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PubMed1982

Diabetes-related goals, practices, and beliefs of practicing pediatricians.

Practicing pediatricians were surveyed to assess their need for diabetes education programs. Pediatricians generally have fewer than five diabetic patients, frequently see them less than once every four months, prescribe single daily insulin injections, and do not include dietetic services in their treatment program. Among the pediatricians surveyed, practices correlated weakly with therapeutic goals for metabolic control, and goals correlated weakly with belief that hyperglycemia causes microvascular complications of diabetes. Belief in the importance of hyperglycemia did not correlate with actual care practices reported. The data support the idea that presentation of the latest advances in scientific rationale is an inadequate basis for physicians' continuing education.

Child↗
PubMed2001

Perspectives on inducing efficient immune control of HIV-1 replication--a new goal for HIV therapeutics?

OBJECTIVES: A goal for long-term therapy of HIV infection is immune control of virus replication rather than the somewhat unrealistic aim of complete viral elimination. This paper will review the evidence that the control of viral infection can be achieved by an active CD8+ T-cell-mediated response. DESIGN: This review will draw on both experimental and clinical sources to discuss the potential mechanisms of the immune control. RESULTS: Data indicate that HIV infection can be effectively controlled by HIV-specific CD8+ T-cell-mediated responses. In infected individuals, the development of active cytotoxic T lymphocytes (CTLs, as measured by lytic activity) is associated with the control of viral replication. Within the simian immunodeficiency virus infection model in rhesus macaques, strong CTL responses are similarly associated with effective viral control. In addition, depletion by antibodies of CD8+ T cells within infected macaques results in rapid increases in viral load. However, in most HIV-infected individuals, the CD8+ T-cells response is inefficient at low antigen dose, probably due to the lack of an effective H V-specific CD4+ T-cell response. If this CD4+ T-cell response is lost due to viral induced anergy, rather than clonal deletion, such responses may be generated by interruptions in antiretroviral treatment, and/or therapeutic immunization in chronically infected patients. A strong immune response stimulated at low-antigen dose early during viral rebound may be critical in preventing accumulation of toxic viral products that might inhibit effective CD4+ T-cell responses. CONCLUSION: Immune control of HIV infection is a realistic goal. Understanding both the basic immune mechanisms of in vivo viral replication and identifying practical therapeutic regimens to activate HIV CD4+ and CD8+ T-cell responses may allow the development of efficient immune control of HIV replication in chronically infected patients.

Acquired Immunodeficiency Syndrome↗
PubMed1988

The senior radiology clerkship. Disparate goals of students and faculty.

A survey of medical students taking our radiology elective over the past five years revealed that 51% were chiefly interested in learning "to read x-rays." Other motivations for taking the elective, such as learning "radiographic workups" were relatively low-priority goals. On the other hand, a survey of our staff revealed a low priority placed on teaching medical students to interpret radiographic images and a high value placed on imparting an understanding of the role of radiology in clinical diagnosis and management. This disparity between the goals of the students and teachers delineates one of the major challenges in designing a radiology curriculum for medical schools.

Clinical Clerkship↗
PubMed2002

Normal versus supranormal oxygen delivery goals in shock resuscitation: the response is the same.

