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Administering, documenting, and tracking blood products and volume expanders.

A quality improvement program designed to facilitate the administration, tracking, and documentation of blood products and volume expanders resulted in improved patient safety, improved efficiency, more accurate documentation, and enhanced resource management. Key to the success of the program were the Transfusion Administration Record, the blood product administration guide, and on-line transfusion history recording.

Blood Transfusion↗

Promoting activity in the elderly through interdisciplinary linkages.

Interdisciplinary collaboration helped a group of health care providers plan, implement, and evaluate an exercise program for sedentary older adults in a long-term care facility. The program, designed as a research study, can be implemented by paraprofessional care givers with minimal supervision. The synergy resulting from collaboration between the investigator and colleagues in the practice arena was the cornerstone of the program's success. This paper describes the results of a Sit and Get Fit exercise program, a project funded by The University of Akron.

Aged↗

Brainvox: an interactive, multimodal visualization and analysis system for neuroanatomical imaging.

A study of cognition emerging from a neurobiological perspective, as opposed to one emerging from a purely computational or psychological perspective, begins with observations of the human brain in normal and pathological states and is furthered by the investigation of hypotheses which are articulated using neuroanatomical nomenclature. Brainvox is an interactive three-dimensional brain imaging software package designed to permit such research through the support of the description and quantification of brain pathology in magnetic resonance images and of the experimental investigation of human cognition in lesion and functional imaging studies. Important general features of Brainvox, for these purposes, are: (1) adaptation of volume rendering for brain lesions and for corendered datasets; (2) shared memory architecture, which enables the user to identify and label anatomical structures, while inspecting the brain in multiple views simultaneously; (3) modular program design, including interlocking command-line utilities, which make Brainvox extensible and empower users without programming expertise to implement new analysis techniques through Unix shell scripting; and (4) full integration of three-dimensional tools for visualization with tools for analysis. Specific features include a new object templating technique (MAP-3) for studies of groups of brain-lesioned subjects, a complete and extensible suite of command-line processing utilities, a three-dimensional optimal graph-searching tool, and a method for planning PET slices and matching MR and PET slices (MP_FIT).

Artificial Intelligence↗

Understanding substrate specificity in human and parasite phosphoribosyltransferases through calculation and experiment.

We present molecular dynamics (MD) simulations on two enzymes: a human hypoxanthine-guanine-phosphoribosyltransferase (HGPRTase) and its analogue in the protozoan parasite Tritrichomonas foetus. The parasite enzyme has an additional ability to process xanthine as a substrate, making it a hypoxanthine-guanine-xanthine phosphoribosyltransferase (HGXPRTase) [Chin, M. S., and Wang, C. C. (1994) Mol. Biochem. Parasitol. 63 (2), 221-229 (1)]. X-ray crystal structures of both enzymes complexed to guanine monoribosyl phosphate (GMP) have been solved, and show only subtle differences in the two active sites [Eads et al. (1994) Cell 78 (2), 325-334 (2); Somoza et al. (1996) Biochemistry 35 (22), 7032-7040 (3)]. Most of the direct contacts with the base region of the substrate are made by the protein backbone, complicating the identification of residues significantly associated with xanthine recognition. Our calculations suggest that the broader specificity of the parasite enzyme is due to a significantly more flexible base-binding region, and rationalize the effect of two mutations, R155E and D163N, that alter substrate specificity [Munagala, N. R., and Wang, C. C. (1998) Biochemistry 37 (47), 16612-16619 (4)]. In addition, our simulations suggested a double mutant (D106E/D163N) that might rescue the D163N mutant. This double mutant was expressed and assayed, and its catalytic activity was confirmed. Our molecular dynamics trajectories were also used with a structure-based design program, Pictorial Representation Of Free Energy Changes (PROFEC), to suggest parasite-selective derivatives of GMP. Our calculations here successfully rationalize the parasite-selectivity of two novel inhibitors derived from the computer-aided design of Somoza et al. (5) and demonstrate the utility of PROFEC in the design of species-selective inhibitors.

