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PubMed1993

Defining normality--art or science?

The problem of defining normality, and in particular the establishment of reference ranges, is discussed. A so-called "objective" method of determining such ranges is described. It is suggested, however, that all currently used methods for defining "normal" ranges rely ultimately on a subjective choice. We propose the use of "How Often That Happens" (HOTH) graphs as an alternative to the conventional reference range. Such graphs show the frequency of results at least as extreme as any observed value. We have used such graphs, along with computer simulation models, in an attempt to describe how the frequency distribution of a given parameter changes as a population ages. Finally, an analogy is drawn between the states of "health", "illness" and "death", and the attractors which arise in non-linear dynamic systems. We conclude that the definition of normality is in fact more of an art than a science.

Adult↗
PubMed1993

Management as the art of politics.

This discussion has furnished a personal view of some of the features involved in managing a busy surgical ICU. Experience has provided the reference frame rather than an extensive literature search and associated bibliography. Physician involvement in ICU management depends on the character of the institution and the ability of the director to influence physician, nursing, and ancillary staff behavior by force of personality rather than by relying on universally accepted behavioral covenants. The issues raised are controversial and should provoke more discussion than acceptance. It is to be hoped, however, that some of the points will be recognized as common problems requiring solution in all similar environments. "Management as the art of politics" summarizes the 1980s' approach to ICU governance, and it is fitting to question its acceptability in an era of cost containment, resource restriction, and increased awareness of the rights of a patient and his or her family to control the extent of medical care rendered. Laissez faire management is unacceptable today, and future governance will reflect increased responsibility for unit managers and the realization that the ICU is an institutional and societal resource that cannot respond to the prerogative of individual users. The Magna Carta of ICU governance remains to be written. It is inappropriate for ICU managers to assume responsibilities that preclude the prerogative of the admitting physician and appropriate medical consultants. It is equally important, however, that the medical community recognizes the importance of adjudicating access to and care within ICUs. Scarce medical resources used in these areas represent as much as 20% of all medical expenditures, the bulk of which is spent in unsuccessful ventures. Management of this resource cannot be relegated to inexperienced, naive, or self-serving clinicians. The tools for managing the ICU in the '90s have been introduced, and they will begin to define the new concept of a successful outcome following admission. Clinicians traditionally have focused on individual patients, and this approach has led to many improvements in care. The next challenge facing the ICU management team will be to organize the process of patient care that will ensure the best possible individual outcome while promoting general efficiency of the available resources to function for all. Physician and nurse managers will be co-responsible for adjudicating a complex, costly, and vital hospital resource; the price of failure is unacceptable.(ABSTRACT TRUNCATED AT 400 WORDS)

Critical Care↗
PubMed1993

Determinants of participation in state-of-the-art cancer prevention, early detection/screening, and treatment trials among African-Americans.

It has been suggested that the greatest potential for reducing cancer mortality in high-risk populations may be realized through aggressive implementation of prevention, diagnostic, and state-of-the-art treatment programs and increasing participation in cancer trials. However, the national data suggest that African-Americans are most often underrepresented in such programs and/or trials. Multiple factors are assumed to contribute to this situation, but currently few studies have been conducted to validate their influence. A study focused on identifying factors that contribute to participation of African-Americans in investigational cancer programs and/or trials was therefore conducted. Two hundred twenty African-American men and women were recruited to participate in a regional survey. There was evidence to support the impact that perceptions, attitudes, and beliefs have on willingness to participate in investigational programs and/or trials. The factor having the greatest influence on willingness to participate in investigational programs and/or trials was perceived efficacy of the investigational programs and/or trials. Among this sample there was an apparent hesitancy of many to participate in research programs and/or trials. The prevailing belief that such programs and/or trials were only for those with the disease or condition under study appeared to influence their response. However, when provided information on the opportunities for participation in prevention, diagnostic, and treatment programs and/or projects for those within the general community (especially for those at higher risk) and on the benefits of participation, a much greater willingness to participate was expressed by participants.

Adolescent↗
PubMed1993

[Acceptance to the incorporation of liberal arts in the curriculum of the Medical School at the University of Puerto Rico].

The acceptance of incorporating courses in liberal arts to the present curriculum of the School of Medicine was assessed. A survey was suministred to 400 subjects that belonged to academic and professional fields of medicine. The results from the survey showed that those who played an acting role in the current curriculum were receptive to innovations. The professors of the clinical aspect of medicine and the practicing physicians were more receptive to curricular change. First year medical students were more receptive than seniors. This positive view constitutes a strong argument for eliciting curricular creativity. These results allow future changes around the medical education of the University of Puerto Rico School of Medicine.

