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PubMed2001

A shared vision of healthcare quality improvement.

SHEA and the American Society for Quality's Health Care Division have been collaborating in areas of common concern to improve healthcare quality. We each possess a heritage of different but complementary approaches and stand a better chance of success together than apart. This presentation describes rapid growth of our interdisciplinary, international, special interest group and progress made thus far, as well as challenges facing hospital epidemiologists and quality improvement professionals.

Cooperative Behavior↗
PubMed1998

Effect of genetic modification of acute inflammatory responsiveness on tumorigenesis in the mouse.

Two distinct bidirectional selective breedings for quantitative traits were initiated from identical genetically heterogeneous mouse populations. The resulting lines are characterized by maximal or minimal acute inflammatory responsiveness (AIR): AIRmax and AIRmin lines, respectively, and by resistance or susceptibility to chemical skin tumorigenesis: Car-R and Car-S lines, respectively. The AIR response to s.c. injection of polyacrylamide microbeads, measured by cell content in the local exudate, was 10 times higher in AIRmax than in AIRmin mice. The response to selection was asymmetrical: the realized heritability was 0.26 in AIRmax and 0.008 in AIRmin, and resulted from the additive effect of 7-11 quantitative trait loci (QTL). Low responsiveness was globally dominant in F1 and 48% of F2 segregant variance was found to be due to genetic factors. These findings are the first demonstration of innate regulation of AIR by germ line genes. Susceptibility to skin tumorigenesis induced by a two-stage initiation (DMBA)-promotion (TPA) protocol was lower in AIRmax mice than in AIRmin mice, a 6-fold difference in tumor induction rate. Intense AIR was found to be associated with resistance, and low AIR with susceptibility to tumorigenesis, in F2 segregants chosen for extreme AIR phenotypes. At least some of the AIR QTLs therefore contain genes controlling tumorigenesis. Tumor phenotypes differed more in Car-R and Car-S than in AIRmax and AIRmin lines, indicating that QTLs unrelated to AIR, contribute to the host response to tumorigenesis. The extreme phenotypes/genotypes of the four selected lines and the known genetic constitution of their foundation population, offer new possibilities to discriminate the genes/mechanisms controlling two important traits: AIR and response to chemical tumorigenesis. Collaborative projects will be favorably considered. The description of tumor resistance genes in AIRmax and Car-R mice may be helpful for epidemiology and therapy of human cancer.

Acute Disease↗
PubMed1999

The PIR-International Protein Sequence Database.

The Protein Information Resource (PIR; http://www-nbrf.georgetown. edu/pir/) supports research on molecular evolution, functional genomics, and computational biology by maintaining a comprehensive, non-redundant, well-organized and freely available protein sequence database. Since 1988 the database has been maintained collaboratively by PIR-International, an international association of data collection centers cooperating to develop this resource during a period of explosive growth in new sequence data and new computer technologies. The PIR Protein Sequence Database entries are classified into superfamilies, families and homology domains, for which sequence alignments are available. Full-scale family classification supports comparative genomics research, aids sequence annotation, assists database organization and improves database integrity. The PIR WWW server supports direct on-line sequence similarity searches, information retrieval, and knowledge discovery by providing the Protein Sequence Database and other supplementary databases. Sequence entries are extensively cross-referenced and hypertext-linked to major nucleic acid, literature, genome, structure, sequence alignment and family databases. The weekly release of the Protein Sequence Database can be accessed through the PIR Web site. The quarterly release of the database is freely available from our anonymous FTP server and is also available on CD-ROM with the accompanying ATLAS database search program.

Amino Acid Sequence↗
PubMed2006

Issues in weaning from mechanical ventilation: literature review.

