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PubMed2002

Transcranial magnetic stimulation for treating depression.

BACKGROUND: Transcranial magnetic stimulation can either excite or inhibit cortical areas of the brain, depending on whether the speed of the repetitive stimulation is applied at high or low frequencies. It has been used for physiological studies and it has also been proposed as a treatment for depression. OBJECTIVES: To assess the clinical efficacy and safety of transcranial magnetic stimulation for treating depression. SEARCH STRATEGY: An electronic search was performed including the Cochrane Collaboration Depression, Neurosis and Anxiety Review Group trials register (last searched June, 2001), the Cochrane Controlled Trials Register (Issue 2, 2001), MEDLINE (1966-2001), EMBASE (1974-2001), PsycLIT (1980-2001), and bibliographies from reviewed articles. Unpublished data and grey literature were searched through personal communications with researchers. SELECTION CRITERIA: Randomised controlled trials assessing the therapeutic efficacy and safety of transcranial magnetic stimulation for depression. DATA COLLECTION AND ANALYSIS: All reviewers independently extracted the information and verified it by cross-checking. Disagreements were resolved through discussion. Continuous data: When similar studies were grouped, the overall standardised mean difference was calculated under a fixed effect model weighted by the inverse variance method with 95% confidence intervals. (In the presence of statistical heterogeneity, a random effects model was to be used.) MAIN RESULTS: Sixteen trials were included in the review and fourteen contained data in a suitable form for quantitative analysis. Most comparisons did not show differences between rTMS and other interventions. No difference was seen between rTMS and sham TMS using the Beck Depression Inventory or the Hamilton Depression Rating Scale, except for one time period (after two weeks of treatment) for left dorsolateral prefrontal cortex and high frequency; and also for right dorsolateral prefrontal cortex and low frequency, both in favour of rTMS and both using the Hamilton scale. Comparison of rTMS (left dorsolateral prefrontal cortex and high frequency) with electroconvulsive therapy showed no difference except for psychotic patients after two weeks treatment, using the Hamilton scale, which indicated that electroconvulsive therapy was more effective than rTMS. REVIEWER'S CONCLUSIONS: The information in this review suggests that there is no strong evidence for benefit from using transcranial magnetic stimulation to treat depression, although the small sample sizes do not exclude the possibility of benefit.

Depression↗
PubMed2002

Benchmarking in emergency health systems.

This paper discusses the role of benchmarking as a component of quality management. It describes the historical background of benchmarking, its competitive origin and the requirement in today's health environment for a more collaborative approach. The classical 'functional and generic' types of benchmarking are discussed with a suggestion to adopt a different terminology that describes the purpose and practicalities of benchmarking. Benchmarking is not without risks. The consequence of inappropriate focus and the need for a balanced overview of process is explored. The competition that is intrinsic to benchmarking is questioned and the negative impact it may have on improvement strategies in poorly performing organizations is recognized. The difficulty in achieving cross-organizational validity in benchmarking is emphasized, as is the need to scrutinize benchmarking measures. The cost effectiveness of benchmarking projects is questioned and the concept of 'best value, best practice' in an environment of fixed resources is examined.

Benchmarking↗
PubMed2000

Targets and reality: a comparison of health care indicators in the U.S. (Pittsburgh Epidemiology of Diabetes Complications Study) and Hungary (DiabCare Hungary).

OBJECTIVE: In the U.S., both primary care and specialist physicians share in the care of type 1 diabetic patients, often in an informal collaboration. In Hungary, however, type 1 diabetic patients are generally managed in special centralized diabetes units. These different treatment settings may lead to different health care practices and outcomes. To determine if this is true, diabetes care indicators and complications were compared across representative study populations from the 2 countries. RESEARCH DESIGN AND METHODS: The Pittsburgh Epidemiology of Diabetes Complications Study (EDC) is a prospective cohort of childhood-onset type 1 diabetic patients. DiabCare Hungary, a multicenter cross-sectional study, was developed for quality control purposes and provides a nationwide data set of diabetic patients. We identified 2 comparable populations (EDC, n = 416; DiabCare, n = 405) in terms of age (> or =14 years) and age at onset (<17 years). RESULTS: EDC patients were less likely to receive diabetes education (P<0.0001), see an ophthalmologist (P<0.0001), be treated by diabetologists (P<0.0001), or perform self-monitoring of blood glucose (P<0.0001). They were more likely to use conservative insulin regimens (i.e., 1-2 injections/day, P<0.0001) and have a higher glycated hemoglobin (P< 0.0001). DiabCare patients more often experienced severe hypoglycemia (P<0.01) and had a lower prevalence of proliferative retinopathy (P<0.0001), legal blindness (P<0.05), and albuminuria (> or =30 mg/day P<0.01). No significant differences in macrovascular complications were seen, although rates were generally low CONCLUSIONS: These data suggest that the 2 populations differ by their diabetes care practices, degree of glycemic control, and microvascular complication status.