Animals↗

The first de novo-designed antagonists of the human NK(2) receptor.

The de novo molecular design program SPROUT has been used in conjunction with a molecular model to produce a molecular template for a new class of NK(2) receptor antagonist. An efficient, stereocontrolled synthesis of a small series of molecules, designed to test the validity of this template, was developed. Competition assays using recombinant human NK(2) receptor support the structural requirements of this new designed molecular template.

Binding Sites↗

The war on obesity: a social determinant of health.

ISSUE ADDRESSED: The weight-centred health paradigm is an important contributor to the broader cultural paradigm in which corpulence is eschewed in favour of leanness. The desirability to reduce body fat or weight or to prevent gaining 'excess' fat is driven by both aesthetic and health ideals. The 'war on obesity' is a broad health-based set of policies and programs designed to problematise 'excess' body fat and create solutions to the 'problem'. There is a substantial body of literature that claims to demonstrate the harmful effects of 'excess' body fat. Recent critiques of 'obesity prevention' programs have highlighted the importance of focusing on environmental changes rather than individuals due in part to the risk of harmful consequences associated with individualistic, victim-blaming approaches. Beyond this, there are suggestions that framing body weight as the source of health problems - known as the weight-centred health paradigm - is in itself a harmful approach. The range of harms includes body dissatisfaction, dieting, disordered eating, discrimination and death. Health promotion policies and programs that operate within the weight-centred paradigm have the potential to have a negative impact on the health and well-being of individuals and communities.

Adolescent↗

Unit-based acute confusion resource nurse: an educational program to train staff nurses.

Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.

Acute Disease↗

Two-dimensional graphic analysis of DNA sequence homologies.

We describe a computer program designed to facilitate the pattern matching analysis of homologies between DNA sequences. It takes advantage of a two-dimensional plot in order to simplify the evaluation of significant structures inherited in the sequences. The program can be divided into three parts, i) algorithm for search of homologies, ii) two-dimensional graphic display of the result, iii) further graphic treatment to enhance significant structures. The power of the graphic display is presented by the following application of the program. We conducted a search for direct repeats in the mouse immunoglobulin kappa-chain genes. Both the five J DNA sequences and other shorter repeats were found. We also found a longer stretch of homology that could indicate the presence of duplicated DNA in the J4, J5 region.

Base Sequence↗

Effect of a medical care evaluation program on physician knowledge and performance.

A model program designed to increase the educational value of medical care evaluation committee meetings was studied to determine its effect on the knowledge and clinical performance of participating physicians. The members of hospital committees in which the program was successfully implemented showed a statistically significant gain in knowledge of the topics discussed by their committees. In addition, several members made substantial changes in their patient care practices. These changes resulted not so much from the acquisition of new medical information as from a rethinking of patient management strategies, stimulated by peer discussion during committee meetings. A structure that encourages such discussions can be incorporated in other types of patient-care-oriented committee activities as well.

Clinical Competence↗

Effectiveness of a program of early hospital discharge of cardiac surgery patients.

Managed care was the impetus for a program designed to move adult patients from acute care to the lowest level of appropriate services after cardiac surgery. Clinical pathways and a home care cardiac specialty team were the major components of the Early Discharge Program. The program was evaluated based on both financial and clinical outcomes. A convenience sample of 119 pretest patients was compared with 101 posttest patients 3 months after program implementation. Hospital length of stay decreased only 0.34 days on average, but inpatient direct variable costs decreased by an average of $1,790 per patient. Based on the 101 patients in the posttest group, $180,790 in direct variable hospital costs were saved. The largest decrease in resource use was in those patients who were discharged to home care. Complications and home caregiver burden after discharge were no higher in patients discharged early. Early discharge of cardiac surgery patients appears to be safe and cost-effective.

Aged↗

COPE: a systematic approach to moving chronic patients into the community.

COPE, a program designed to help chronic psychiatric patients make the transition from institutionalization to independent living in the community, emphasizes both in-hospital training the systematic aftercare as two points on a continuum of treatment. The program includes four training phases, with each phase based upon the skills acquired in the preceding one. The residents are thereby assured of having the necessary skills for progressing to more complex tasks as they proceed through the program. During the last phase, support by the mental health system is gradually replaced by help from community support systems.