BACKGROUND: Shock resuscitation is integral to early management of severely injured patients. Our standardized shock resuscitation protocol, developed in 1997 and implemented as a computerized intensive care unit (ICU) bedside decision support tool in 2000, used oxygen delivery index (Do I) > or = 600 mL/min/m as the intervention endpoint. In a recent publication, Shoemaker et al. refuted positive outcome effect of early supranormal Do (i.e., Do I > or = 600) resuscitation. In response to and because of ongoing concern for excessive volume loading, we decreased our Do I endpoint from 600 to 500. Our hypothesis was that by decreasing the Do I endpoint, less crystalloid would be administered. We compare resuscitation responses to the protocol with goals of Do I > or = 600 versus 500 in two patient cohorts. METHODS: A standardized protocol was used to direct bedside decisions for resuscitation of patients with major injury (Injury Severity Score > 15), blood loss (> or = 6 units of packed red blood cells), metabolic stress (base deficit > or = 6 mEq/L), and no severe brain injury. The protocol logic is to attain and maintain Do I > or = a specified goal for the first 24 ICU hours using primarily blood and volume loading. Two cohorts were compared: Do I > or = 500 (18 patients admitted February-August 2001) versus Do I > or = 600 (18 patients admitted during 2000 age and gender matched with the Do I > or = 500 group). Data were analyzed using analysis of variance, chi, and t tests (p < 0.05). RESULTS: Both groups had similar demographics (age 30 +/- 3 years; 78% men; Injury Severity Score 27 +/- 3), hemodynamics, and severity of shock at start of resuscitation in the ICU. Resuscitation response was Do I increase to > or = 600 for both cohorts within approximately 12 hours. Throughout the 24-hour ICU process, the Do I > or = 500 cohort received less lactated Ringer's volume than the Do I > or = 600 cohort (total of 8 +/- 1 vs. 12 +/- 2 L; p < 0.05) and tended to receive less blood transfusion (total of 3 +/- 1 vs. 5 +/- 1 units of packed red blood cells). CONCLUSION: Shock resuscitation using Do I > or = 500 was indistinguishable from Do I > or = 600 mL/min/m. Less volume loading was required to attain and maintain Do I > or = 500 than 600 using computerized protocol technology to standardize resuscitation during the first 24 ICU hours.

Adult↗
PubMed1978

Oxytocin challenge test: achieving the desired goals.

The desired goals of the oxytocin challenge test (OCT) are preventing stillbirth and avoiding unnecessary premature intervention. To effectively reduce stillbirth the test should be done on a significant proportion of those fetuses who would subsequently succumb in utero. To analyze whether or not the OCT is achieving these goals. 5351 deliveries over a 2-year period at the University of California, Irvine, Medical Center were studied retrospectively. Four hundred and thirty of these patients had 823 OCTs performed. There were ten positive and 19 suspicious tests, and five neonatal deaths in these two groups. In patients who were studied with OCTs only one stillbirth occurred (in a patient who was noncompliant). During the same period, all stillbirths were reviewed. In the group in which stillbirth occurred, it was determined that 11 or 35% of the patients had indications for antepartum testing but were not tested. All 11 of these patients were transferred to the University hospital or had no prenatal care. It is suggested that these stillbirths may have been prevented had appropriate prenatal care allowed identification of patients for antepartum testing.

False Positive Reactions↗
PubMed2000

Achieving target goals most precisely using nonparametric compartmental models and "multiple model" design of dosage regimens.

Multiple model (MM) design and stochastic control of dosage regimens permit essentially full use of all the information contained in either a Bayesian prior nonparametric EM (NPEM) population pharmacokinetic model or in an MM Bayesian posterior updated parameter set, to achieve and maintain selected therapeutic goals with optimal precision (least predicted weighted squared error). The regimens are visibly more precise in the achievement of desired target goals than are current methods using mean or median population parameter values. Bayesian feedback has now also been incorporated into the MM software. An evaluation of MM dosage design using an NPEM population model versus dosage design based on conventional mean population parameter values is presented, using a population model of vancomycin. Further feedback control was also evaluated, incorporating realistic simulated uncertainties in the clinical environment such as those in the preparation and administration of doses.

Anti-Bacterial Agents↗
PubMed1995

Goal-publication, feedback, and communication processes: views of the Finnish health care work force.

This article describes a study that investigated several aspects of organizational behavior in Finnish hospitals and other areas of Finnish health care. It was hypothesized that health care providers often lack awareness of organizational goals, that feedback about how their performance contributes to achieving the goals is frequently inadequate, and that the knowledge available in organizations is commonly maldistributed because of ineffective communication. The findings of the questionnaire survey supported the hypotheses.

Attitude of Health Personnel↗
PubMed2003

Goal-oriented shock resuscitation for major torso trauma: what are we learning?

