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[Community requirements relating to drugs derived from human blood and plasma].

Since the adoption of the first pharmaceutical directive in 1965, the pharmaceutical legislation of the European Community has constantly pursued two objectives: the protection of public health and the free movement of products. Directive 89/381/EEC covers stable industrially prepared blood derivatives, intended for a large number of patients, namely albumin, coagulation factors and immunoglobulins. Whole blood, plasma and cellular components are excluded from the scope of the directive. As a consequence of the inclusion of blood derivatives in Community pharmaceutical legislation, these products are now subject to its general provisions regarding manufacturing and marketing authorization. The principles of good manufacturing practice laid down in Directive 91/356/EEC and detailed in a guide for manufacturers have become mandatory, as well as the tests in Directive 91/507/EEC aimed at demonstrating quality, safety and efficacy for the purpose of marketing authorization. The European format for the application file as well as the Community procedures for marketing authorization are applicable. In addition to these general provisions, which are applicable to all medicinal products, Directive 89/381/EEC contains several elements which are specific to medicinal products derived from human blood or plasma. The measures for selection and control of blood donors recommended by the Council of Europe and the World Health Organization have become compulsory. Moreover, for these particularly sensitive products, the Council has explicitly demanded the application of validated manufacturing and purification processes, in order to guarantee, insofar as the state of technology permits, the absence of specific viral contamination. For new medicinal products, the Directive entered into force on 1 January 1992. For products already on the market, a transitional period of one year was provided, during which the Member States had to proceed with the review of these products. The objective of Community self-sufficiency in blood and blood derivatives by voluntary unpaid donations is clearly expressed in the text of the Directive and the Member States have to inform the Commission on measures taken in this area. Thus, in adopting the Directive, the 12 Member States established as an objective that self-sufficiency be attained through voluntary unpaid blood donation. But, in addition to the Directive, the general rules of the EC Treaty are applicable, namely with regard to free movement of products, public procurement and monopolies.

Blood↗

HIV and other viruses in surgery: a continued occupational risk.

Hepatitis viruses and HIV represent known and suspected occupational risks to surgeons. A better understanding of these diseases will allow surgeons to provide better and more compassionate care for their patients. It is essential that surgeons view blood as a toxic substance in the operating room. Reducing potential risks can be achieved best by improvement of operating room barriers, modification of techniques used in operations, and a prompt response when blood contact or exposure occurs. Mandatory or socially imposed voluntary testing for HIV testing for patients and physicians (1) is unnecessary; (2) is expensive; and (3) continues the socio-political debate about this disease. It is time for HIV to be treated like a disease and not a social pariah. To do otherwise will result in denial of care for patients and will result in yet another adversarial issue to be interposed between surgeons and patients.

Acquired Immunodeficiency Syndrome↗

The "seat belt mark" sign: a call for increased vigilance among physicians treating victims of motor vehicle accidents.

The use of seat belts is shown to cause a specific pattern of internal injuries. Skin bruise corresponding to the site of the seat belt is known as the "seat belt mark" (SBM) sign and is associated with a high incidence of significant organ injuries. No study has yet defined the exact incidence of injuries requiring intervention at the presence of this sign. The objective of this study was to find the incidence of surgically correctable injuries in belted car occupants with a SBM sign and to define strategies of early detection and treatment of such injuries. The prospective study included consecutive patients involved in road traffic accidents who were admitted at an academic Level I trauma center. Of 650 car occupants, 410 (63%) were restrained and 77 (12%) had a SBM across the abdomen, chest or neck. The injuries of these 77 patients were compared with the injuries of belted patients without an SBM sign. Of patients with SBMs, 9 per cent had neck bruises, 32 per cent had chest bruises, 40 per cent had abdominal bruises, and 19 per cent had bruises in multiple sites. No significant neck injuries were detected. Three patients were found to have myocardial contusion, and 10 patients had intra-abdominal injuries (predominantly bowel and mesenteric lacerations) requiring laparotomy. There was a near 4-fold increase in thoracic trauma (22.5% versus 6%; P=0.01) and a near 8-fold increase in intra-abdominal trauma (23% versus 3%; P < 0.0001) between the groups of patients with and without SBMs. The presence of the SBM sign should alert the physician to the high likelihood of specific internal injuries. Routine laparotomy or mandatory evaluation by specific diagnostic tests is not justified; rather, a high index of suspicion with a low threshold for appropriate diagnostic evaluation and/or surgical exploration should be maintained for the optimal management of such patients.

