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PubMed2000

Organ transplantation in Latin America.

Organ transplantation is currently a form of treatment for end-stage organ disease in Latin America for which enthusiasm appears to be growing both in individual countries as well as in the whole region. The Latin-American Transplant Registry has been a factor in the development of communication among the different countries of the region and a focus for unification. Both renal and extra-renal organ transplantation have increased significantly during 1999 and for kidneys the activity is currently 12% of the world renal transplant statistics. Important evidence for the continuing development and maturity of transplantation in the region includes the number of new transplantation societies, the increase in the number of renal and extra-renal transplant programs, the development of national organ transplant registries, efforts towards analyzing costs and administration in transplantation and the incorporation of new immunosuppressants. The development of cardiac transplantation in Bolivia, Cuba, Paraguay, Perú, Puerto Rico and Uruguay, intestinal transplantation in Argentina, and liver transplantation in Bolivia all reflect a marked interest in organ transplantation in the different countries. Similarly, liver and cardiac transplantation are increasing at a very fast rate. End-stage organ disease is recognized as a growing health priority and organ donation as a critical limiting factor. Governments are directly and indirectly supporting transplantation initiatives. The return of trained transplant practitioners to their countries of origin also accounts for part of the increase in activity and for the organizational aspects of transplantation. The statistics presented in this report signify increasing maturity in the transplantation activities of Latin America.

Government Programs↗
PubMed1990

Barriers to the care of persons with dual diagnoses: organizational and financing issues.

Among the frustrations of managing the dual disorders of chronic mental illness and alcohol and drug abuse is the fact that knowing what to do (by way of special programming) is insufficient to address the problem. The system problems are at least as intractable as the chronic illnesses themselves. Organizing and financing care of patients with comorbities is complicated. At issue are the ways in which we administer mental health and alcohol and drug treatment as well as finance that care. Separate administrative divisions and funding pools, while appropriate for political expediency, visibility, and administrative efficiency, have compounded the problems inherent in serving persons with multiple disabilities. Arbitrary service divisions and categorical boundaries at the State level prevent local governments and programs from organizing joint projects or creatively managing patients across service boundaries. When patients cannot adapt to the way services are organized, we risk reinforcing their overutilization of inpatient and emergency services, which are ineffective mechanisms for delivering the care these patients need. This article reviews the barriers in organization and financing of care (categoric and third party financing, including the special problem of diagnosis-related groups limitations) and proposes strategies to enhance the delivery of appropriate treatment.

Alcoholism↗
PubMed2002

The Italian way to Continuing Education in Medicine.

BACKGROUND: Continuing education is a right and a duty for all professionals working in the healthcare system, and the Ministry of Health, has recently developed and introduced an experimental program for Continuing Education in Medicine (ECM) throughout Italy. METHODS: The guiding principles and values of ECM are to assure the quality of educational events and to ensure that professionals can choose from among several opportunities for gaining credits. Although promoted by regional healthcare authorities, the educational program must be homogeneous throughout the national territory. RESULTS: Over the last few months, the National Commission for ECM has defined the role and responsibilities of different organisms and authorities involved in the ECM program. Each professional is expected to gain a total score of at least 150 credits over a 5-year timespan. Moreover, the Commission has established criteria for the accreditation of educational initiatives, the verification of their quality, and the evaluation of the educational benefit participants have from them. CONCLUSIONS: The ECM program in Italy is here to stay. It provides professionals with the opportunity to improve the quality of their knowledge, competence, and skills. Medical associations can now reevaluate their role and commitment to improving the quality of healthcare by providing all professionals with a better education and qualifications.

Algorithms↗
PubMed2000

Police enforcement as part of a comprehensive bicycle helmet program.