Shock resuscitation is an obligatory intervention for severely injured patients who present in shock. During the past 15 years, with widespread acceptance of "damage control" surgery and early triage to the intensive care unit (ICU) to optimize resuscitation, the lives of many major trauma victims have been saved, and much has been learned about shock resuscitation. Due largely to the work of Shoemaker et al., a resuscitation strategy based on a standardized process using O(2) delivery index (DO(2)I) as an endpoint and physiologic performance goal for interventions has been developed, studied, and refined for resuscitation of shock caused by major trauma. DO(2)I >or=600 mL O(2)/min-m2 is the only resuscitation endpoint variable that has been tested in prospective randomized trials (PRTs) of trauma patient outcome. These PRTs are limited, and their results are not conclusive. Results from other investigators, including our group, using similar process and endpoints, are indicating similar performance and outcomes. We believe that DO(2)I is a useful endpoint because it integrates three important variables, ie, hemoglobin concentration [Hb], arterial hemoglobin O(2) saturation, and cardiac output. We have found DO(2)I >or=500 mL O(2)/min-m2 to be an endpoint with more general applicability, but we believe that the standardized process is more important than the specific endpoint. To standardize our process, we have developed a computerized decision support tool for shock resuscitation. This technology has provided novel data collection and has permitted refinement of the bedside process. Our data analysis indicates that the next challenge will be to develop a similar pre ICU resuscitation process that will use less invasive monitors and different endpoints. Identification of the high-risk resuscitation nonresponders early in the resuscitation process will be needed to redirect their clinical trajectories. As an endpoint for interventions for goal-directed resuscitation in the critically injured trauma patient, systemic O(2) delivery is the current state of the art and the basis for near future development of clinical processes for resuscitation of shock due to major trauma.

Clinical Protocols↗
PubMed2005

Optimal goals for statin use in patients with coronary artery disease.

PURPOSE OF REVIEW: Coronary artery disease is the largest cause of premature death in the Western world. Lipid-lowering therapy with statins has revolutionized the management of this condition over the past decade. RECENT DEVELOPMENTS: Successive clinical trials have lowered the treatment bar for statin therapy in patients with coronary artery disease. In addition to traditional markers of efficacy such as low-density lipoprotein cholesterol, emerging targets such as C-reactive protein are becoming recognized as important therapeutic goals. SUMMARY: This review focuses on the important contributions to the literature during the past year and provides an expert opinion of the therapeutic goals for statin therapy.

Atherosclerosis↗
PubMed2006

A reappraisal of isoproterenol in goal-directed therapy of septic shock.

The goal of the study was to evaluate the effect of isoproterenol prescribed in goal-directed therapy for septic shock. Out of a cohort of 89 patients with septic shock, 14 patients treated with fluid and norepinephrine had inappropriate mixed venous oxygen saturation (SvO2<70%) not responding to correction of hypoxemia and anemia (>8 g.dL-1). Isoproterenol administration was started at a dose of 0.04 microg.kg-1.minute-1 with 0.025 microg.kg-1.minute-1 increments every 30 minutes until SvO2 was greater than 70%. Mean arterial pressure was maintained>or=65 mm.Hg by adjusting the norepinephrine infusion. Hemodynamic, oxygen, and renal variables were collected during a 12-h period. Patients with a known prior history of coronary disease were not eligible. Isoproterenol administration increased significantly SvO2 (62%+/-10% to 71%+/-9%), cardiac index (3.1+/-0.6 to 4.4+/-1.4 L.min-1.m-2), stroke index (27+/-3.4 to 38+/-6.1 mL.m-2), and left ventricular stroke work index (24+/-3.4 to 40+/-5.0 g.m-1.m-2). Heart rate rise did not reach a significant level. Arterial lactate concentration decreased significantly during the study period (5.7+/-2.8 to 3.4+/-1.6 mmol.L-1). No cardiac adverse events occurred with any electrocardiographic aspects of myocardial ischemia. This study suggests that isoproterenol is efficient to improve hemodynamics and oxygen variables in septic shock patients. There is a need for future investigations in larger groups of patients to determine whether isoproterenol can be an alternative to dobutamine.

Adrenergic beta-Agonists↗
PubMed2005

Boundary following and globally convergent path planning using instant goals.

In this paper, an Instant Goal approach is proposed for collision-free boundary following of obstacles of arbitrary shape and globally convergent path planning in unknown environments. Firstly, for effective knowledge representation and manipulation, a vector representation is presented, which not only saves much space but also conforms to the physical properties of range sensors. Secondly, the concept of Instant Goals is introduced enabling the robot to perform boundary following in a "natural" human-like manner, with additional measures taken to ensure that the robot is moving "forward" along the boundary, even if the obstacle is of arbitrary shape and disturbing obstacles are present. Collision checking is performed simultaneously and, when needed, collision avoidance is efficiently incorporated in. Based on the approach of boundary following, a realistic sensor-based path planner with global convergence property is designed for the robot capable of acquiring discrete and noisy range data. Realistic simulation experiments validate the effectiveness of the proposed approaches.