Adolescent↗
PubMedDate not supplied

International perspectives: the profession of dietetics.

A survey about the professional characteristics of dietetics practice was mailed to 109 countries and representatives from 61 countries responded. Using the Human Development Index (HDI), a measure that reflects the life expectancy, education, and income of the population of each nation, countries were categorized as high, medium, or low HDI. This allowed comparisons among the HDI scores in the areas of education, professional practice, education, and practice competencies. Responding countries were 36.1% high HDI, 49.2% middle HDI, 8.2% low HDI, and 6.6% were unclassified. Dietetics was a nationally recognized profession in 81% of countries, with most having a professional association that represented dietitians. Clinical dietetics was the most frequently selected area of practice, followed by food service. Undergraduate academic programs in dietetics were available in 79% of countries and 49% offered graduate degrees. Most respondents rated competencies in clinical and community nutrition, along with competencies in professional practice, as important to their work. The results of this study can serve as a baseline as the profession evolves. Leaders in the dietetics profession can use these results to identify areas that need improvement. Collaboration with the United Nations family and sources that fund global initiatives can help in providing resources for the advancement of the profession. When the effectiveness of dietitians is improved, favorable changes in nutritional well-being on the global level can be expected.

Cross-Sectional Studies↗
PubMedDate not supplied

Infection control to quality improvement: the right time, the right place, the work to be done.

Many infection control epidemiologists are moving into the quality improvement field. The marriage of epidemiology with quality improvement is a logical step. Several things have to happen for this union to be successful, however. Most importantly, collaborative relationships must be forged with a variety of healthcare providers and practical, reliable, and valid indicators, and the methods for measuring them must be developed. This will take time, but epidemiologists should insist on and support the development of a robust discipline that combines the best of both worlds.

Cross Infection↗
PubMed2003

Experiences of professionals providing community care for disabled people in Nagasaki and Southampton.

OBJECTIVE: To report on the factors affecting the resolution of problems experienced by community care professionals and to refine a checklist of methodological issues for future cross-cultural comparative studies. DESIGN: A preliminary comparative study between Japan and the UK. SUBJECTS: 630 subjects in Nagasaki, Japan and 109 subjects in Southampton, UK who were physically disabled, aged over 40 years, living at home and currently using at least 1 of the community disability care services. METHODS: Community care professionals from a range of professions were asked about the backgrounds, physical disabilities and needs of their disabled subjects, and the difficulties experienced in providing them with care and rehabilitation services. RESULTS: The proportion of subjects for whom difficulties were experienced in providing services increased with increasing severity of disability in Southampton. By contrast, this trend was less pronounced in Nagasaki where difficulties were reported in approximately 95% of all cases. However, it proved much more difficult to enlist collaboration for this survey in Southampton than in Nagasaki and this led to selection bias in the Southampton sample. The professionals in Nagasaki were hampered by a lack of medical information about their subjects and by a lack of available resources for relieving family members from some of their burden of care. The nature and impact of multidisciplinary team meetings appeared to differ in the 2 countries. CONCLUSION: It is suggested that the provision of medical information and advice to staff working in community care is a factor of fundamental importance in enabling them to define objectives and to help identify disabled people's care and rehabilitation needs. The means by which such information and advice is shared appeared to differ in the 2 countries. Attenuated resources for community care and poor linkage between care organizations impair the ability of professional staff to resolve problems once they have been identified. It is suggested that each country could learn something from the other in improving the efficiency and impact of multidisciplinary community-based teams. In order to avoid the methodological difficulties in study design and implementation that we experienced, a 7-point checklist has been constructed to assist others who may be planning further cross-cultural studies in this field.