BACKGROUND: Bicycle-related head injuries cause >150 deaths and 45 000 nonfatal injuries among children in the United States annually. Although bicycle helmets are highly effective against head injury, only 24% of US children regularly wear one. Georgia mandated bicycle helmet use for children, effective July 1993. During that summer, 1 rural Georgia community passed an ordinance instructing police officers to impound the bicycle of any unhelmeted child. We evaluated the effect of active police enforcement of this ordinance, combined with a helmet giveaway and education program. METHODS: During April 1997, approximately 580 children in kindergarten through grade 7 received free helmets, fitting instructions, and safety education. Police then began impounding bicycles of unhelmeted children. We conducted an observational study, unobtrusively observing helmet use just before helmet distribution, several times during the next 5 months, and once 2 years later. RESULTS: Before the program began, none of 97 observed riders wore a helmet. During the next 5 months, helmet use among 358 observed children averaged 45% (range: 30%-71%), a significant increase in all race and gender groups. In contrast, adult use did not change significantly. Police impounded 167 bicycles during the study, an average of 1 per day. Two years after program initiation, 21 of 39 child riders (54%) were observed wearing a helmet. CONCLUSIONS: Without enforcement, the state and local laws did not prompt helmet use in this community, yet active police enforcement, coupled with helmet giveaways and education, was effective and lasting.

Adolescent↗
PubMed2004

Environmental performance rating and disclosure: China's Green Watch program.

In this paper we describe a new incentive-based pollution control program in China, in which the environmental performance of firms is rated from best to worst using five colors--green, blue, yellow, red and black--and the ratings are disseminated to the public through the media. We focus on the first two municipal disclosure programs, which have been implemented at very different levels of economic and institutional development. In both cases, the increases in compliance with pollution regulations have been similar to increases produced by public disclosure programs in Indonesia, the Philippines, and Vietnam. The results suggest that incentives created by public disclosure may significantly reduce pollution in China, even though environmental NGO's play little role and there is no formal channel for public participation in environmental regulation.

China↗
PubMed1999

The Denver school-based adolescent hepatitis B vaccination program: a cost analysis with risk simulation.

OBJECTIVES: This study sought to compare the cost-effectiveness of a school-based hepatitis B vaccine delivery program with that of a vaccine delivery program associated with a network health maintenance organization (HMO). METHODS: The vaccination program enrolled 3359 sixth-grade students from 18 middle schools in Denver, Colo. Immunization status and direct and indirect program costs were compiled. The sensitivity of the outcomes was assessed by simulation methods. RESULTS: The per-dose cost-effectiveness ratio for the school-based delivery system was $31. This cost-effectiveness ratio remained stable when the model was simulated with costs that were underestimated or overestimated by 20%. In the network HMO, the direct cost per dose was $68 and the societal cost was $118 when the child's father worked full-time and the mother worked part-time. There is less than a 5% chance that the network HMO-based vaccination program could be more cost-effective than the school-based program. CONCLUSIONS: The cost per dose of the school-based program was significantly less than that of the network HMO-based program, because in the school program government-purchased vaccine was available at a lower cost and parents did not incur work-loss costs.

Adolescent↗
PubMed2002

Transcriptional program of mouse osteoclast differentiation governed by the macrophage colony-stimulating factor and the ligand for the receptor activator of NFkappa B.

Cytokines macrophage colony stimulating factor (M-CSF) and the receptor activator of NFkappaB ligand (RANKL) induce differentiation of bone marrow hematopoietic precursor cells into bone-resorbing osteoclasts without the requirement for stromal cells of mesenchymal origin. We used this recently described mouse cell system and oligonucleotide microarrays representing about 9,400 different genes to analyze gene expression in hematopoietic cells undergoing differentiation to osteoclasts. The ability of microarrays to detect the genes of interest was validated by showing expression and expected regulation of several osteoclast marker genes. In total 750 known transcripts were up-regulated by > or =2-fold, and 91% of them at an early time in culture, suggesting that almost the whole differentiation program is defined already in pre-osteoclasts. As expected, M-CSF alone induced the receptor for RANKL (RANK), but also, unexpectedly, other RANK/NFkappaB pathway components (TRAF2A, PI3-kinase, MEKK3, RIPK1), providing a molecular explanation for the synergy of M-CSF and RANKL. Furthermore, interleukins, interferons, and their receptors (IL-1alpha, IL-18, IFN-beta, IL-11Ralpha2, IL-6/11R gp130, IFNgammaR) were induced by M-CSF. Although interleukins are thought to regulate osteoclasts via modulation of M-CSF and RANKL expression in stromal cells, we showed that a mix of IL-1, IL-6, and IL-11 directly increased the activity of osteoclasts by 8.5-fold. RANKL induced about 70 novel target genes, including chemokines and growth factors (RANTES (regulated on activation, normal T cell expressed and secreted), PDGFalpha, IGF1), histamine, and alpha1A-adrenergic receptors, and three waves of distinct receptors, transcription factors, and signaling molecules. In conclusion, M-CSF induced genes necessary for a direct response to RANKL and interleukins, while RANKL directed a three-stage differentiation program and induced genes for interaction with osteoblasts and immune and nerve cells. Thus, global gene expression suggests a more dynamic role of osteoclasts in bone physiology than previously anticipated.