Abdominal Injuries↗

Thiobarbituric acid-reactive malondialdehyde formation during superoxide-dependent, iron-catalyzed lipid peroxidation: influence of peroxidation conditions.

A systematic study of the influence of biological lipid peroxidation conditions on lipid hydroperoxide decomposition to thiobarbituric acid-reactive malondialdehyde is presented. A superoxide-dependent, iron-catalyzed peroxidation system was employed with xanthine oxidase plus hypoxanthine plus ferric iron-adenosine diphosphate complex as free radical generator. Purified cardiac membrane phospholipid (as liposomes) was the peroxidative target, and 15-hydroperoxy-eicosatetraenoic acid was used as a standard lipid hydroperoxide. Exposure of myocardial phospholipid to free radical generator at physiological pH (7.4) and temperature (37 degrees C) was found to support not only phospholipid peroxidation, but also rapid lipid hydroperoxide breakdown and consequent malondialdehyde formation during peroxidation. Under lipid peroxidation conditions, oxidative injury to the phospholipid polyunsaturated fatty acids required superoxide radical and ferric iron-adenosine diphosphate complex, whereas 37 degrees C temperature and trace iron were sufficient for lipid hydroperoxide decomposition to malondialdehyde. Harsh thiobarbituric acid-test conditions following peroxidation were not mandatory for either lipid hydroperoxide breakdown or thiobarbituric acid-reactive malondialdehyde formation. However, hydroperoxide decomposition that had begun in the peroxidation reaction could be completed during a subsequent thiobarbituric acid test in which no lipid autoxidation took place. Iron was more critical than heat in promoting the observed hydroperoxide decomposition to malondialdehyde during the lipid peroxidation reaction at 37 degrees C and pH 7.4. These data demonstrate that the radical generator, at physiological pH and temperature, serves a dual role as both initiator of membrane phospholipid peroxidation and promotor of lipid peroxide breakdown and thiobarbituric acid-reactive malondialdehyde formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Human immunodeficiency virus, hepatitis C and hepatitis B infections among blood donors in Germany 2000-2002: risk of virus transmission and the impact of nucleic acid amplification testing.

Blood and plasma donations in Germany are collected by several institutions, namely the German Red Cross, community and hospital-based blood services, private blood centres, commercial plasma donation sites and transfusion services of the army. All blood donation centres are required to report quarterly data on infection markers to the Robert Koch Institute, thus providing current and accurate epidemiological data. The prevalence and incidence of relevant viral infections are low in the blood donor population in Germany, with a decreasing trend for hepatitis C infections in new and repeat donors since 1997. The implementation of mandatory nucleic acid amplification technique (NAT) testing for hepatitis C virus (HCV) in 1999 has markedly improved transfusion safety. HIV-NAT became mandatory in 2004 but was done voluntarily by the majority of the blood donation services before then. The potential benefit of hepatitis B virus (HBV) minipool NAT is not as clear because chronic HBV carriers with very low virus levels might donate unidentified. The residual risk of an infectious window period donation inadvertently entering the blood supply can be estimated using a mathematic model which multiplies the incidence rate by the number of days during which an infection may be present but not detectable, i.e. the length of the window period. The risk of an undetected infection without NAT testing was estimated to be 1 in 2,770,000 for HIV, 1 in 670,000 for HCV and 1 in 230,000 for HBV in 2001/2002. This contrasts with 1 in 5,540,000 for HIV, 1 in 4,400,000 for HCV and 1 in 620,000 for HBV with minipool NAT testing. This demonstrates that NAT testing can further reduce the already very small risk of infectious donations entering the blood supply.

Blood Transfusion↗

Japanese healthcare system: in vitro diagnostic tests and reimbursements.

In 1961, a new and mandatory National Health Insurance plan was enacted in Japan. This healthcare system has succeeded in providing universal coverage while also containing the growth of national medical expenditures (NME) to the rate of growth of the gross national product (GNP), namely, approximately 4-5% annually, for several decades. All Japanese medical procedures, including dental procedures, prescription drugs, and diagnostic tests, are reimbursed by a fee schedule set by the Ministry of Health and Welfare. The combination of strict fee control and low administration costs has kept the Japanese NME growth below that of the GNP. In 1990, NME was 20.6 trillion yen ($187 billion), total diagnostic testing expenditures (DTE) were 2.3 trillion yen, representing 11.2% of national medical expenditures (NME). Of this amount, in vitro diagnostic testing accounted for 1.4 trillion yen, representing 61% of DTE and 6.8% of NME. Annually, 1.8 billion in vitro diagnostic tests are performed.

