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PubMed1995

Perspectives on thromboelastography.

The knowledge of these sources of error together with strict methodology assure reliable results and avoid what some authors consider limitations of the test. These so-called limitations are actually due to incomplete information or insufficient experience. It is our opinion that the key for success when using TEG is to use the test in those cases for which it has been indicated. Also, the fact that TEG is a global test of coagulation should be kept in mind and therefore the need for additional hemostatic tests should be evaluated when applicable (Fig.3). According to this review, the established applications of TEG are as follows: (1) detection of hypercoagulable states, particularly in the postoperative period and for patients with malignancies; (2) management of patients who are administered intravenous heparin; (3) monitoring the coagulation state during liver transplantation; (4) monitoring the coagulation state and management of patients during cardiopulmonary bypass; and (5) diagnosis and treatment of hematologic dysfunctions, particularly hemophilia. Management of patients under warfarin administration, as well as monitoring of the adjustment of subcutaneous heparin prophylaxis in several surgical procedures, should probably belong to this list, but further studies are needed to confirm these roles. Used by experienced hands, TEG is a valuable hemostatic test, the future of which is already present.

Artifacts↗
PubMed2004

[The assessment of (in)competence to make a will].

Based upon German law and jurisdiction, psychiatric literature as well as the author's experiences, essential criteria for the assessment of testamentary capacity are presented, peculiarities of the posthumous assessment of psychopathology are explained and the anachronistic idea of the "lucid interval" is critically discussed. The legal term "freedom to determine one's will", decisive for the competence to contract and to make a will, corresponds to the psychopathological dimension of judgement. In the practice of experts' assessments, this criterion is most likely to be impaired by delusional misinterpretation of reality, lack of insight in being ill, pathological dominance of affects or suggestibility, while cognitive deficits are less often decisive. Using knowledgeably all available sources of information, a posthumous expert's statement on the legal ability to make a will is possible with the reliability legally required in more than 90 % of cases.

Cognition Disorders↗
PubMed2005

Brain correlates of subjective reality of physically and psychologically induced pain.

Meaningful behavior requires successful differentiation of events surfacing from one's mind from those arising from the external world. Such judgements may be especially demanding during pain because of the strong contribution from psychological factors to this experience. It is unknown how the subjective reality of pain (SRP) is constructed in the human brain, and neuronal mechanisms of the subjective reality are poorly understood in general. To address these questions, 14 suggestion-prone healthy subjects rated reality of pain that was induced either by laser pulses to the skin or by hypnotic suggestion during functional MRI. Both pain states were associated with activation of the brain's pain circuitry. During laser stimulation, the sensory parts of this circuitry were activated more strongly, and their activation strengths correlated positively with the SRP. During suggestion-induced pain, the reality estimates were lower and correlated positively with activation strengths in the rostral and perigenual anterior cingulate cortex and in the pericingulate regions of the medial prefrontal cortex; a similar trend was evident during laser-induced pain. These findings support the view that information about sensory-discriminative characteristics of pain contributes to the SRP. Differences in such information between physically and psychologically induced pain, however, could be quantitative rather than qualitative and therefore insufficient for judging the reality of pain without knowledge about the source of this information. The medial prefrontal cortex is a likely area to contribute to such source monitoring.

Adult↗
PubMed1996

Messages of distinction: the HIV/AIDS media campaign in Thailand.

In predominantly rural Thailand, television is a primary source of HIV/AIDS knowledge. Since 1990, HIV/AIDS warning messages have been aired regularly and repeatedly on television as part of the national strategy to minimize transmission of HIV. The education and prevention messages chosen do more than suggest measures to avoid infection. Within a logic of risk, these messages also define characteristics of people who are signified as threatening agents of infection. In Thailand, prostitutes and drug users are portrayed as the feared Other. Because commercial sex is so widespread, the demarcation of prostitutes as a high risk group signals a diffuse threat not easily subject to conceptual distancing. It is the pervasive and often fear-based associations born of the media material that, in large part, establish the basis for emergent practice when thoughts or actions are triggered by consideration of HIV/AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed2003

Action research on own practice. Methodological challenges.

