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PubMed2005

Acoustic analysis of the voice in pediatric cochlear implant recipients: a longitudinal study.

OBJECTIVE: To characterize inherent acoustic abnormalities of the deaf pediatric voice and the effect of artificially restoring auditory feedback with cochlear implantation. DESIGN: Inception cohort. SETTING: Academic referral center. PATIENTS: Twenty-one children with severe to profound hearing loss (15 prelingually deaf, 6 postlingually deaf) accepted into the cochlear implant program were followed for up to 6 months. Patients unable to perform the vocal exercises were excluded. INTERVENTIONS: Objective voice analysis was performed using the Computerized Speech Laboratory (Kay Elemetrics) prior to cochlear implantation, at the time of implant activation and at 2 and 6 months postactivation. Assessments were based on sustained phonations and dynamic ranges. MAIN OUTCOME MEASURE: Fundamental frequency, long-term control of fundamental frequency (vF0) and long-term control of amplitude (vAM) were derived from sustained phonations. The dynamic frequency range was derived from scale exercises. Formant frequencies (F1, F2, F3) were determined using linear predictive coding. RESULTS: Fundamental frequency was not altered by implant activation or experience (P = 0.342). With profoundly deaf subject, the most prevalent acoustic abnormality was a poor long-term control of frequency (vF0, 2.81%) and long-term control of amplitude (vAm, 23.58%). Implant activation and experience had no effect on the long-term control of frequency (P = 0.106) but normalized the long-term control of amplitude (P = 0.007). The mean frequency range increased from 311.9 Hz preimplantation to 483.5 Hz postimplantation (P = 0.08). The F1/F2 ratio remained stable (P = 0.476). CONCLUSION: In children, severe to profound deafness results in poor long-term control of frequency and amplitude. Cochlear implantation restores control of amplitude only and implies the need for additional rehabilitative strategies for restoration of control of frequency.

Acoustics↗
PubMed2006

Implementation of a norepinephrine-based protocol for management of septic shock: a pilot feasibility study.

BACKGROUND: The subject of the best vasopressor for hemodynamic management of septic shock (SS) is controversial. One of the difficulties in planning such studies is that physicians are reluctant to use one vasopressor exclusively, and there is considerable variation in practice. The aim of this study was to test the feasibility of implementing a single pressor-based algorithm (in this case, norepinephrine [NE]). METHODS: A NE-based algorithm was applied prospectively to 100 consecutive SS patients. A formal training program was implemented before starting the protocol and applied to 72 physicians and nurses involved in intensive care unit (ICU) patient care. Compliance, protocol violations, probable adverse effects, and outcome were evaluated on a daily basis by an independent group of fellows and a research nurse. RESULTS: In 100 patients, there were 7,139 hours of algorithm use. Only 13 protocol violations were observed, mostly in the timing of inotropic drugs. Senior staff physicians or busy night shifts accounted for most of these violations. ICU mortality was 33%, which is comparable to that predicted by Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. Adverse events probably related to NE were not observed. CONCLUSIONS: The present algorithm, applied after a strict training program, obtained an overall good acceptance and compliance with very few protocol violations in more than 7,000 hours of use. Safety was demonstrated by a global mortality comparable to that predicted by severity scores and absence of specific drug-related morbidity. The implementation of a single pressor-based algorithm for SS is feasible and safe.

Adult↗
PubMed2005

Survey of the practice of electroconvulsive therapy in teaching hospitals in India.

OBJECTIVES: We sought to obtain an overview of electroconvulsive therapy (ECT) practice in teaching hospitals in India. METHOD: From September 1, 2001, to August 31, 2002, a 29-item questionnaire enquiring about ECT practice during the past year was sent to 188 teaching institutions and psychiatric hospitals. RESULTS: Seventy-four institutions (39.4%) completed the questionnaire. ECT was available in 66 institutions. A total of 19,632 patients received 114,111 instances of ECT from 316 psychiatrists, of which 13,891 patients (70.8%) received 89,475 treatments (78.4%) from 128 psychiatrists in the psychiatric hospitals. The male-to-female ratio was 1.56 to 1. Brief-pulse device was used in 39 institutions. EEG monitoring was used routinely in only 8 institutions. Bilateral ECT was used in almost all institutions. Patients with schizophrenia received ECT most frequently (36.5%), followed by patients with major depression (33.5%), mania (17.9%), catatonia (6.2%), and dysthymia (2.8%). Patients who received ECT were in age group of 45-64 years (43.9%), followed by 25-44 years (34.5%), 65 years and older (14.7%), 18-24 years (5.6%), and younger than 18 years (1.4%). A total of 10,234 patients (52%) received unmodified ECT 52,450 treatments (46%) at 33 institutions. There was one case of ECT-related death during a survey. Continuation ECT was performed in 29 institutions and maintenance ECT in 17. CONCLUSIONS: More than 70% of ECT administrations in India were performed in the psychiatric hospitals. Approximately half of ECT use was unmodified ECT. The majority of patients who received ECT were diagnosed with schizophrenia and major depression. ECT training programs for psychiatry residents were acceptable.