Clinical Laboratory Techniques↗

Screening children for tuberculosis based on residence in a high-prevalence inner-city community.

In January 1994, the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP) published detailed guidelines on tuberculin skin testing of children. These guidelines required mandatory screening of all children residing in high-prevalence communities. In February 1996, the AAP published updated and revised guidelines that allowed for targeted screening of such children based on epidemiologic risk of acquiring tuberculosis. We report on an assessment of the effectiveness of mandatory screening for tuberculosis in a high prevalence community.

Child↗

Development and initial evaluation of a novel urology curriculum for medical students.

PURPOSE: After the development and implementation of a novel urology curriculum for medical students we evaluated urological learning by medical students using a validated measure of learning in the 4 clinical areas of benign prostatic hyperplasia, erectile dysfunction, prostate cancer and prostate specific antigen screening. MATERIALS AND METHODS: Third year medical students completed an online validated pre-test and post-test immediately before and after the mandatory 1-week clinical rotation in urology. Online pre-surveys and post-surveys were also administered. Overall student participation was 90% (37 of 41) with 63% of students (26 of 41) completing all 4 tests and surveys. RESULTS: Student overall test scores improved significantly upon completion of the 1-week clinical rotation in urology (p <0.001). A trend toward increased learning by male students was identified (p = 0.07). Significant variation in exposure to outpatient clinics and in the performance of physical examination skills was observed among the different teaching sites. CONCLUSIONS: This study demonstrates significant learning by medical students during their 1-week clinical rotation in urology. Further data are needed to confirm the trend toward increased learning by males and elucidate its etiology. Scheduling changes have been implemented to address the inconsistencies across clinical sites.

Adult↗

Acute inhalation toxicity testing: considerations of technical and regulatory aspects.

The EU regulatory statute for the acute hazard identification of chemicals requires selection of the two most appropriate routes of administration. Testing employing the oral route is mandatory, whereas selection of the dermal or inhalation route requires expert judgement, i.e. considerations of structural alerts with regard to the inherent acute inhalation toxicity as well as the likelihood of dermal and inhalation exposure, respectively. Currently, testing of chemicals requires acute inhalation exposure of 4-h and 1-h durations according the EU classification and labelling and UN Transport Guidelines, respectively. The analysis made revealed that 1-h exposures appear to add little knowledge in addition to existing 4-h LC50 values and a default value of 4 should be used for conversion of 4-h to 1-h LC50 values, independently of the physical state of the chemical. Therefore, also the unit of concentration of exposure atmospheres should be independent of nominal features of the test substance. Hence, the preferred dose metric is mass (mg/liter air) rather than volume (ppm). Taking into account the overall variability of acute toxicity data the recommendations given are classification into the following groups of 4-h LC50 values: < or = 0.05, > 0.05-0.2, > 0.2-1, > 1-5 and > 5.0 mg/l. No distinction should be made concerning vapours and aerosols with regard to units and conversion factors from 4-h to 1-h LC50 values and the default factor of 4 appears to be most suitable. Further differentiation of classification is not indicated due to technical variability of acute inhalation testing and resolution of the acute bioassay.

Administration, Inhalation↗

Ethical considerations in testing workers for the -Glu69 marker of genetic susceptibility to chronic beryllium disease.

OBJECTIVE: The most compelling real-world example of genetic testing for susceptibility to a workplace exposure involves those industries that process or fabricate beryllium. We examined ethical issues associated with testing for susceptibility to chronic beryllium disease. METHODS: Using ethical and clinical criteria, we examined voluntary employer-sponsored testing programs in which individual results are reported directly to workers in a confidential manner. RESULTS: Under reasonable assumptions, the longitudinal positive predictive value of the HLA-DPB1-Glu69 marker of susceptibility to beryllium disease is 12%. Interpretive challenges further limit the utility of the test and may inadvertently suggest a false sense of safety among workers. Concerns about confidential participation and pressures to be tested also must be addressed. CONCLUSIONS: Difficulties surrounding the interpretation of the HLA-DPB1-Glu69 marker, lack of assurance regarding the protection of worker confidentiality, and the potential lowering of social barriers to the implementation of mandatory worker screening combine to make testing beryllium workers inappropriate at this time.