Activities of Daily Living↗

Toward a national health risk management approach in Australia.

There has been increasing international consensus about the importance of competition for achieving national growth and community well-being. The Australian government accordingly has introduced policies to promote such competition. Major legislative review and many public inquiries have assisted implementation of national competition policy and the development of national goals and standards related to international agreements to promote health and sustainable development. Since the 1980s, Australia has had legislation that requires the identification and control of health risks arising at work. The management structures necessary for coordinated delivery of national programs designed for effective identification and control of health risks arising in communities to achieve national health and development goals are still being developed, however. Major difficulties related to this development are discussed. National health development programs should be approached primarily through establishment of regional partnerships between bodies responsible for managing community health, local government, and employment placement, in consultation with other relevant organizations and the community. Related research and evaluation programs are required.

Australia↗

Disordered expression of HOX genes in human non-small cell lung cancer.

We hypothesized that the disordered tissue architecture in cancer results from the cells executing the program designed during ontogeny in a spatio-temporally inappropriate manner. HOX genes are known as master regulators of embryonic morphogenesis, and encode transcription factors which regulate the transcription of the downstream genes to realize the program of body plan. In this study, we quantified the expression levels of 39 HOX genes in 41 human non-small cell lung cancer (non-SCLC) and non-cancerous lung tissues by a comprehensive analysis system based on the real-time RT-PCR method. We found that the expression levels of HOXA1, A5, A10 and C6 in squamous cell carcinoma tissues (and HOXA5 and A10 in adenocarcinoma tissues) were significantly higher than those in the non-cancerous tissues. Comparison of HOX gene expressions between adenocarcinoma and squamous cell carcinoma tissues showed higher expressions of HOXA1, D9, D10 and D11 in squamous cell carcinoma tissues than in adenocarcinoma tissues. Immunohistochemical analysis revealed that HOXA5 and A10 proteins were localized in the cytoplasm of tumor cells in both adenocarcinoma and squamous cell carcinoma tissues. These results suggest that the disordered patterns of HOX gene expressions were involved not only in the development of non-SCLC but also in the histologically aberrant diversity such as adenocarcinoma and squamous cell carcinoma.

Adult↗

5 A Day for better health--nine community research projects to increase fruit and vegetable consumption.

One of the national objectives in "Healthy People 2000" is for members of the public to increase their consumption of fruits and vegetables to five or more servings daily. The National Cancer Institute (NCI) began a nationwide campaign to achieve this objective in 1991. As part of this campaign, the NCI funded nine research studies in 1993. These projects are implementing and evaluating community-based programs designed to increase fruit and vegetable consumption among different segments of the population in Alabama, Arizona, Georgia, Louisiana, Maryland, Massachusetts, Minnesota, North Carolina, and Washington. The settings for these projects include the Special Supplement Food Program for Women, Infants, and Children (WIC Programs), churches, worksites, and schools. The projects are led by multidisciplinary teams and entail extensive collaboration among academic, governmental, private sector, and voluntary agencies within each State. The projects represent a model public health paradigm for conducting this type of research.

Diet↗

[Vietnam: appropriate management of a pediatric hospital in the context of limited resources].

To cope with problems arising from limited economic resources, the pediatric hospital of Ho Chi Minh City, Vietnam, integrated several primary health care concepts into its overall policy: designation of priority diseases, adaptation of therapeutic modalities, decentralisation, and community funding. These concepts have been in use since 1988. Five diseases were designated for priority, i.e. diarrhea, acute pulmonary infection, dengue fever (DF), malaria, and routine pediatric emergencies, malnutrition. Training courses focusing on these diseases have been organized for hospital staff and health care assistants and education programs have been offered to the families of patients. Outpatient treatment is encouraged to lower the number of unnecessary hospitalizations and use of simple, cost-effective therapies has been developed for priority diseases. Responsibility has been delegated to department heads. Treatment is provided at no cost to the poorest but a small fee is requested from others and funding is also obtained from local authorities and non-governmental organizations. In five years, these concepts have achieved a 40% reduction in overall mortality. Funding from non-governmental organizations has been allocated to training and research programs designed to respond to specific community needs. This experience shows that reducing mortality does not depend only on budgetary increases but also to a great extent on rational spending and managing available resources. These can be effective in any developing countries that cannot increase budgetary spending.