Activities of Daily Living↗
PubMed1994

Early urinary markers of target nephron segments as studied in cadmium toxicity.

A number of chemicals may adversely affect one or more of the anatomical structures of the kidney, such as the glomerulus, the tubular apparatus, the medullary, or interstitial cells. To recognize subclinical renal dysfunction, a battery of new, non-invasive tests was applied in comparison to established ones. The study on cadmium exposed subjects, performed within the framework of a collaborative European research project, exemplifies the concept of target selectivity within a nephron. One hundred seventy-two subjects were classified according to urinary cadmium excretion as controls (< 1.5 micrograms/g creatinine), or subjects with moderate or high cadmium body burden (1.5 to 5 micrograms/g creatinine, > 5 micrograms/g creatinine). Twenty-six urinary analytes (such as serum derived proteins, tubular enzymes, eicosanoids) and four plasma markers, related to the function or integrity of specific nephron segments, were investigated in a cross-sectional study. The group with the moderate cadmium body burden showed alterations of proximal tubular integrity, that is, increased excretion of tubular brush-border antigens. The group with higher cadmium body burden revealed an involvement of the whole nephron. The most prominent quantitative changes were found for the glomerular markers high molecular weight proteins, and thromboxane B2 and for the proximal tubular markers retinol binding protein, alpha 1-microglobulin, N-acetyl-beta-D-glucosaminidase, and the intestinal alkaline phosphatase. A diagnostic approach to screen for nephrotoxicity due to environmental hazards like cadmium should include proximal tubular markers (alpha 1-microglobulin and tubular enzymes, that is, intestinal alkaline phosphatase) but the measurement of glomerular markers is also advisable.

Adult↗
PubMed2003

Health career promotion in the New England area of New South Wales: a program to support high school career advisers.

OBJECTIVE: To facilitate the area's high school careers advisers' ability to effectively promote health careers to students. DESIGN: Three cross sectional evaluation surveys at the end of each one-day workshop. SETTING: Conference rooms in three regional centres (Armidale, Moree and Tamworth, New South Wales). SUBJECTS: Twenty-two high school careers advisers. INTERVENTION: One-day workshop. MAIN OUTCOME MEASURES: High school careers advisers' self-rated assessment in terms of the effective delivery of appropriate information and opportunities to network. RESULTS: Participants agreed that the workshop conveyed relevant information (3.8), were of high standard (3.5) and enabled them to identify students wanting to pursue health careers (2.9). Networking between health professionals and career advisers was rated as the most beneficial aspect by a majority of participants (60%). The scenario was rated as a useful tool to educate advisers about health careers (3.8). CONCLUSION: Collaborative workshops between advisers and health professionals are useful in facilitating networks to promote health careers in high schools in rural areas. The use of a farm injury scenario as a learning tool was effective in educating advisers about health careers. WHAT IS ALREADY KNOWN: Previous research carried out in the USA6 and Australia demonstrated that high school careers advisers needed to target high school students earlier in their studies before senior subjects were decided and that about a quarter of careers advisers indicated poor knowledge about health careers.10 WHAT THIS STUDY ADDS: Provision of practical support to high school careers advisers, such as distributing a mentorship directory and up-to-date health career kits as well as facilitating networking with health professionals constitute effective means to promote health careers to high school students.

Career Choice↗
PubMed2005

Towards consensus in the long-term management of relapse prevention in schizophrenia.