AIM: The aim of this paper is to raise questions on the effect of skill mix and organizational structure on weaning from mechanical ventilation. BACKGROUND: Mechanical ventilation is an essential life-saving technology. There are, however, numerous associated complications that influence the morbidity and mortality of patients receiving intensive care. Therefore, it was essential to use the safest and most effective form of ventilation for the shortest possible duration. Because of the potential complications and costs of mechanical ventilation, research to date have focused on accurate weaning readiness assessment, methods and organizational aspects that influence the weaning process. METHOD: In early 2005, the literature was reviewed from 1986 to 2004 by accessing the following databases: Medline, Proquest, Science Direct, CINAHL, and Blackwell Science. The keywords mechanical ventilation, weaning, protocols, critical care, nursing role, decision-making and weaning readiness were used separately and combinations. DISCUSSION: Controversy exists in weaning practices about appropriate and efficacious weaning readiness assessment indicators, the best method of weaning and the use of weaning protocols. Arguably, the implementation of weaning protocols may have little effect in an environment that favours collaboration between nursing and medical staff, autonomous nursing decision-making in relation to weaning practices, and high numbers of nurses qualified at postgraduate level. CONCLUSION: Further research is required that better quantifies critical care nurses' role in weaning practices and the contextual issues that influence both the nursing role and the process of weaning from mechanical ventilation.

Australasia↗
PubMed2001

Deficiency of Pten accelerates mammary oncogenesis in MMTV-Wnt-1 transgenic mice.

BACKGROUND: Germline mutations in the tumor suppressor PTEN predispose human beings to breast cancer, and genetic and epigenetic alterations of PTEN are also detected in sporadic human breast cancer. Germline Pten mutations in mice lead to the development of a variety of tumors, but mammary carcinomas are infrequently found, especially in mice under the age of six months. RESULTS: To better understand the role of PTEN in breast tumor development, we have crossed Pten heterozygous mice to MMTV-Wnt-1 transgenic mice that routinely develop ductal carcinomas in the mammary gland. Female Wnt-1 transgenics heterozygous for Pten developed mammary tumors earlier than Wnt-1 transgenics that were wild type for Pten. In most tumors arising in Pten heterozygotes, the Pten wild-type allele was lost, suggesting that cells lacking Pten function have a growth advantage over cells retaining a wild type allele. Tumors with LOH contained high levels of activated AKT/PKB, a downstream target of the PTEN/PI3K pathway. CONCLUSIONS: An animal model has been developed in which the absence of Pten collaborates with Wnt-1 to induce ductal carcinoma in the mammary gland. This animal model may be useful for testing therapies specific for tumors deregulated in the PTEN/PI3K/AKT pathway.

Journal Article↗
PubMed2003

Effects of communities, neighborhoods and stores on retail pricing and promotion of beer.

OBJECTIVE: This study examines how communities, neighborhoods and stores influence retail pricing and promotion of beer. METHOD: In the year 2000, trained field staff conducted observations in 2,024 retail alcohol stores in 160 communities throughout the contiguous United States. Based on a nationally representative sample of schools, we selected communities defined by the school's catchment area, or the vicinity from which the majority of students are drawn. We randomly selected off-sale alcohol retail establishments from a complete list of stores likely to sell tobacco or alcohol in the selected communities. Beer price and promotions are based on observations of Miller and Budweiser beer brands in the stores. Neighborhoods are defined by the store's census block. We used cross-sectional, hierarchical regression models and mixed methods procedures to analyze data. RESULTS: Community, neighborhood and store characteristics were related to beer price; however, only community and store characteristics were predictive of beer promotions. CONCLUSIONS: Overall, the pricing and promotion of beer vary systematically by some characteristics of communities, neighborhoods and stores, but not significantly by the number of young people populating a neighborhood. In addition, pricing and promotion of Budweiser and Miller beers, in particular, do not appear to target racial minority populations. Because of the significant effect of store characteristics, public health agencies and advocates might focus prevention efforts on collaborations with liquor control agencies to reduce variations in pricing and promotion of beer, which ultimately encourage risky drinking behaviors. Further studies are needed to examine the effects of pricing and promotion on alcohol-related social problems.

Adolescent↗
PubMed2003

Laparoscopic techniques versus open techniques for inguinal hernia repair.