OBJECTIVE: Using experiences from a study on clinical communication, the objective was to clarify the methodological challenges that general practitioners are faced with when researching their own practice. DESIGN: A case study of the methodological challenges of an action research project in which the researcher is both participating observer and observing participator. The material comprised notes and transcripts from audiotapes, and was investigated with a view to highlighting experiences that might facilitate the research process. SETTING: The practice of the author. SUBJECTS: 36 consultations with 16 patients during which the illness diary method was applied. RESULTS: The challenges of the project are presented as turning-point stories, i.e. stories demonstrating relations, perspective shifts and metapositions. Perspective shifts were established by introspection through dialogues with oneself, and by relation to helpers through dialogues with patients and supervisors. Reflexivity was promoted by combining pictures from different perspectives. CONCLUSION: It is possible and sensible to study oneself in interaction. The information gained from carefully designed research in one's own practice could be an underestimated source of valuable knowledge about the personal and existential aspects of clinical medicine.

Family Practice↗
PubMed1999

Understanding HIV risks of chronic drug-using men who have sex with men.

Focus groups and individual structured interviews were conducted in six cities with 98 predominantly street-recruited men who had a recent history of smoking crack or injecting drugs and who reported having had sex with other men (MSM) in the past year. Twenty-six focus groups explored the cultural and social context of participant's drug use and sexual activity and addressed outreach and HIV prevention issues pertinent to this population. Narrative summaries developed from verbatim focus group transcripts identified seven themes: (a) sexual orientation and gender identity; (b) interactions within and between MSM networks; (c) drug use, sexual activity and personal relationships; (d) HIV transmission bridges; (e) preferred HIV information sources; (f) HIV knowledge, prevention practices and risk behaviours; and (g) availability of HIV and drug-related services. Of the 98 MSM drug users, 42% identified publicly as gay or homosexual; 35% identified publicly, but only 21% privately, as heterosexual. A total of 51% had one or more female sex partners in the past year. There was a high frequency of unprotected sex in conjunction with drug use and a distinct preference for having sex when high. For most participants, drug use rather than sexual orientation formed the core of personal identity. Participants reported associating primarily with other drug users, usually MSM, and had limited contact with people who did not use drugs and the mainstream gay community. Participants' sexual and drug-injecting activities were judged to be a bridge for transmission of HIV to both people who used drugs and those who did not.

Adolescent↗
PubMed2003

General practitioners' perceptions of continuing medical education's role in changing behaviour.

CONTEXT: The effectiveness of moving to compulsory, prescriptive continuing medical education (CME) for New Zealand general practitioners (GPs) is questioned. Motivational interviewing theory suggests that a series of interventions gradually increase awareness of the need to change until change is finally actioned. This study aimed to explore GPs' views on their need for CME, experiences regarding its provision and perceptions on the effect of CME in changing their clinical behaviour. METHOD: Qualitative study using semi-structured interviews of 24 GPs from Auckland and North Island rural areas assessing their CME experiences and preferences. FINDINGS: All participants acknowledged that CME is a life-long process essential for GPs. Changing behaviour is generally seen as an incremental, evolutionary process with reinforcement of knowledge from different sources. Single events were perceived to effect change rarely. These were often high-impact, either punitive or incentive-based. GPs have a myriad of CME sources including reading, the internet, specialist letters, conversations with colleagues, quality assurance feedback, as well as traditional meetings. Credit-based quota requirements received mixed opinions but mostly were perceived negatively, discouraging needs-based approaches to learning. GPs' greatest barrier to obtaining CME is time. DISCUSSION: GPs perform poorly in assessing their specific learning needs. Their behaviour change is likely to be incremental. Therefore multi-faceted interventions and reinforcement from different sources are likely to be most effective in changing clinical practice. Understanding this is important for CME providers, GP Colleges and funders. Narrow, credit-based approaches to CME may discourage time-strapped GPs obtaining motivation to change from exposure to a wide variety of CME sources.

Attitude of Health Personnel↗
PubMed2005

Understanding prevention effectiveness in real-world settings: the National Cross-Site Evaluation of high risk youth programs.