APPROACH TO DEVELOPING GUIDANCE: When developing guidance for the long-term management of schizophrenia, one approach is to adopt a proactive strategy that sets out clear treatment goals and strategies. This should involve a broad view being taken, embracing overall mental and physical well-being rather than simply the absence of illness. Although relapse prevention is an important goal of any long-term management strategy, there are other aspects that need to be considered, such as reintegration into society, regaining independence and quality of life. CURRENT TREATMENT: To help achieve these goals, a range of interventions can be incorporated into long-term management strategies for schizophrenia, including pharmacological interventions, psychosocial therapies and alliance-building initiatives. The current UK National Institute for Clinical Excellence guidelines already recommend that continuous therapy should be practised using an atypical (second-generation) antipsychotic drug, whenever possible, in preference to older typical drugs. The launch of the first long-acting atypical antipsychotic is an interesting new advance that may benefit many patients with schizophrenia. Psychosocial interventions, particularly family-based therapies, as well as cognitive behavioural and compliance therapies, when used alongside antipsychotics, have been shown to reduce relapse rates dramatically and to assist in social reintegration. In addition, forging collaborative alliances with patients and their carers can help to demystify schizophrenia and empower patients to take responsibility for their illness. CONSENSUS STATEMENT: This article outlines a consensus reached by a panel of leading UK healthcare professionals working with schizophrenia brought together to discuss long-term management strategies.

Antipsychotic Agents↗
PubMed2006

Association of serum MIP-1alpha, MIP-1beta, and RANTES with clinical manifestations, disease activity, and damage accrual in systemic lupus erythematosus.

The aim of this study was to determine if macrophage inflammatory protein (MIP) 1alpha, MIP-1beta, and RANTES (regulated upon activation normally T-cell expressed and secreted) serum concentrations are associated with clinical manifestations, disease activity, and damage accrual in patients with systemic lupus erythematosus (SLE). A cross-sectional study was performed in 62 SLE patients (per American College of Rheumatology criteria) participating in a longitudinal study and 20 healthy subjects. MIP-1alpha, MIP-1beta, and RANTES serum concentrations were determined by enzyme-linked immunosorbent assay. Demographic parameters, clinical manifestations, serologic features, pharmacologic treatments, disease activity, and damage accrual were determined at study visit. Disease activity was assessed with the Systemic Lupus Erythematosus Activity Measure (SLAM), and disease damage was assessed with Systemic Lupus International Collaborating Clinic Damage Index (SDI). The relation between the variables was studied with the Student t test and the Pearson r correlation test. SLE patients were more likely to have higher concentrations of MIP-1beta and RANTES than healthy individuals. In addition, they had a trend to have higher concentrations of MIP-1alpha. Patients with discoid lupus were more likely to have higher levels of MIP-1alpha. Elevation of MIP-1beta correlated with higher SDI score. No association was found between serum chemokines levels and disease activity. In conclusion, SLE patients have higher serum levels of MIP-1beta and RANTES than healthy individuals. MIP-1alpha is associated with discoid lupus, and MIP-1beta correlates with damage accrual in SLE. This study suggests that chemokines may have a role in the pathogenesis of SLE.

Adult↗
PubMed2001

Implementing and evaluating a rotating surveillance system and infection control guidelines in 4 intensive care units.

BACKGROUND: In clinical practice, scientific evidence about infection control is often ignored and hygiene rituals are followed. METHODS: Within an evidence-based infection control program, a quarterly rotating surveillance program for nosocomial infections was implemented in 4 intensive care units (ICUs) at the Aachen University Hospital, Germany. RESULTS: For the first time, the unit-specific nosocomial infection situation was made clear to the clinical staff by interpretive feedback of the surveillance data. This led to an increased awareness of infection control and a critical review of hygiene practices. After the first surveillance period, the hygiene practices of each ICU were revised and modified. The Centers for Disease Control and Prevention/Hospital Infection Control Practices Advisory Committee guidelines for the prevention of nosocomial infections were adopted and established in tight collaboration with the ward staff. CONCLUSIONS: Within the surveillance process, communication and team spirit between infection control and patient care personnel showed a remarkable improvement. Awareness and compliance with hospital hygiene and infection control practices could be raised without directive interaction.

Attitude of Health Personnel↗
PubMed2006

The level of cultural self-efficacy among a sample of Spanish nurses in southeastern Spain.