Animals↗
PubMed2001

New opportunities and proven approaches in complementary and alternative medicine research at the National Institutes of Health.

This presentation describes some of the issues that arise when applying the clinical-trial approach of conventional medicine to complementary and alternative medicine (CAM) modalities. Conventional medicine has been making the evolution to using an evidence base and to making recommendations only when the evidence is strong. The National Center for Complementary Medicine (NCCAM), one of twenty-five Institutes or Centers of the National Institutes of Health (NIH), is working to hold CAM to the same high standards, not by rejecting previous CAM research, but by building on that strong evidence base of what works and what is safe. The process for conventional drug and device development follows an orderly process of preclinical studies (usually on animals), phase I, phase II, and phase III studies (with the large human clinical trial phase taking place in phase III). Today, the randomized controlled trial is recognized as providing the highest level of scientific evidence. This conventional medicine approach to development is now being used to develop complementary and alternative therapies. For instance, the discovery and development of Taxol (Bristol-Meyers Squibb, New York, NY), an extract from the bark of the Pacific yew tree that is now a widely used chemotherapeutic agent, followed the conventional pathway to approval and marketing. But for most CAM products, the pathway is not so straightforward. Most CAM therapies are traditional therapies or new products that are already available to the public. Most of what is known about these therapies is of an anecdotal nature. There has been little isolation of the active principals from the crude product and there has usually been no preclinical testing. This presentation details various approaches and programs that address how to plan and conduct a rigorous clinical trial of a CAM product. And, while it takes a good deal of persistence and a strong focus on what are the critical principals in a trial, I conclude that it is possible to apply randomized controlled trials to most of the CAM modalities.

Complementary Therapies↗
PubMed2003

Characteristic substructures and properties in chemical carcinogens studied by the cascade model.

MOTIVATION: Chemical carcinogenicity is an important subject in health and environmental sciences, and a reliable method is expected to identify characteristic factors for carcinogenicity. The predictive toxicology challenge (PTC) 2000-2001 has provided the opportunity for various data mining methods to evaluate their performance. The cascade model, a data mining method developed by the author, has the capability to mine for local correlations in data sets with a large number of attributes. The current paper explores the effectiveness of the method on the problem of chemical carcinogenicity. RESULTS: Rodent carcinogenicity of 417 compounds examined by the National Toxicology Program (NTP) was used as the training set. The analysis by the cascade model, for example, could obtain a rule 'Highly flexible molecules are carcinogenic, if they have no hydrogen bond acceptors in halogenated alkanes and alkenes'. Resulting rules are applied to predict the activity of 185 compounds examined by the FDA. The ROC analysis performed by the PTC organizers has shown that the current method has excellent predictive power for the female rat data. AVAILABILITY: The binary program of DISCAS 2.1 and samples of input data sets on Windows PC are available at http://www.clab.kwansei.ac.jp/mining/discas/discas.html upon request from the author. SUPPLEMENTARY INFORMATION: Summary of prediction results and cross validations is accessible via http://www.clab.kwansei.ac.jp/~okada/BIJ/BIJsupple.htm. Used rules and the prediction results for each molecule are also provided.

Algorithms↗
PubMed2001

The u-boot mutation identifies a Hedgehog-regulated myogenic switch for fiber-type diversification in the zebrafish embryo.