The National Cross-Site Evaluation is a large multisite evaluation (MSE) of 48 substance abuse prevention programs, 5,934 youth participating in programs, and 4,539 comparison youth programs. Data included a self-report questionnaire administered at 4 points in time, detailed dosage data on over 217,000 program contacts, and detailed site visit information. In a pooled analysis, the programs did not demonstrate significant positive effects on a composite outcome measure of tobacco, alcohol, and marijuana use in the previous 30 days. However, disaggregated analyses indicated that 1) sites in which comparison groups had strong opportunity to participate in prevention programs suppressed observed effects; 2) youth who had already started using before they entered programs reduced use significantly more than comparison youth who had started using; and 3) both males and females who participated in programs significantly reduced use relative to comparisons, but in very different patterns. Combining these patterns produced an apparent null effect. Finally, programs that incorporated at least 4 out of 5 effective intervention characteristics identified in the study significantly reduced use for both males and females relative to comparison youth. The lessons produced by this study attest to the value of MSE designs as a source of applicable knowledge about prevention interventions.

Adolescent↗
PubMed2000

Genome resource banking for wildlife research, management, and conservation.

Cryobiology offers an important opportunity to assist in the management and study of wildlife, including endangered species. The benefits of developing genome resource banks for wildlife are profound, perhaps more so than for traditional uses in terms of livestock and human fertility. In addition to preserving heterozygosity and assisting in the genetic management of rare populations held in captivity, frozen repositories help insure wild populations against natural and human-induced catastrophes. Such banks also are an invaluable source of new knowledge (for basic and applied research) from thousands of species that have yet to be studied. However, it is crucial that genome resource banks for wildlife species be developed in a coordinated fashion that first benefits the conservation of biodiversity. Spurious collections will be of no advantage to genuine conservation. The Conservation Breeding Specialist Group (CBSG; of the International Union for the Conservation of Nature and Natural Resources' Species Survival Commission) has promoted international dialogue on this topic. CBSG working groups have recognized that such repositories be developed according to specific, scientific guidelines consistent with an international standard that ensures practicality, high-quality ethics, and cost-effectiveness. Areas requiring priority attention also are reviewed, including the need for more basic research, advocacy, and support for developing organized repositories of biomaterials representing the world's diverse biota.

Animals↗
PubMed1996

Epithelial cell hyperproliferation induced in the exocrine pancreas of mice by a western-style diet.

BACKGROUND: Pancreatic cancer is a common cause of mortality in the United States, with an estimated 27,800 people dying of the disease in this country in 1996. Epidemiologic studies have suggested that Western diets containing high fat, high protein, and low calcium contents are associated with increased incidence of pancreatic cancer. PURPOSE: We investigated whether a Western-style diet containing increased fat content and decreased calcium and vitamin D contents would induce epithelial cell hyperproliferation (excess cell duplication) or hyperplasia (excess cell accumulation) in the pancreas, as was previously demonstrated in the colon and mammary gland. METHODS: C57BL/6J mice at 4 weeks of age were randomly assigned to one of two groups of 14 mice each. One group received the control diet ad libitum, and the other group was given the Western-style diet ad libitum. After 6, 9, and 15 weeks on the diet, four or five mice per group were infused with 5-bromo-2'-deoxyuridine (BrdU) for 72 hours by use of subcutaneously implanted Alzet osmotic pumps. The mice were then killed, and the pancreas of each mouse was removed. In the exocrine pancreas with ductal secretion, the duct system (including interlobular and intralobular ducts and centroacinar [i.e., centroductular] cells) and acini were measured both histopathologically and immunohistochemically (BrdU) and were analyzed without knowledge of the source of the specimens. Two-way analysis of variance was carried out. All P values were generated from two-sided tests for statistical significance. RESULTS: The number of pancreatic ducts (interlobular, intralobular, and centro-acinar-cancer-prone regions in certain rodent models and in humans) and acini per mouse in the Western-style diet group was similar to that in the control diet group during the entire feeding period (P = .76, .32, .93, and .42, respectively). Statistically significant higher BrdU-labeling indices of the ductal interlobular and intralobular epithelial cells were seen in mice fed the Western-style diet than in mice fed the control diet during the entire observation period (P = .014 and .016, respectively). There was no statistically significant difference (P = .098) between both diet groups in the BrdU-labeling indices of the centroacinar epithelial cells. CONCLUSIONS: A Western-style diet induced pancreatic epithelial cell hyperproliferation in mice, further suggesting that increased fat content and decreased calcium and vitamin D contribute to the development of pancreatic neoplasms.

Animals↗
PubMed2002

Nutrient substrates used by bacterial isolates from the poultry processing environment.