BACKGROUND: Inguinal hernia repair is the most frequently performed operation in general surgery. The standard method for inguinal hernia repair had changed little over a hundred years until the introduction of synthetic mesh. This mesh can be placed by either using an open approach or by using a minimal access laparoscopic technique. Although many studies have explored the relative merits and potential risks of laparoscopic surgery for the repair of inguinal hernia, most individual trials have been too small to show clear benefits of one type of surgical repair over another. OBJECTIVES: The objective of this review was to compare minimal access laparoscopic mesh techniques with open techniques. Comparisons of open mesh techniques versus open non-mesh techniques have been considered in a separate Cochrane review. SEARCH STRATEGY: We searched MEDLINE, EMBASE, and The Cochrane Central Controlled Trials Registry for relevant randomised controlled trials. The reference list of identified trials, journal supplements, relevant book chapters and conference proceedings were searched for further relevant trials. Through the EU Hernia Trialists Collaboration (EUHTC) communication took place with authors of identified randomised controlled trials to ask for information on any other recent and ongoing trials known to them. Specialists involved in research on the repair of inguinal hernia were contacted to ask for information about any further completed and ongoing trials. The world wide web was also searched. SELECTION CRITERIA: All published and unpublished randomised controlled trials and quasi-randomised controlled trials comparing laparoscopic groin hernia repair with open groin hernia repair were eligible for inclusion. Trials were included irrespective of the language in which they were reported. DATA COLLECTION AND ANALYSIS: Individual patient data were obtained, where possible, from the responsible trialist for all eligible studies. All reanalyses were cross-checked by the reviewers and verified by the trialists before inclusion. Where IPD were unavailable additional aggregate data were sought from trialists and published aggregate data checked and verified by the trialists. IPD were available for 25 trials, additional aggregated data for seven and published data only for nine. Where possible, time to event analysis for hernia recurrence and return to usual activities were performed on an intention to treat principle. The main analyses were based on all trials. Sensitivity analyses based on the data source and trial quality were also performed. Pre-defined subgroup analyses based on recurrent hernias, bilateral hernias and femoral hernias were also carried out. MAIN RESULTS: 41 published reports of eligible trials were included involving 7161 participants. Sample sizes ranged from 38 to 994, with follow-up from 6 weeks to 36 months. Duration of operation was longer in the laparoscopic groups (WMD 14.81 minutes, 95% CI 13.98 to 15.64; p<0001). Operative complications were uncommon for both methods but more frequent in the laparoscopic group for visceral (Overall 8/2315 versus 1/2599) and vascular (Overall 7/2498 versus 5/2758) injuries. Length of hospital stay did not differ between groups (WMD -0.04 days, 95% CI -0.08 to 0.00; p=0.05, but return to usual activity was earlier for laparoscopic groups (HR 0.56, 95%CI 0.51 to 0.61; p<0.0001 - equivalent to 7 days). The data available showed less persisting pain (Overall 290/2101 versus 459/2399; Peto OR 0.54, 95% CI 0.46 to 0.64; p<0.0001), and less persisting numbness (Overall 102/1419 versus 217/1624; Peto OR 0.38, 95% CI 0.4286 to 0.49; p<0.0001) in the laparoscopic groups. In total, 86 recurrences were reported amongst 3138 allocated laparoscopic repair and 109 amongst 3504 allocated to open repair (Peto OR 0.81, 95% CI 0.61 to 1.08; p = 0.16). The use of mesh during laparoscopic hernia repair is associated with a reduction in the risk of hernia recurrence, significantly so for the transabdominal preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus preperitoneal repair (TAPP) versus open non-mesh repair (overall 26/1440 versus 47/1119; Peto OR 0.45, 95% CI 0.28 to 0.72; p=0.0009). However, no difference was detected when comparing laparoscopic methods with open mesh methods of hernia repair. REVIEWER'S CONCLUSIONS: The use of mesh during laparoscopic hernia repair is associated with a relative reduction in the risk of hernia recurrence of around 30-50%. However, there is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair. The data suggests less persisting pain and numbness following laparoscopic repair. Return to usual activities is faster. However, operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries.