Curriculum↗
PubMed1993

State-of-the-art in restorative aesthetic dentistry - 1993: an overview.

Major changes have taken place in the profession of dentistry during the last three decades. In this overview, the author summarizes developments in vital tooth bleaching, resin bonding in the anterior and posterior Class II locations, veneers, inlays/onlays, all-ceramic crowns, and sonic cementation. An up-to-date knowledge of the state-of-the-art in the profession of dentistry is the learning objective of this overview.

Crowns↗
PubMed1996

Relief of suffering: where the art and science of medicine meet.

The physical, emotional, and spiritual components of suffering are myriad. Fortunately, physicians have available an ever-increasing array of scientific advances to provide relief and comfort from physical pain and distress. Relief of the emotional and spiritual suffering that is part of the human condition requires more--it requires physicians to look beyond the bounds of clinical treatment and draw upon the time-honored wisdom of the art of medicine.

Analgesics↗
PubMed1996

Laboratory precision performance: state of the art versus operating specifications that assure the analytical quality required by clinical laboratory improvement amendments proficiency testing.

OBJECTIVE: To estimate the percent of laboratories with precision performance sufficient to satisfy the operating specifications and guarantee the quality required by the proficiency testing criteria defined by the Clinical Laboratory Improvement Amendments of 1988 (CLIA). DESIGN: Cumulative distributions that describe state-of-the-art laboratory imprecision were obtained for 1500 laboratories participating in the 1990 College of American Pathologists Quality Assurance Service. Allowable imprecision was estimated from the x-intercepts of charts of operating specifications prepared for commonly used single and multirule quality control procedures having two to four control measurements per run. MAIN OUTCOME MEASURE: The derived values for allowable imprecision were imposed on the cumulative distributions to obtain graphical estimates of the percent of laboratories satisfying the operating specifications. RESULTS: Up to 28% of laboratories achieve the imprecision allowable for albumin, up to 64% for total bilirubin, 52% for calcium, 35% for chloride, 48% for cholesterol, 28% for cortisol, 84% for creatinine, 9% for digoxin, 61% for glucose, 64% for high-density lipoprotein cholesterol, 88% for hemoglobin, 95% for potassium, 66% for total protein, 18% for sodium, 29% for thyroxine, 87% for triglycerides, 35% for urea nitrogen, and 81% for uric acid. CONCLUSION: Improvements in precision are still needed for many laboratory tests to assure the analytical quality required by the CLIA proficiency testing total error criteria.

Blood Chemical Analysis↗
PubMed1995

[Bioadhesives: rationale, state of the art and therapeutic potential].

Pharmaceutical research is going on the way to formulate drugs in dosage forms and delivery systems able to improve their biopharmaceutical properties. For some routes of administration, among them the transmucosal ones, such improvements may be reached by increasing the time and the nature of the contact between mucosal tissues and drug dosage forms via chemical or physical bioadhesive links. Biopharmaceutical AFI Study Group efforts were oriented in analyzing the actual state of the art in the field of bioadhesive drug delivery. Rationals of use of drug dosage forms with bioadhesive properties, analytical method of control of bioadhesion (both in vitro and in vivo) and therapeutical potentialities are the matter of this review.

Animals↗
PubMed1996

State of the art on the development of the implantable hearing device for partial hearing loss.

This article summarizes the state of the art of the implantable hearing devices for partial hearing loss. Devices such as temporal bone stimulators and piezoelectric and electromagnetic middle and inner ear transducers are discussed. Cochlear implants are excluded. (See "Update on Cochlear Implantation" in this issue.) Those readers interested in a more in-depth study of implantable hearing devices should consult the February 1995 issue of The Otolaryngologic Clinics of North America which is dedicated to this matter (Guest Editor: Anthony J. Maniglia, MD).

Bone Conduction↗
PubMed1996

Acoustic assessment of fracture healing. Capabilities and limitations of "a lost art".