In order to successfully prevent pathogens found in biofilms in poultry processing facilities from contaminating products, knowledge of the sources and properties of the bacteria from these environments is needed. Bacteria were isolated from fresh cut-up meat samples (breast with or without skin, wings, and thighs) that were not stored or were stored at 4 or 13 C (temperatures relevant to poultry processing facilities). Profiles of the nutrient substrates used by individual bacterial species were determined using Biolog microtiter plates with different substrates in 95 wells of each plate. Pure cultures of bacterial isolates were inoculated onto gram-positive (GP) or gram-negative (GN) Biolog plates, and transformation of specific substrates was determined by reduction (indicated by a purple color) of the tetrazolium violet included in each well. Of the 62 substrates common to GP and GN microtiter plates, one-third were used by 50% or more of all bacterial isolates. Similarly, approximately one-third of the substrates were used by gram-negative bacteria but not by gram-positive bacteria. One-fourth of the substrates were also only used by a single isolate in the respective gram-type category. For the remaining 33 substrates on each of the GP and GN plates, a higher percentage of substrates on GN than on GP plates were used by the respective isolates. These substrate utilization profiles of bacteria isolated from the poultry processing environment are a useful reference for selecting nutrients for the growth or control of these bacteria, especially pathogens.

Animals↗
PubMed2000

Physicians and famine in Japan: Takano Chōei in 1830s.

Takano Chōei (1804-50) was a rangakusha: a scholar of Dutch learning, and a physician of Western medicine. Although he was one of the foremost scholars in his field, his career was cut off in its prime when he became the victim of an intrigue in 1839. As a result, much of his early work has been overshadowed by the political events that followed. This article takes a different approach to the writing of Chōei's history by presenting an example of his work as a physician in the period before his arrest. It examines the responses of Chōei and his colleagues to the famine and pestilence which ravaged the population during the Tempō Famine of the 1830s. The study is based on two short articles: one concerns the precautions people should take against epidemic disease, while the other deals with hardy, rapidly maturing crops thought helpful in warding off starvation. The focus of this article is on the way knowledge from Western sources was 'received'; that is, how it was actively assimilated and transformed, through a process of cultural exchange.

Communicable Disease Control↗
PubMed1998

What students say about learning and teaching in longitudinal ambulatory primary care clerkships: a multi-institutional study.

PURPOSE: Ambulatory primary care clerkships have become crucial elements in medical education. Although most such clerkships employ a block-rotation format, an alternative longitudinal approach has been developed. This study examines students' perceptions of learning and instruction occurring during longitudinal ambulatory clerkships. METHOD: Characteristics of longitudinal ambulatory primary care clerkships at five medical schools are described. Responses of 429 medical students to a standardized survey administered at these institutions are analyzed to ascertain perceptions of learning and teaching occurring during longitudinal ambulatory clerkship experiences. RESULTS: Enhancements of interpersonal communication and clinical skills were perceived to be the most positive learning attributes of the longitudinal ambulatory clerkships. No advantage was discerned with respect to disease-pattern recognition or generation of differential diagnoses. While significant inter-institutional variation was present, particularly with respect to instructional format, there was notable agreement regarding several aspects of clerkship-related learning and the adequacy of faculty supervision. CONCLUSION: Students perceived that learning during longitudinal ambulatory clerkships had greater impact on skill enhancement than on attainment of knowledge-related objectives. Sources of variation in student opinion, perceptions of learning as a function of career preference, and correlation of students' perceptions of learning to demonstrable changes in their competence require further investigation.

Ambulatory Care↗
PubMed2006

Safety in the academic medical center: transforming challenges into ingredients for improvement.

Patient safety has emerged as an important challenge to the leadership of academic medical centers (i.e., teaching hospitals with significant research activity). This article describes the evidence regarding patient safety at academic medical centers (AMCs) and the special circumstances of AMCs that create challenges and opportunities for making improvements. While the research on the relative safety of patients in AMCs compared to other types of hospitals is sparse, it seems clear that AMCs in general do not stand out as models of patient safety. AMCs are unique as health care providers because of the multiple consequences of their three missions: patient care, research, and teaching. Aspects of these missions can serve to both enhance an AMC's ability to address safety issues and at the same time create unique and challenging barriers. For example, the research enterprise may distract managers' focus on safety issues but at the same time provide a wealth of highly trained talent for investigating and reducing safety problems. By addressing these challenges, AMCs have the opportunity, even the obligation, to be both the source of new knowledge on health care safety as well as the transmitter of new skills in safe patient care for the health care providers of the future.