Hernia, Inguinal↗
PubMed2002

The role of glycosyl phosphatidyl inositol (GPI)-anchored cell surface proteins in T-cell activation.

Glycosylphosphatidylinositol (GPI)-anchored cell surface proteins are widely expressed in tissues, including cells of immunohematopoietic origin. Cross-linking of GPI-linked proteins on T lymphocytes, such as Thy-1 (CD90), Ly-6 A/E, CD48, CD59 and others, induces T-cell mitogenesis. Similar to cross-linking with T-cell receptor (TcR)-specific antibodies, ligation of GPI-anchored proteins induces an intracellular flux of calcium, an up-regulation of activation-associated cell surface proteins and the elaboration of growth-promoting lymphokines. These events are dependent on p56(lck)-mediated tyrosine phosphorylation of substrates. GPI-linked proteins are constitutively clustered in sphingolipid-rich membrane domains. Actin-driven rearrangements of the cytoskeleton are probably responsible for the physical approximation of TcR and GPI-anchored proteins in mature immunological synapses. Functionally, GPI-linked proteins can supplant for signal I and productively collaborate with CD28 to fully activate T cells.

Animals↗
PubMed2002

Juvenile justice mental health services.

As the second century of partnership begins, child psychiatry and juvenile justice face continuing challenges in meeting the mental health needs of delinquents. The modern juvenile justice system is marked by a significantly higher volume of cases, with increasingly complicated multiproblem youths and families with comorbid medical, psychiatric, substance abuse disorders, multiple family and psychosocial adversities, and shrinking community resources and alternatives to confinement. The family court is faced with shrinking financial resources to support court-ordered placement and treatment programs in efforts to treat and rehabilitate youths. The recognition of high rates of mental disorders for incarcerated youth has prompted several recommendations for improvement and calls for reform [56,57]. In their 2000 annual report, the Coalition for Juvenile Justice advocated increased access to mental health services that provide a continuum of care tailored to the specific problems of incarcerated youth [58]. The specific recommendations of the report for mental health providers include the need for wraparound services, improved planning and coordination between agencies, and further research. The Department of Justice, Office of Juvenile Justice and Delinquency Prevention has set three priorities in dealing with the mental health needs of delinquents: further research on the prevalence of mental illness among juvenile offenders, development of mental health screening assessment protocols, and improved mental health services [59]. Other programs have called for earlier detection and diversion of troubled youth from juvenile justice to mental health systems [31,56]. Most recently, many juvenile and family courts have developed innovative programs to address specific problems such as truancy or substance use and diversionary or alternative sentencing programs to deal with first-time or nonviolent delinquents. All youths who come in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing. Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system [58]. If delinquent youths do not receive the necessary evaluation, treatment, and rehabilitation, they face the real prospect of further incarceration in adult correctional facilities. Improved screening and treatment require better interagency collaboration, established standards of care, and continuing research on the mental health needs of youth in the juvenile justice system. Better mental health care for youth in the juvenile justice system supports the goal of rehabilitation. Mental health professionals should support these efforts as the appropriate response to meet the challenges of the new century.

Adolescent↗
PubMed2006

Somatoform disorders in the workplace in Japan.

The literature related to somatoform disorders in the workplace is very limited, and these disorders need more attention from mental health professionals in the workplace as well as from employers. Over the last decade, major changes have taken place in the work environment in Japan. More stress and less support from supervisors or colleagues in the workplace have made employees stressed out. The number of employees with mental disorders, including somatoform disorders, taking sick leave has significantly increased. In our multi-centre collaborative study, somatoform disorders were the third most prevalent psychiatric disorder in employees, after mood and schizophrenic disorders. Employees with neurotic disorders manifested physical symptoms more frequently than those without. Young employees frequently reported somatic symptoms such as general malaise, nausea, constipation, diarrhoea, headache, stiff shoulder, and dizziness. A rational new approach is needed to tackle this important psychopathology increasingly seen among employees.