Developmental programs that govern the embryonic diversification of distinct kinds of muscles in vertebrates remain obscure. For instance, the most widely recognized attribute of early diversity among skeletal myoblasts is their ability to differentiate exclusively into fibers with slow or fast contractile properties. However, we know little about the developmental basis and genetic regulation of this seminal event in vertebrate myogenesis. Here we show that in the zebrafish, the u-boot gene acts as a myogenic switch that regulates the choice of myoblasts to adopt slow versus fast fiber developmental pathways. In u-boot mutant embryos, slow muscle precursors abort their developmental program, failing to activate expression of the homeobox gene prox1 and transfating into muscle cells with fast fiber properties. Using oligonucleotide-mediated translational inhibition, we have investigated the role of prox1 in this program. We find that it functions in the terminal step of the u-boot controlled slow fiber developmental pathway in the regulation of slow myofibril assembly. Our findings provide new insight into the genetic control of slow versus fast fiber specification and differentiation and indicate that dedicated developmental pathways exist in vertebrates for the elaboration of distinct elements of embryonic muscle pattern.

Animals↗
PubMedDate not supplied

Early intervention for children and families: with special needs.

The purpose of this article is to provide a general overview of early intervention and how nurses can interface with this important program for children. "Early intervention" in this context refers to services for young children (birth to age 3) who have developmental delays or are at risk for delays, as well as for their families. These programs are administered by each state but are federally funded under Part C of the Individuals with Disabilities Act. The primary objective of early intervention is to maintain or maximize a child's development; a wide range of services may be provided including nursing, physical therapy, occupational therapy, and family counseling. Overall, early intervention programs have been shown to improve developmental outcomes, strengthen parent-child interactions, and provide a supportive family environment. There is a continued need for research, however, in many areas, including assessing the long-term effects of services for specific groups, determining the most effective means of providing services, and evaluating outcomes of family functioning.

Child Health Services↗
PubMed2002

The upward spiral of drug costs: a time series analysis of drugs used in the treatment of hemophilia.

BACKGROUND: Hemophilia is an expensive disease because its treatment is heavily dependent on costly clotting factor drugs. Over the last nine years,a consortium of three Comprehensive Hemophilia Treatment Centers and other hospitals, which purchased clotting factors for their patients, has seen treatment costs escalate on average 17% annually. Currently, new, even more expensive drugs are entering the market. METHODS: This study analyzes 3,244 purchases that were made over a nine-year period totaling nearly 500 million units of clotting factor, representing every product on the market. Purchases were made both apart from and under the Federal Public Health Service (PHS)discount pricing rules. FINDINGS: The main cause of the increases was the move to newer, more expensive products. The average price of existing products increased less than 2%per year, but new products were priced, on average, 47% higher than existing products. Overall consumption increased by an average of 5% per year, likely reflecting prophylactic treatment modalities that require greater amounts of clotting factor. Government pricing programs, such as the PHS program, were ineffective or counterproductive at reducing costs. There is a notable absence of competition in this market, with a few dominant companies having a functional monopoly in the largest segments of the market. Prices of older products are not lowered, even when new products are brought to market. A few products that serve small patient groups have had their prices increased substantially. INTERPRETATION: This escalation is likely to continue as new, more expensive clotting factor drugs are developed. Since these new products are not proven to be any safer or more effective than the current products, this situation creates a risk of intervention by government and insurers to address both treatment costs and exhaustion of patients' insurance caps. Drug companies are not serving the patients by pricing new, but often very similar, products so aggressively. The trends seen in this patient group will likely be seen in other patient groups in the future. Ultimately, doctors and patients will lose treatment options and health care availability unless collaborative strategies are developed to reduce costs.

Blood Coagulation Factors↗
PubMed2006

Multidrug-resistant tuberculosis management in resource-limited settings.

