulfate and magnesium concentrations increase. These variations were addressed by a recent geochemical study, suggesting that ground water inflow plays a major role. To further examine the role of ground water, we applied mass-balance calculations, using detailed flow rate measurements, water samplings, and chemical analyses along the northern (upstream) part of the river. Our flow-rate measurements showed that the river base-flow during 2000 and 2001 was 500 to 1100 L s(-1), which is about 40 times lower than the historical flow rates. Our measurements and calculations indicate that ground water input was 20 to 80% of the river water flow, and 20 to 50% of its solute mass flow. This study independently identifies the composition of possible end-members. These end-members contain high sulfate concentration and have similar chemical characteristics as were found in agricultural drains and in the "saline" Yarmouk River. Future regional development plans that include the river flow rate and chemistry should consider the interactions between the river and its shallow ground water system.

Environmental Monitoring↗

Procaine oral stabilised--Samaritan pharmaceuticals: SP-01, SP001.

Samaritan Pharmaceuticals (formerly Steroidogenesis Inhibitors) is developing a high-dose oral stabilised formulation of procaine hydrochloride [AnticortSP 01, SP001, Virucort] as an anticortisol drug for the treatment of HIV and AIDS. Preclinical investigations for its potential in the treatment of patients with Alzheimer's disease are also underway with Samaritan. The levels of cortisol, a hormone produced by the adrenal gland, are increased in many diseases, including AIDS. Serum cortisol levels are elevated during all stages of HIV infection, particularly in AIDS patients, whereas dehydroepiandrosterone (DHEA) levels are higher in the early stages of disease rather than in the advanced stages. Anticortisol drugs have been shown to reduce both the infectivity and the production of HIV in vitro. Anticort is available for licensing. Altachem Pharma had an exclusive licence to manufacture, use, distribute and sell oral procaine in Canada with an option to purchase the same rights for other Commonwealth countries. However, this agreement has been terminated. Cato Research in the US has been enlisted to implement a long-range clinical and business development plan to facilitate US FDA approval and manufacturing of the procaine formulation worldwide. Altachem Pharma received approval to begin a phase I trial of Anticort in Canada in HIV-positive patients receiving anti-HIV treatment. In January 2004, Cortisol Research International-Romania filed for orphan drug designation with the US FDA for Virucort 50 for the treatment of depression in children with HIV. A study examining the efficacy of Anticort in children infected with HIV has been conducted in Romania. One aspect of this study will investigate the possibility of reducing the dosage of zidovudine required if it is used in combination with Anticort. Following early indications that children treated with placebo in this trial have deteriorated while some children under the Anticort have shown improvements, especially in the 150-200mg group, Romanian clinicians have asked the Romanian FDA Commissioner for approval to switch children receiving placebo to receive Anticort.

Clinical Trials as Topic↗