The ability of bone to conduct sound was applied clinically over 50 years ago to identify the presence of fresh fractures, although the technique has become a relatively "a lost art" as more sophisticated X-ray and other imaging techniques have been developed. The objective of this report is to challenge clinical orthopaedic surgeons unfamiliar with the technique to explore this simple beside method in the clinical management of fractures. A portable computer-based vibrational analysis device was employed and experiments conducted to objectively evaluate the capabilities of auscultatory percussion techniques. Auscultatory percussion can, with certain limitations, detect the presence of fractures, assess qualitatively the progress of healing, detect delayed or nonunions, and indicate when sufficiently firm continuity has occurred to permit early mobilization or loadbearing. Vibrational assessment is, however, subject to systematic and random errors, and thus cannot always discriminate between the stages of healing in a fractured bone; in addition, various artifacts can lead to significant uncertainty in the diagnosis. Nevertheless, auscultatory percussion is a useful tool in clinical fracture management, and particularly where roentgenographic facilities are inadequate or not available. Computerized vibrational analysis can be used in place of classical percussion/stethoscope methods by those with poor tonal capabilities,or when more objective record keeping is desired.

Auscultation↗
PubMed1996

[Cryopreservation of embryos--used for treatment of infertility by means of assisted reproductive techniques (ART)].

Freezing of the human embryos has been routinely used in the world for over 10 years in the treatment of infertility by the ART. Excessive fertilized oocytes and embryos can be frozen and preserved in the temperature of liquid nitrogen. The risk of multiple pregnancies is reduced and enhancement of pregnancy rates can be obtained owing to cryopreservation. The author presents theoretical principles of embryo freezing by slow cooling with 1, 2 propanediol and saccharose as a cryoprotectant.

Cryopreservation↗
PubMedDate not supplied

Basic science research in chiropractic: the state of the art and recommendations for a research agenda.

A position paper was prepared as background information for participants in the National Workshop to Develop the Chiropractic Workshop Agenda conducted by the Palmer Center for Chiropractic Research, Davenport, Iowa. The paper was revised in light of comments and suggestions at the workshop by participants and by a workgroup composed of basic scientists from within and outside of chiropractic. This final article documents the history of basic science research in chiropractic, and the current state of the art of basic science research conducted since 1975 by chiropractors or investigators at chiropractic institutions in North America. Seed recommendations contained in the working paper for the development of an adequate infrastructure needed to conduct future research and seed recommendations for a future basic science research agenda were also modified and revised by the workgroup participants through a modified nominal group process. The final recommendations contained in this article represent a synthesis of these recommendations and those of the authors.

Animals↗
PubMedDate not supplied

Outcomes research in chiropractic: the state of the art and recommendations for the chiropractic research agenda.

OBJECTIVE: To examine and document the state of the art in outcomes research in chiropractic, including the limitations of available data, and to make recommendations for further progress in this area. METHODOLOGY: An extensive search of the literature from 1990 through 1994 was undertaken using electronic databases (Medline, Index to Chiropractic Literature, EMBASE, and ERIC) and hand searches were conducted for relevant studies published in 1995. Publication in English, publication in a peer-reviewed journal, weight of evidence (study design) and measurement of patient-relevant outcomes were primary inclusion criteria. We prepared a draft with recommendation, rationale, actions required, responsible parties and expected outcomes for each seed statement. An outcomes workgroup, convened at the Research Agenda Work shop, added its perspective to the seed recommendations and actions required. Finally, the white paper authors prepared the final recommendations for outcomes research in chiropractic. RESULTS: This white paper presents six recommendations, emphasizing four general areas in which to develop the outcomes research agenda in chiropractic: research culture, infrastructure, opportunities and topics in outcomes research. CONCLUSION: The long-term goals of the chiropractic research agenda must be to advance the profession and to better meet the health needs of the public. Our final recommendations serve as a foundation for the development of proposals for future strategy with outcomes research a priority.

Case-Control Studies↗
PubMedDate not supplied

The art of negotiation. A delicate balance.

Successful negotiation is the art of gentle persuasion, not a "winner-take-all" showdown. Accordingly, it is essential to begin the process with a positive outlook and with the goal of reaching an agreement that is acceptable to all parties involved. Although the term "opponent" is used in this article to describe the person or group with whom you are negotiating, it is not used in the adversarial context. It is important to maintain a non-adversarial relationship, to the extent possible.

Humans↗
PubMed1997

[The art of therapy in Islamic medicine].