Evidence of successful management of multidrug-resistant tuberculosis (MDRTB) is mainly generated from referral hospitals in high-income countries. We evaluate the management of MDRTB in 5 resource-limited countries: Estonia, Latvia, Peru, the Philippines, and the Russian Federation. All projects were approved by the Green Light Committee for access to quality-assured second-line drugs provided at reduced price for MDRTB management. Of 1047 MDRTB patients evaluated, 119 (11%) were new, and 928 (89%) had received treatment previously. More than 50% of previously treated patients had received both first- and second-line drugs, and 65% of all patients had infections that were resistant to both first- and second-line drugs. Treatment was successful in 70% of all patients, but success rate was higher among new (77%) than among previously treated patients (69%). In resource-limited settings, treatment of MDRTB provided through, or in collaboration with, national TB programs can yield results similar to those from wealthier settings.

Antitubercular Agents↗
PubMed2003

Times, they are a-changing.

The outcome of the US elections in the fall of 2002 serve as symbol of the high degree of change currently affecting the fate of people with HIV. The political and economic environment raises serious concerns about the future of treatment access, support for medical care and the overall priority given the fight against HIV within the federal government. HIV programs, with the exception of research at the National Institutes of Health, have not seen increases in the President's budget since the current administration took office, despite obvious increases in demand. The recent election gives little reason to think that will change. Not only are different attitudes affective every aspect of HIV funding, but different people, with different agendas, have significant influence over federal HIV policy.

Anti-HIV Agents↗
PubMed2006

Updating the WIC food packages: it's about time.

This issue brief reviews key revisions to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program proposed by the USDA, which are based substantially on recommendations by the Institute of Medicine. Should the changes become regulation, they will be the most significant revision of the WIC food packages in over 25 years. This brief describes the changes, the impetus for their consideration, and possible implementation issues from the perspectives of vendors, state and local WIC agencies, and participants.

Adult↗
PubMed2003

Partners invited to participate in Steps to a HealthierUS. Notice.

The Department of Health and Human Services (HHS) seeks to work with other public and private sector organizations to support a new Federal initiative to promote better health for all Americans. This initiative is called Steps to a HealthierUS and is part of the President's HealthierUS Initiative to help Americans live longer, better, and healthier lives. This Steps Partnership initiative is not a grant or contract award program and each partner will be responsible for supporting its own activities. Working together, it is intended that these partnerships will provide innovative opportunities to promote healthier living and successfully promote the principles and efforts of the Steps initiative. More information about Steps is available at: http://www.healthierus.gov/steps/. Partnerships are not limited to any existing list of priority projects.

Community Health Planning↗
PubMed1999

Confessions of a psychotherapist.

The evolution of a therapist is the result of personal style, training, and social context. The author describes how his active involvement with people, love of telling stories, and desire to interact with others set the stage for his training as a psychoanalyst. He also discusses how the specific needs of patients drew him toward more active interaction with them, both within and outside therapeutic sessions. Supporting patients in their need to cope with a daily life meant intervening in their total system. The author's parallel work with community mental health and the development of the Healthy Cities program led to a broader understanding of the holistic sociopsychological experiences of people. As a result, he combined storytelling, assisting with job placement, dealing with day-to-day emergencies, and many more activities with analytic and cognitive therapy. Although the author recognizes that as a therapist he breaks boundaries, he respects the approaches of therapists who work in more standard ways, which are also helpful, effective, and needed.

California↗
PubMed2002

Violence against women: the state of batterer prevention programs.

While both men and women can be victims, domestic violence usually consists of assaults on women, and most violence against women occurs within an intimate relationship. In the past twenty years, numerous state and provincial programs to intervene in domestic violence cases have developed. The programs tend to focus on treating batterers, although they also offer counseling to domestic violence victims. The jury remains out on the effectiveness of these programs. A major issue is whether the programs use appropriate standards. After an overview of the prevalence and nature of domestic violence, this article provides a discussion of those standards--their nature, effectiveness, and limitations. Another section discusses use of a batterer intervention program in an urban setting. Yet another section explores the implications of intimate partner violence and looks again at the effectiveness of batterer treatment within intervention programs. The article closes with a look at the way one state addresses domestic violence and treats it as a crime. An inescapable conclusion to be drawn from the discussion is that violence against women has its roots in cultural assumptions that must undergo change if the incidence of that violence is to be reduced.

Battered Women↗