Academic Medical Centers↗
PubMedDate not supplied

Integrating Web-based technology into distance education for nurses in China: computer and Internet access and attitudes.

To increase continuing education accessibility, nurses around the world are turning to Web-based instruction. However, for Internet education to be successful, particularly in developing countries, nurses must have access to computers and the Internet as well as positive attitudes toward this form of learning. As part of a distance education project for nurses of the Tianjin Municipality in China, a survey of nurses was conducted to examine their sources of professional knowledge as well as their computer and Internet access and attitudes. The attitudes of the nurses were generally positive, and there was evidence of rapidly increasing use of and access to computers and the Internet. This article reports the results of that survey and their implications for Web-based teaching of Chinese nurses.

Adolescent↗
PubMed2006

A Markov model for blind image separation by a mean-field EM algorithm.

This paper deals with blind separation of images from noisy linear mixtures with unknown coefficients, formulated as a Bayesian estimation problem. This is a flexible framework, where any kind of prior knowledge about the source images and the mixing matrix can be accounted for. In particular, we describe local correlation within the individual images through the use of Markov random field (MRF) image models. These are naturally suited to express the joint pdf of the sources in a factorized form, so that the statistical independence requirements of most independent component analysis approaches to blind source separation are retained. Our model also includes edge variables to preserve intensity discontinuities. MRF models have been proved to be very efficient in many visual reconstruction problems, such as blind image restoration, and allow separation and edge detection to be performed simultaneously. We propose an expectation-maximization algorithm with the mean field approximation to derive a procedure for estimating the mixing matrix, the sources, and their edge maps. We tested this procedure on both synthetic and real images, in the fully blind case (i.e., no prior information on mixing is exploited) and found that a source model accounting for local autocorrelation is able to increase robustness against noise, even space variant. Furthermore, when the model closely fits the source characteristics, independence is no longer a strict requirement, and cross-correlated sources can be separated, as well.

Algorithms↗
PubMed2004

Clinical trials: deliberations on their essence and value.

RATIONALE, AIM & OBJECTIVES: In the context of the evidence-based medicine (EBM) movement, the clinical trial has come to be hailed as the ultimate source of medical knowledge, and especially of clinical pharmacology. By subjecting the premises of this procedure to a thorough analysis, the author hopes to achieve a sound rating of its epistemological significance in the context of medical research. METHOD: Current claims on the basic importance of the evidence provided by standardized clinical trials are confronted with conflicting observations concerning their current application in medical practice. The stereotyped trials of present research in multiple sclerosis serve as an example to illustrate this point. RESULTS: Traditional assumptions concerning the validity of standardized clinical trials are based on an illusion of absolute objectivity and reliability. Apart from being subject to tough publish (conveniently)-or-perish and commercial influences, the results of clinical trials, especially drug trials, are of limited informative value in diverse respects, such as (i) clinical trials do not identify every possible drug reaction for every instance of a disease; (ii) their results never allow the prediction of the efficacy of a specific drug in any given individual; (iii) clinical trials have no inherent potential to provide concrete insights into the nature and cause(s) of a definite morbid condition; and (iv) extensions of clinical drug trials to ever-larger study groups indicate serious problems in basic theoretical respects. CONCLUSION: A clinical trial cannot indicate a certain prevention or cure for any particular instance of a disease, and the correctness of its individual predictions is always only contingent. This can be explained by the fact that the correspondence between the nature of each of all pathological conditions presented by the different members of a clinical trial population and by the individual patients being treated according to the results of the trial is never complete.

Austria↗
PubMed1989

The response of young, non-sexually abused children to anatomically correct dolls.

Ninety-one children aged 3-6 yrs were observed and video-recorded playing with the anatomically correct dolls in unstructured play settings. Parental permission had been obtained. The children's emotional, behavioural and overall play responses were rated. Whilst the dolls' difference from other dolls was clearly noticed, they did not traumatise the children, most of whom incorporated the dolls in imaginative play. Only five children's play with the dolls showed any sexualized quality, in three the source of sexual knowledge becoming apparent. Whereas the absence of sexualized play does not reliably exclude abuse, we suggest that explicit sexual play with the dolls may well arise from previous exposure to explicit sexual information or activity.

Child↗