History is a witness of the great importance and influence of islamic science from the period of "Golden Age of Arabic Civilisation". A famous scientist said: "Sciences has no country, it is international; we all share in fruits of investigations of people from different traditions and all ages." Scientists from the early period of islamic era had set fire of a stream of man's thought and progress, observation, experiments and tradition, that have become a weapon of modern science. All of that was based upon Quran and Hadiths, that have been their guidelines when setting free human mind from taboos. Medieval Arabian scientists have followed the words of Holly Prophet Mohammad s.a.v.s., saying that searching for knowledge have had to be the most important task for people, and that ink more saint than blood of the saints. These attitudes of Holly Prophet have awaken desire for studying with muslim scientists. The result of that desire became a key of scientific progress. There are many worldwide famous arabian scientists: El-Kindi, Er-Razi, Ibn Sina, El-Biruni, Ibu Hajsem, Ez-Zahravi, El-Farabi, Ibn Zuhr, Ibn Ruzd etc. These names, among several hundreds of arabian physicians, attribute "Golden Age" of islamic science. That period was characterised by movements, reprocessing of ideas. That reprocessing of ideas has gained the great minds together, and that process is continuous. That is why we have to be grateful to them. Famous Muslim physicians defined medicine as skill that dealt in keeping good health, coped with ills and health recovering. They have also modified many Greek writings and established basic principles of the art of medicine. What is significant is that, regardless of historical past and modern technical and technological presence, these principles are still accurate for understanding of medical science. These principles are what the author is discussing in detail in this paper about.

History, Ancient↗
PubMed1997

[The art of delivering a lecture. Thoughts at a Scandinavian congress].

During a Nordic scientific meeting 29 lectures were evaluated according to the written instructions about how to present a paper. Three speakers (10 per cent) were able to fulfil all rules. Nordic Conferences should continue to be a forum, where young scientists are invited to present their work but senior co-authors are advised to give better instructions about the art of oral presentation.

Humans↗
PubMed1997

In vitro evaluation of sealing pits and fissures with newer glass-ionomer cements developed for the ART technique.

Four conventional glass-ionomer cements specifically developed for use with the atraumatic restorative treatment (ART) technique were compared with a resin-based sealant for marginal and surface dye penetration, material voids, and completeness of enamel fissure penetration. Thirty sound permanent mandibular molar teeth were randomly divided into five groups. After delayed placement of the glass-ionomer cement sealants using standardized finger pressure, and conventional placement of the resin-based sealant using a dental probe, the teeth were first thermocycled then the crowns immersed in methylene blue dye before being sectioned. There were no statistically significant differences found between any of the five materials, apart from less marginal dye leakage being present for the resin-based sealant than for one of the glass-ionomer cements. The cements, however, showed better fissure penetration than did the sealant. Despite the delayed placement and higher viscosity, all of the glass-ionomer cements showed satisfactory penetration of the enamel fissures and minimal marginal and surface dye penetration, and material voids, when placed using firm finger pressure. The cements could prove to be useful in the dental treatment of apprehensive children.

Analysis of Variance↗
PubMed1998

[Current prenatal care with reference to state of the art knowledge].

Every physician taking care of pregnant women believes to be well acquainted with the state-of-the-art requirements. However, changes imposed by the new Swiss health insurance legislation (KVG) and by the pressure of Evidence Based Medicine brought these into a new scope. In Switzerland there is no general agreement on optimal pregnancy-care. We propose a care-standard, based on rational and efficient clinical, laboratory and sonographic checks, which allow a timely diagnosis of pregnancy-at-risk. Targeted laboratory investigations as well as the anti-D-immunoprophylaxis, and screening for diabetes mellitus efficiently help to avoid long-term sequelae for mother and child. Screening for toxoplasmosis, HIV, and hepatitis B are compulsory. A vaginal pH below 4.5 prevents premature birth. Diagnosis and treatment of vaginal chlamydial and candida infection are also very important in this respect. The number of sonographies to be performed during pregnancy is a highly political issue, and we have to comply with our dirigistic governmental regulations. However, sonography including search for increased nuchal translucency done early in pregnancy is a key procedure for quality assurance. Supplementation of folic acid started before conception, almost entirely prevents neural tube defects. Hence women need appropriate advice before conception. A new information brochure is available for future parents in Switzerland, and makes all former self-made guidelines unnecessary. UNICEF declared 1998 as the year of safe motherhood. Worldwide still too many women die from pregnancy and delivery. Care for normal pregnancy, and not only for at-risk-pregnancy will therefore continue to make sense.

Evidence-Based Medicine↗