Ambulatory Care↗

Parent involvement in a treatment program for obese retarded adults.

Two groups of moderately retarded, obese adults were given a 10-week behavioral treatment program designed to produce changes in their eating, activity and self-reinforcement patterns and to produce weight loss. In one group (N = 8, X = 27 years) parents of the participants were actively involved in the treatment program; in the second group (N = 7, X age = 29) parents were minimally involved. At the end of treatment, subjects in the parent-involved group lost significantly more weight (X = 7.4 pounds) with less intra-group variability (S.D. = 2.26 pounds) than the other treatment group (X = 2.4 pounds; S.D. = 4.38 pounds). A strong correlation was also found between degree of subject involvement in treatment (as measured by the number of daily homework forms completed) and weight loss. Implications of the data for future treatment programs are discussed.

Adult↗

Remediation of intonation contours of hearing-impaired students.

Incorrect production of intonation contours is a common phonatory problem among the hearing impaired. Programs designed to remediate this problem include those that employ a systematic sequence of training steps as well as those that use sensory aids to provide visual or tactile feedback of contour production. A speech-training program that incorporates both is described. The program utilizes a hierarchical curriculum with either a tactile or a visual display of fundamental frequency for the remediation of incorrectly produced intonation contours. The displays are interfaced with a microprocessor, thus allowing regular collection of data and monitoring of the program's effectiveness. Three case studies are presented as representative examples of the students' progress. Implementation of the systematic curriculum with the use of the sensory aids results in improved performance in the phonatory skills of these students. The successes and difficulties encountered in speech training are discussed.

Adolescent↗

Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program.

STUDY OBJECTIVE: Feasibility of laparoscopic extraperitoneal surgical staging for locally advanced cervical carcinoma in a gynecologic oncology fellowship training program. DESIGN: Retrospective analysis (II-2) of all patients who underwent laparoscopic extraperitoneal surgical staging at Women and Children's Hospital for locally advanced cervical cancer between June 2002 and June 2005. SETTING: Gynecologic oncology fellowship training program at a University-County Hospital PATIENTS: Thirty-two patients with clinical stage IIB-IVA cervical carcinoma were identified. INTERVENTIONS: Laparoscopic extraperitoneal surgical staging for clinical stage IIB-IVA cervical cancer. MEASUREMENTS AND MAIN RESULTS: A total of 32 cases of laparoscopic extraperitoneal surgical staging for locally advanced cervical cancer performed by fellows-in-training were identified. Fellows were first assistant surgeon in 10 cases, and operating surgeon in 22 cases. Each fellow was mentored an average of 5 cases as first assistant surgeon. As operating surgeon, all 22 fellow cases (100%) were successfully performed without conversion to laparotomy. Fellow mean operative time was 163 minutes. Fellow mean aortic nodal count was 14. Fellow mean blood loss was 42 mL. The mean hospital stay was 1.6 days. Overall, 2 patients (6.2%) experienced a complication from the procedure. Over one half (53%) of the patients reported a prior abdominal surgery. No lymphedema has been reported in patients who underwent laparoscopic extraperitoneal surgical staging with a median follow-up of 10 months. Surgical comorbidities such as hypertension, diabetes, and obesity were common in the study group. A steep surgical learning curve for the fellows was demonstrated by comparing mean operative times to academic year. Aortic nodal metastasis was detected in 25% of cases, and 14% were occult. CONCLUSIONS: It is feasible to teach laparoscopic extraperitoneal surgical staging to fellows-in-training. Our data suggest that by the end of training, fellows can become proficient with the procedure and are capable of surgical outcomes and complication rates comparable to reported literature.

Adolescent↗