Adult↗
PubMed2005

Toward a new payment system for inpatient rehabilitation. Part I: Predicting resource consumption.

BACKGROUND: The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs. OBJECTIVES: We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models. RESEARCH DESIGN: A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting. RESULTS: We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed. CONCLUSION: We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

Diagnosis-Related Groups↗
PubMed1994

Mental health services in Army primary care: the need for a collaborative health care agenda.

Epidemiologic studies have shown that more than half of mentally ill patients in the United States receive their psychiatric care exclusively in primary care settings. This fraction may be even higher in the military due to concern over possible occupational repercussions resulting from use of specialty psychiatric care and specialist shortages. Collaboration between generalists and mental health care specialists could potentially improve mental health care delivery and reduce psychiatric disability for a large segment of the Army population who have a psychiatric disorder but may not seek specialty care. Collaborative efforts can reinforce military generalists' essential gate-keeping function, thereby decreasing unnecessary medical utilization and health care costs. The authors review the problems associated with mental health care delivery in primary care and provide examples of collaborative models previously studied or currently being explored. A four-part Army Primary Care-Mental Health Services Agenda is proposed, consisting of: (1) coordinated research including primary care-mental health services research and community-based epidemiologic studies; (2) formation of a primary care-mental health services advisory committee for aiding with policy and program development; (3) graduate and continuing medical education in primary care-mental health services emphasizing interdisciplinary collaborative skills; and (4) clinical implementation of feasible collaborative interdisciplinary mental health care models adapted to the range of unique Army primary care settings. The main goal of the Army Primary Care-Mental Health Services Agenda is to improve access to Army mental health care in the most efficacious and cost-effective way and to help minimize the organizational impact of disability related to psychosocial distress.

Cross-Sectional Studies↗
PubMed2001

Primary dysmenorrhea in adolescent girls and treatment with oral contraceptives.

This review examines the prevalence, associated morbidity, and treatment of primary dysmenorrhea in adolescent girls. Relevant literature was examined by systematic, evidence-based review using MEDLINE and Cochrane Collaboration databases. Dysmenorrhea is highly prevalent during adolescence. Despite differences in measurement methods, 20%-90% of adolescent girls report dysmenorrhea and about 15% of adolescents describe their dysmenorrhea as severe. During adolescence, dysmenorrhea leads to high rates of school absence and activity nonparticipation. Most adolescents with dysmenorrhea self-medicate with over-the-counter preparations; few consult healthcare providers. Combined oral contraceptives (COC) are an accepted treatment for dysmenorrhea in nonadolescent women. However, data supporting the efficacy of COC is limited. Very small studies show decreased prostaglandin in menstrual fluid associated with high-dose COC use. Larger studies are limited to cross-sectional comparisons showing lower prevalence of dysmenorrhea in low-dose COC users compared to non-COC users. One small, randomized controlled trial including some adolescents demonstrated an improvement in dysmenorrhea with high-dose COC treatment compared to placebo. The efficacy of low-dose COC in the treatment of adolescent dysmenorrhea has yet to be determined. If effective, well-established safety and noncontraceptive health benefits may make COC an ideal treatment for dysmenorrhea in adolescent girls.

Absenteeism↗
PubMed2000

EcoGene: a genome sequence database for Escherichia coli K-12.

The EcoGene database provides a set of gene and protein sequences derived from the genome sequence of Escherichia coli K-12. EcoGene is a source of re-annotated sequences for the SWISS-PROT and Colibri databases. EcoGene is used for genetic and physical map compilations in collaboration with the Coli Genetic Stock Center. The EcoGene12 release includes 4293 genes. EcoGene12 differs from the GenBank annotation of the complete genome sequence in several ways, including (i) the revision of 706 predicted or confirmed gene start sites, (ii) the correction or hypothetical reconstruction of 61 frame-shifts caused by either sequence error or mutation, (iii) the reconstruction of 14 protein sequences interrupted by the insertion of IS elements, and (iv) pre-dictions that 92 genes are partially deleted gene fragments. A literature survey identified 717 proteins whose N-terminal amino acids have been verified by sequencing. 12 446 cross-references to 6835 literature citations and s are provided. EcoGene is accessible at a new website: http://bmb.med.miami.edu/EcoGene/EcoWeb. Users can search and retrieve individual EcoGene GenePages or they can download large datasets for incorporation into database management systems, facilitating various genome-scale computational and functional analyses.