Algorithms↗
PubMed2005

Goals in maternal and perinatal care in Latin America and the Caribbean.

Ten goals have been developed to guide perinatal caregivers by the Latin American Centre for Perinatology (CLAP), a PAHO/WHO unit dedicated to improving perinatal care in Latin America and The Caribbean. The goals were inspired by the current troubled perinatal care situation, the need to make significant changes, principles of evidence-based medicine, and reviews of many sources from other regions or countries.

Female↗
PubMed2005

Efficacy and safety of ezetimibe co-administered with ongoing atorvastatin therapy in achieving low-density lipoprotein goal in patients with hypercholesterolemia and coronary heart disease.

This randomised, double-blind, placebo (PBO)-controlled study evaluated the efficacy and safety of ezetimibe (EZE) co-administered with ongoing atorvastatin (ATV) therapy in 450 hypercholesterolemic patients with coronary heart disease (CHD) who had not achieved their low-density lipoprotein cholesterol (LDL-C) goal < or =2.60 mmol/l while on a stable dose of ATV 10 or 20 mg/day for > or =6 weeks. After a 4-week diet/baseline active run-in period, patients with LDL-C >2.60 mmol/l and < or =4.20 mmol/l were stratified by ATV dose and randomised (1 : 1) to EZE 10 mg or PBO for 6 weeks while continuing open-label ATV. Significantly more patients achieved an LDL-C goal < or =2.6 mmol/l with EZE than PBO (81.3 vs. 21.8%; p < or = 0.001). Compared to PBO, co-administration of EZE with ongoing ATV led to significantly (p < or = 0.001) greater reductions in LDL-C, total cholesterol, triglycerides, non-high-density lipoprotein cholesterol (non-HDL-C), and apolipoprotein B; HDL-C was significantly (p < or = 0.05) increased. Co-administration of EZE and ATV was well tolerated, with an overall safety profile similar to ATV alone.

Adult↗
PubMed2006

Effects of writing about emotions versus goals on psychological and physical health among third-year medical students.

A randomized, controlled trial compared writing about emotional topics (EMO) to writing about goals as the "best possible self" (BPS; after King, 2001) and evaluated emotional approach coping, i.e., efforts to cope through processing and expressing emotion, as a moderator of writing effects on psychological and physical health in 64 third-year medical students. In participants with higher baseline hostility, the EMO condition was associated with less hostility at 3 months compared to the BPS and control conditions. Emotional processing (EP) and emotional expression (EE) moderated the effect of experimental condition on depressive symptoms at 3 months; high EP/EE participants reported fewer depressive symptoms in the EMO condition, whereas low EP/EE individuals reported fewer depressive symptoms in the BPS condition compared to the EMO and control conditions. A moderating effect of EP on physical health was also identified, such that low EP individuals who wrote about goals (BPS) had fewer health care visits at 3 months compared to low EP participants in the EMO and control conditions.

Adaptation, Psychological↗
PubMed1987

Probabilistic reliability analysis, quantitative safety goals, and nuclear licensing in the United Kingdom.

Although unpublicized, the use of quantitative safety goals and probabilistic reliability analysis for licensing nuclear reactors has become a reality in the United Kingdom. This conclusion results from an examination of the process leading to the licensing of the Sizewell B PWR in England. The licensing process for this reactor has substantial implications for nuclear safety standards in Britain, and is examined in the context of the growing trend towards quantitative safety goals in the United States.

Accident Prevention↗
PubMed2002

First information and support provided to parents of children with Down syndrome in Sweden: clinical goals and parental experiences.