Berylliosis↗

Volume-controlled intermittent mandatory ventilation in preterm infants with hypoxemic episodes.

OBJECTIVE: To test the hypothesis in ventilated very low birth weight infants with frequent hypoxemic episodes that volume-controlled synchronized intermittent mandatory ventilation (SIMV) vs. pressure-controlled SIMV reduces by at least 20% the time with hypoxemia (defined as SpO(2)<80%). DESIGN: Randomized cross-over design. SETTING: University-based tertiary neonatal intensive care unit. PATIENTS: 15 mechanically ventilated very low birth weight infants with frequent hypoxemic episodes. INTERVENTIONS: The infants were exposed in random order to volume-controlled and pressure-controlled SIMV for 4 h each. The target tidal volume during volume-controlled SIMV was matched to the tidal volume measured during pressure-controlled SIMV. FIO(2) was adjusted using uniform criteria to maintain SpO(2) within the target range (SpO(2) 80-92%). MEASUREMENTS AND RESULTS: Primary outcome measure was the time with an SpO(2)<80%. Although tidal volume was maintained better during desaturations with volume-controlled SIMV, there was neither a significant difference in time with an SpO(2)<80% (expressed as proportion of total experimental time; median, interquartile range)-volume-control 10.6% (9.2-13.7%) vs. pressure-control 10.8% (8.3-13.3%)-nor in FIO(2) exposure. During volume-controlled SIMV the infants spent less time with an SpO(2) above the target range and had fewer associated bradycardias. CONCLUSION: Volume-controlled SIMV did not decrease the time with an SpO(2)<80%, although tidal volume was better maintained during these episodes and bradycardias were less frequent than with pressure-controlled SIMV in this population of very low birth weight infants with frequent hypoxemic episodes.

Cross-Over Studies↗

[Human papillomavirus and screening for cervical cancer: state of art and prospects].

More than 99% of all cervical cancers contain high risk HPV. Only a persistent infection with high risk HPV of the cervical epithelium results in cervical cancer. Because the risk of cervical cancer is identical for all different HPV types, tests which detect all 14 high risk HPV types at one time are sufficient for clinical management. Testing for hr-HPV is mandatory for women with mild dyskaryosis and for the follow-up of women treated for CIN lesions. Based on efficiency to detect CIN3 and cervical cancer and preliminary cost benefit analysis, the combination of a high risk HPV test in conjunction with a cervical smear appears to be the best way of cervical cancer screening. A definite point of view on using high risk HPV testing for primary screening for cervical cancer will be obtained after the completion of a randomized trial of 44,000 women, in which the efficiency to detect CIN3 and cervical cancer by high risk HPV testing in conjunction with a cytomorphological smear is compared with screening by classical cytology.

Adult↗

Social acceptability of HIV screening among pregnant women.

The paper presents the results of a survey about risk perception, knowledge, and attitudes towards HIV infection among 397 pregnant women in France. The survey was carried out between December 1987 and March 1988 in two Paris-region maternity hospitals where HIV testing is routinely proposed during the first prenatal visit. Uptake of HIV prenatal testing has been rapid in France: before coming to the maternity hospitals, 26.5% of women had already been tested. Social acceptability of testing is high, 68.8% of the sample even supporting mandatory prenatal HIV screening. Such acceptability appears to be based less on an in-depth knowledge about the risks of transmission from mother-to-fetus than on the general French context of free-of-charge mandatory prenatal care and on the potentially reassuring effect of a true negative test. Consensus about abortion for HIV-infected pregnant women is strong (80.1%) and is not influenced by religious beliefs, in contrast to attitudes toward abortion in the case of fetal handicaps. This social environment creates special difficulties for the management of the complex dilemmas regarding pregnancy and childbearing for HIV-infected women.

AIDS Serodiagnosis↗

Notification of HIV carriers: possible effect on uptake of AIDS testing.

Passing of the AIDS Prevention Bill, which demands the notification of human immunodeficiency virus (HIV) carriers, seems imminent in Japan. Its effect on people's willingness to be tested for the HIV antibody was assessed among heterosexual subjects (students, office workers) and groups at high risk of the acquired immunodeficiency syndrome (AIDS) (prostitutes, homosexual males) by means of a questionnaire. More than 70% of the 811 students and 509 workers replied that, if notification became mandatory, they would agree to be tested but 10% of the males and 17% of the females in these two groups would prefer testing at institutes not complying with the clause; all 198 prostitutes said that they would be prepared to undergo testing but 35% of them would prefer to go to non-complying clinics; 45% (410) of 902 homosexual males replied that they would refuse testing, and 65% of those who would agree to be tested (492) would prefer to go to non-complying clinics. These findings strongly suggest that when the bill is passed the greater the self-perceived risk of HIV infection the poorer will be the uptake of AIDS testing. Hence the bill would be counterproductive in the surveillance of potential HIV carriers.