A collaborative study between faculty from the United States and Spain was undertaken to investigate levels of cultural self-efficacy among a sample of Spanish nursing students and nurses. Bandura's self-efficacy theory provided the conceptual framework for this descriptive study. The Spanish version of the Cultural Self-Efficacy Scale (CSES-S) was translated from the original developed by Bernal and Froman using the back-translation technique recommended by Brislin. The CSES-S was administered to 113 Spanish nurses and students. Alpha coefficient results for the CSES-S ranged from .90 to .95. Low to neutral levels of confidence in caring for four ethnic groups were found. Regression analyses showed significant relationships between cultural exposure and cultural self-efficacy for the practicing nurses. Results will assist this collaborative transcultural nursing research effort between the United States and Spain to develop and implement programs and experiences to increase cultural self-efficacy among Spanish nurses and improve care provided to Spain's diverse population.

Adult↗
PubMed1993

[How frequent is the diagnosis of GI metastasis in an endoscopic patient sample in general internal medicine clinics> Results of a questionnaire survey of 34 medical clinics].

With the aim of analysing the frequency of gastrointestinal (GI) metastases identified by endoscopic procedures, a survey was conducted by questionnaire, which was completed by 34 of 127 medical departments. Peritoneal carcinosis and direct tumor extension were disregarded. One GI metastasis (duodenum) was verified among 3477 upper GI tract endoscopies. Primary site was cutaneous melanoma. In another case metastatic origin is discussed (esophagus). Considering the average frequency of 102 upper GI tract endoscopies performed by the collaborating centers, one case of gastroduodenal metastasis could be expected every 17 (34) months in these institutions. 1634 examinations of the colon and rectum did not reveal any metastatic tumor growth. A longterm study is planned to provide further statistically reliable prevalence data.

Aged↗
PubMedDate not supplied

Job design for nurse case managers. Intended and unintended effects on satisfaction and well-being.

As managed care expands, nursing case management is becoming increasingly widespread. Yet little is known about the characteristics of the case manager job and its effects on nurses' workplace well-being. This study investigated hypothesized differences between the characteristics of nurse case manager and staff nurse jobs, including both intended positive and unintended negative effects associated with changes incorporated in the nurse case manager job. Nurse case managers reported significantly higher levels of autonomy, job identity, feedback from agents, and collaboration with physicians than staff nurses; however, they also reported higher levels of required interaction, role conflict, overload, and ambiguity. These findings have important implications for nurse case manager and the organizations that employ them, in relation to job design, career/candidate selection, and orientation and ongoing development.

Adult↗
PubMed2004

Health care and burden of illness in systemic lupus erythematosus compared to rheumatoid arthritis: results from the National Database of the German Collaborative Arthritis Centres.

During the past 20 years, outcome studies in the rheumatic diseases have, on the one hand, given increasing evidence of the unfavourable long-term prognosis of rheumatoid arthritis (RA) and on the other hand determined continuous improvement of prognosis in systemic lupus erythematosus (SLE). The aim of the study was to investigate how this translates into the current spectrum of patients with rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) seen by rheumatologists in Germany and to compare aspects of the burden of disease, disease outcomes and treatment between these two important rheumatic diseases using a large clinical database. Current health care was analysed with data from the German rheumatological database of 10 068 patients with RA and 1248 patients with SLE seen by rheumatologists in 2001. In addition, of a total of 3546 patients with SLE and 24 969 patients with RA seen at the German Collaborative Arthritis Centres between 1994 and 2001, 3465 cases of SLE were matched by age, sex, disease duration and referral status with a corresponding RA case. There were considerable differences in treatment of patients before referral to a rheumatologist and in rheumatologic care. In 2001, patients with SLE were treated by their rheumatologists mainly with antimalarials (AM, 37%), azathioprine (29%) and nonselective NSAIDs (16%). Of them, 61% received at least one immunosuppressive drug (including AM) plus glucocorticoids. In RA, methotrexate was the predominant medication (63%), and 56% received at least one immunosuppressive drug plus glucocorticoids. Matched pairs analysis showed that SLE patients with a short disease duration were almost equally burdened by pain, functional limitations and reduced health status as RA patients. After a disease duration of >10 years, however, patients with RA showed poorer outcomes than those with SLE: RA patients reported significantly more often severe pain (30% in RA versus 17% in SLE) and poor global health status (52 versus 38%), and their disease activity as well as severity was rated higher by the rheumatologists. In conclusion, comparing large groups of RA and SLE patients we found a similar burden in early but not in late disease. Taking into account limitations as to the generalizability of the results (recruitment in rheumatologic care, cross-sectional data, underestimation of SLE-specific outcomes), the discrepancy between the high increase in disease-related negative outcomes with longer disease duration in RA but not in SLE indicates a better long-term prognosis in SLE concerning the items observed. The great disparity in treatment intensity between rheumatologists and nonrheumatologists shows that the involvement of a specialist is needed equally in both diseases.