Databases, Factual↗
PubMed2006

Beyond the sound of one hand clapping: experiences in six countries using health equity research in policy.

In an attempt to better understand the complex and sometimes tenuous relationship between health equity research and health policy, we undertook a collaborative comparison of six case studies with researchers from the United States, the United Kingdom, the Netherlands, China, South Africa, and Chile. Patterns in factors contributing to governments' interest in research included the role of domestic advocacy, interest in their international standing, and the existence of internal government champions. Strategies used by researchers to promote their findings included carefully crafting messages and selecting messengers in accordance with their audience's concerns, delaying publication until interactions with policy makers had occurred, monitoring public opinion, and a host of ideas relating to the style and content of government-sponsored commission reports. Most of the similarities crossed the developing/developed country divide, although it did appear that in the three case studies from the north, greater attention was paid to the professional legitimacy of institutions, individuals, and journals, while in the three developing countries the existence of trusted personal messengers appeared essential. While there are no prescriptions for ensuring the use of health equity research in policy, the comparison across such different international settings stimulated participants to question their assumptions about what works, when, and why.

Chile↗
PubMed2005

[Situation of adult patients with inborn errors of metabolism. A survey in Germany].

BACKGROUND AND PURPOSE: Advances in diagnosis and therapy of inborn errors of metabolism have improved prognosis and outcome of affected patients. Many patients have reached adulthood already, and thus may be attended by adult physicians. In this study the authors evaluated the situation of adult patients with metabolic diseases in Germany. METHODS: 26 pediatric departments with a special metabolic unit were asked to answer a questionnaire of 14 questions. RESULTS: 16/26 departments completed the questionnaire. Only one hospital maintains an outpatient department for adult patients with metabolic diseases. Two additional internal medical departments collaborate with a pediatric metabolic center. Many of the answering pediatric departments conceded problems in the treatment of adult patients with metabolic diseases. CONCLUSION: Adults with inborn errors of metabolism are mostly attended by pediatricians, also beyond adolescence. There is an urgent need for structures that guarantee appropriate and sufficient treatment of this continuously growing population.

Adolescent↗
PubMed2005

Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence.

Findings from research on psychiatric epidemiology, disaster effects, discrepancies in service use, and cross-cultural psychology are reviewed to generate guidelines for culturally responsive postdisaster interventions. Ethnicity and culture influence mental health care at various points: on need for help; on availability and accessibility of help; on help-seeking comfort (stigma, mistrust), and on the probability that help is provided appropriately. There are aspects of disaster mental health practice that may ameliorate many of barriers that contribute to ethnic disparities in service use. It is proposed that interventions should give greater attention to socially engaged emotions and functioning. To promote disaster recovery, practitioners are advised to: assess community needs early and often; provide easily accessible services; work collaboratively and proactively to reduce stigma and mistrust and engage minorities in care; validate and normalize distress and help-seeking; value interdependence as well as independence as an appropriate developmental goal; promote community action; and advocate for, facilitate, or conduct treatment and evaluation research. Notwithstanding the pain and stress they cause, disasters create opportunities to de-stigmatize mental health needs and build trust between providers and minority communities.

Community Mental Health Services↗
PubMedDate not supplied

Sowing the seeds of public health nursing--1920-39.

The Florence Nightingale International Foundation and the Florence Nightingale International Courses played an important role in the development of public health nursing leadership in Europe and remain an outstanding example of international collaboration. Through the International Courses 203 nurses from 40 countries were prepared to organize and implement systems of public health nursing where none had previously existed; another 97 nurses were prepared for leadership as administrators and teachers. Below, how the courses started and their impact as viewed by nursing leaders of that era.

Europe↗