UNLABELLED: When parents are informed that their newborn child has Down syndrome (DS), they often respond with a traumatic crisis reaction. The aims of this study were to assess the clinical goals regarding the first information and support provided to parents of newborn children with DS at the Swedish paediatric departments, and to analyse the parents' experiences of how they were first informed and treated. Data were collected during 1992-1993 from all of the 51 departments of paediatrics in Sweden. Information on the parents' experiences, collected retrospectively in 1996, was based on recollection by 165 parents of 86 children with DS born between 1989 and 1993 at 10 of the paediatric departments considered representative for Sweden. Seventy-five percent of the families were informed about the diagnosis within 24 h post partum. Some parents felt they were informed too late, and a few parents that they were told too soon. Half of the parents were satisfied with the timing. About 70% of the parents considered the information insufficient and 60% felt that they had been unsupported. Seventy percent would have liked more frequent information. Parental criticisms concerning the way in which the information was provided were that they received too much negative information about DS and that both the communication skills and the basic knowledge of DS on the part of the professionals could have been better. CONCLUSION: The Swedish paediatric departments fall short of their reported strong clinical goals regarding the initial information in Sweden, and improvements in this area are desirable.

Adaptation, Psychological↗
PubMed2005

Family therapy treatment: working with obese children and their families with small steps and realistic goals.

UNLABELLED: Childhood obesity treatment can be discussed from several points of view, and there are many forms of treatment. Solution-focused brief therapy (SFBT) and systemic family therapy can be useful in a wide range of contexts and settings such as social care, education and healthcare. They can also be used wherever practitioners sometimes feel that they have very little impact on the patient and where the patient seems to be resistant to acknowledging his/her problem. Health professionals need to assist by starting to explain main goals and medical information in terms of a single, small, concrete and important goal, described as the beginning of a new behaviour, not as the end of something. This report focuses on some useful tools and methods taken from casework examples from multidisciplinary obesity team meetings with more than 300 families during a 3-y project approximately between 2002 and 2003 at the Childhood Obesity Unit at University Hospital, Malmö. Other casework examples are taken from supervision and training professionals who are currently working with or are going to work with childhood obesity using a solution-focused model. The main aim of this report is to discuss and think about the difference between problem-solving and solution-building interview questions when it comes to treatment regarding how best to help children and parents with serious obesity health problems. CONCLUSION: There is a great need for treatment models and the prevention of childhood obesity now and in future, which presents an interesting and urgent challenge for open-minded thinking and new fields of research.

Adolescent↗
PubMed2001

Signal processing by vestibular nuclei neurons is dependent on the current behavioral goal.

The vestibular sensory apparatus and associated vestibular nuclei are generally thought to encode angular head velocity during our daily activities. However, in addition to direct inputs from vestibular afferents, the vestibular nuclei receive substantial projections from cortical, cerebellar, and other brainstem structures. Given this diversity of inputs, the question arises: How are the responses of vestibular nuclei neurons to head velocity modified by these additional inputs during naturally occurring behaviors? Here we have focused on the signal processing done by two specific classes of neurons in the vestibular nuclei: (1) position-vestibular-pause (PVP) neurons that mediate the vestibulo-ocular reflex (VOR), and (2) vestibular-only (VO) neurons that are thought to mediate, at least in part, the vestibulo-collic reflex (VCR). We first characterized neuronal responses to passive rotation in the head-restrained condition, and then released the head to record the discharges of the same neurons during self-generated head movements. VOR interneurons (i.e., PVP neurons) faithfully transmitted head velocity signals when the animal stabilized its gaze, regardless of whether the head motion was actively or passively generated; their responses were attenuated only when the monkey's behavioral goal was to redirect its axis of gaze relative to space. In contrast, VCR interneurons (i.e., VO neurons) faithfully transmitted head velocity signals during passive head motion, but their responses were greatly (and similarly) attenuated during all behaviors (i.e., gaze shifts, gaze pursuit, gaze stabilization) during which the monkey's behavioral goal was to move its head relative to the body. To characterize the mechanism(s) that underlie this differential processing, we tested neurons during passive rotation of the head relative to the body, as well as during a task in which a monkey actively "drove" both its head and body together in space. We conclude that neither passive activation of neck proprioceptors nor knowledge of self-generated head-in-space motion directly mediate the observed reductions in head-velocity-related modulation. Instead, we propose that the VOR and VCR pathways use efference copies of oculomotor and neck movement commands, respectively, for the differential processing of vestibular information.

Action Potentials↗