Adult↗
PubMed2003

Functional interaction of cytochrome P450 with its redox partners: a critical assessment and update of the topology of predicted contact regions.

The problem of donor-acceptor recognition has been the most important and intriguing one in the area of P450 research. The present review outlines the topological background of electron-transfer complex formation, showing that the progress in collaborative investigations, combining physical techniques with chemical-modification and immunolocalization studies as well as site-directed mutagenesis experiments, has increasingly enabled the substantiation of hypothetical work resulting from homology modelling of P450s. Circumstantial analysis reveals the contact regions for redox proteins to cluster on the proximal face of P450s, constituting parts of the highly conserved, heme-binding core fold. However, more variable structural components located in the periphery of the hemoprotein molecules also participate in donor docking. The cross-reactivity of electron carriers, purified from pro- and eukaryotic sources, with a diversity of P450 species points at a possible evolutionary conservation of common anchoring domains. While electrostatic mechanisms appear to dominate orientation toward each other of the redox partners to generate pre-collisional encounter complexes, hydrophobic forces are likely to foster electron transfer events by through-bonding or pi-stacking interactions. Moreover, electron-tunneling pathways seem to be operative as well. The availability of new P450 crystal structures together with improved validation strategies will undoubtedly permit the production of increasingly satisfactory three-dimensional donor-acceptor models serving to better understand the molecular principles governing functional association of the redox proteins.

Animals↗
PubMed2003

NELF and DSIF cause promoter proximal pausing on the hsp70 promoter in Drosophila.

NELF and DSIF collaborate to inhibit elongation by RNA polymerase IIa in extracts from human cells. A multifaceted approach was taken to investigate the potential role of these factors in promoter proximal pausing on the hsp70 gene in Drosophila. Immunodepletion of DSIF from a Drosophila nuclear extract reduced the level of polymerase that paused in the promoter proximal region of hsp70. Depletion of one NELF subunit in salivary glands using RNA interference also reduced the level of paused polymerase. In vivo protein-DNA cross-linking showed that NELF and DSIF associate with the promoter region before heat shock. Immunofluorescence analysis of polytene chromosomes corroborated the cross-linking result and showed that NELF, DSIF, and RNA polymerase IIa colocalize at the hsp70 genes, small heat shock genes, and many other chromosomal locations. Finally, following heat shock induction, DSIF and polymerase but not NELF were strongly recruited to chromosomal puffs harboring the hsp70 genes. We propose that NELF and DSIF cause polymerase to pause in the promoter proximal region of hsp70. The transcriptional activator, HSF, might cause NELF to dissociate from the elongation complex. DSIF continues to associate with the elongation complex and could serve a positive role in elongation.

Animals↗
PubMed1996

Learning about another culture: project and curricular reflections.

Over the past two years, an innovative collaborative project in the care of Ethiopian Jews who immigrated to Israel has been carried out. In this project, both students and faculty joined in activities of research and practice through a clinic at a trailer court that houses 96 Ethiopian immigrant families. This project brought about several favorable changes: a) Health of the underprivileged and underserved was enhanced through bi-weekly services provided to the poor and sick trailer court inhabitants; b) An educational program for learning in a cross-cultural community setting was developed. This curricula advanced recognition of the growing cultural and racial diversity of both individual and family lifestyles, as well as allowed for learning events that are based on substantive contact with, or participation by, persons at health risk; c) An educational milieu that fosters the use of research-based interventions was developed. This article describes the cross-cultural educational project which was designed as a pilot for a new baccalaureate program in nursing, and critiques it based on the criteria of the five major concepts--primacy of the teacher-student relationship, social responsibility, centrality of caring, interpretive stance and theoretical pluralism, proposed by the promoters of the "curriculum revolution."

Community Health Nursing↗