Acquired Immunodeficiency Syndrome↗

Teaching research methodology in medical schools: students' attitudes towards and knowledge about science.

OBJECTIVE: To explore the relationship between teaching scientific methodology in Year 2 of the medical curriculum and student attitudes towards and knowledge about science and scientific methodology. DESIGN: Anonymous questionnaire survey developed for this purpose. SETTING: Zagreb University School of Medicine, Croatia. PARTICIPANTS: A total of 932 students (response rate 58%) from all 6 years were invited to participate. MAIN OUTCOME MEASURES: Score on attitude scale with 45 Likert-type statements and score on knowledge test consisting of 8 multiple choice questions. RESULTS: The average attitude score for all students was 166 +/- 22 out of a maximum of 225, indicating a positive attitude towards science and scientific research. The students' average score on the knowledge test was 3.2 +/- 1.7 on 8 questions. Students who had finished Year 2 had the highest mean attitude (173 +/- 24) and knowledge (4.7 +/- 1.7) scores compared with other year groups (P < 0.001, anova and Tukey posthoc test). For students who had attended a mandatory Year 2 course on the principles of scientific research in medicine (Years 3 to 6), multiple linear regression analysis showed that knowledge test score (B = 3.4; SE = 0.4; 95% confidence interval 2.5-4.2; P < 0.001) and average grades (B = 7.6; SE = 1.5; 95% CI 4.6-10.6; P < 0.001) were significant predictors of attitude towards science, but not sex or failure to pass a year (B = - 0.6; SE = 1.7; 95% CI - 3.9-2.6; P = 0.707; and B = - 3.1; SE = 1.9; 95% CI - 6.8-5.7; P = 0.097, respectively). CONCLUSION: Medical students have generally positive attitudes towards science and scientific research in medicine. Attendance of a course on research methodology is related to a positive attitude towards science.

Biomedical Research↗

Skin-test screening and tuberculosis transmission among the homeless.

We describe the implementation of a mandatory tuberculosis (TB) screening program that uses symptom screening and tuberculin skin testing in homeless shelters. We used the results of DNA fingerprinting of Mycobacterium tuberculosis isolates to evaluate the effect of the program on TB incidence and transmission. After the program was implemented, the proportion of cases among homeless persons detected by screening activities increased, and the estimated TB incidence decreased from 510 to 121 cases per 100000 population per year. Recent transmission, defined by DNA fingerprinting analysis as clustered patterns occurring within 2 years, decreased from 49% to 14% (p=0.03). Our results suggest that the shelter-based screening program decreased the incidence of TB by decreasing its transmission among the homeless.

Colorado↗

Nuclear medicine imaging to predict response to radiotherapy: a review.

PURPOSE: To review available literature on positron emission tomography (PET) and single photon emission computerized tomography (SPECT) for the measurement of tumor metabolism, hypoxia, growth factor receptor expression, and apoptosis as predictors of response to radiotherapy. METHODS AND MATERIALS: Medical literature databases (Pubmed, Medline) were screened for available literature and critically analyzed as to their scientific relevance. RESULTS: Studies on 18F-fluorodeoxyglucose PET as a predictor of response to radiotherapy in head-and-neck carcinoma are promising but need confirmation in larger series. 18F-fluorothymine is stable in human plasma, and preliminary clinical data obtained with this marker of tumor cell proliferation are promising. For imaging tumor hypoxia, novel, more widely available radiopharmaceuticals with faster pharmacokinetics are mandatory. Imaging of ongoing apoptosis and growth factor expression is at a very early stage, but results obtained in other domains with radiolabeled peptides appear promising. Finally, for most of the tracers discussed, validation against a gold standard is needed. CONCLUSION: Optimization of the pharmacokinetics of relevant radiopharmaceuticals as well as validation against gold-standard tests in large patient series are mandatory if PET and SPECT are to be implemented in routine clinical practice for the purpose of predicting response to radiotherapy.

Apoptosis↗