Adult↗
PubMed1981

Computer analysis of electronystagmographic data.

Manual calculation of the parameters of nystagmus is imprecise and time consuming. Therefore, a computer program for analysis of nystagmus has been built up in our laboratory. The program is based on automatic extraction of the minimum and maximum values nystagmus. These values are stored for calculations of duration, amplitude and velocity of the fast and slow phase. The distinction between the slow and fast phase is based on the duration of the phases. The program is thus able to accept nystagmus in different directions.

Computers↗
PubMed1981

"The rise and fall" of dental caries: some global aspects of dental caries epidemiology.

The purpose of this paper was to review some global aspects of dental caries epidemiology. Existing data show that caries activity has increased, often rapidly, in developing countries in recent years while marked reductions have occurred in some industrialized countries during the last 10-15 years. Changes in the prevalence of a multifactorial disease like dental caries are difficult to explain but the obvious ones seem to coincide either with increased intake or refined sugar-containing products or with increased use of fluorides. Furthermore it would appear that restorative treatment along has little impact on caries activity when viewed in a life long perspective. Experience, the existing geographic distribution of oral health problems and resources to cope with them suggest an urgent need for co-operation in dental education and research between developing and industrialized countries to develop acceptable cost-effective preventive programs in countries where caries activity is higher or increasing rapidly.

Adolescent↗
PubMed1983

Mutagenicity and carcinogenicity correlations between bacteria and rodents.

Detection of mutation in bacteria has acquired the status of an accepted procedure in genetic toxicology programs. The methods presently employed in such programs include both forward and reverse mutation-induction techniques in strains of Salmonella typhimurium and Escherichia coli. The specific strains used in these techniques have been selected over the years on the basis of their sensitivity to a broad range of chemical mutagens. In addition, it has been reported that chemical carcinogens can be presumptively identified on the basis of these assays, and bacterial testing has been generally considered the front-line test procedure for the identification of presumptive mutagenic carcinogens. An analysis of correlative studies both retrospective and cross-sectional shows a range of predictive capabilities depending on features such as chemical class, carcinogenic mechanism, and requirements for specific metabolic toxification processes. The greatest limitations associated with the use of bacteria mutation testing is the real and/or perceived issue of the test or a misinterpretation of the correlation coefficients under conditions of routine application. Concerns related to the performance (reliability, reproducibility, and predictability) and relevance of bacteria assays perpetuate controversy surrounding their application to hazard assessment. A review of several studies comparing mutation induction and tumor induction indicates that the Ames test can be useful in screening large numbers of chemicals, but the true correlation coefficient is only about 80% when compared to tumor responses in mice and rats.

Animals↗
PubMed1998

Successes and failures in the tropical bont tick eradication campaigns in the French antilles.

The Amblyomma variegatum eradication campaigns, based on three phases and a 5-year program, as in other islands of the Caribbean, started in the French Antilles in April 1994 with various financial inputs. The progress of the campaigns in the two islands of Guadeloupe and Martinique contrast sharply. Owing to a shortage and inadequacy of results with regard to the initial objectives, particularly in organization, communication efforts, cattle identification, and application of acaricides on livestock, the European Community which was the most important donor, did not support the Guadeloupean program in 1996 and 1997. This induced a deep crisis in the local sanitary organization, which has the responsibility for the execution of the project, and the almost total interruption of acaricide treatments in Guadeloupe and its dependencies (Marie-Galante, St Martin, Désirade). In Martinique on the contrary, a well-defined organization, communication strategy, and personnel training effort resulted in a generalized census of livestock owners. Identification of cattle increased dramatically in number and the systematic treatment of livestock started in satisfying conditions. It is too early to anticipate on the final result of the campaign, but it is clear that a longer period of time than previously planned, will be necessary to achieve the program. If this prolongation is accepted, it may allow Guadeloupe to take part again in the campaign, a condition absolutely necessary for its regional success.

Animal Husbandry↗
PubMed1977

Computer-aided medical decision making in radiotherapy.

Radiotherapy departments are becoming sophisticated in working with computers for isodose computations, treatment machine verifications and administrative and medical records. The next step lies in computer-assisted medical decision making. The logic for a patient's diagnostic work-up and treatment protocol can be stored in a computer. It can then be used as an aid in making the diagnosis, in prescribing the treatment and for quality control. For patients who fit established protocols the computer can select and list treatment using the logic of that protocol. Such a system has been implemented for the postoperative radiotherapy of breast cancer on a trial basis. Its potential usefulness is illustrated by results in 25 consecutive patients. Physician acceptance and costs of the program are under investigation.

Breast Neoplasms↗
PubMed1992

Dose of dialysis: what index?

Wider patient acceptance criteria in hemodialysis (HD) programs do not seem to completely explain the increasing mortality reported in the United States at a time characterized by reduced treatment time and dose. This raises the question of HD standard and adequacy. It stimulated us to analyze patient survival with unchanged 'old-times' methods. 445 unselected patients have been treated for 22 years by the same unchanged methods (24 m2/week, flat-plate dialyzers, cuprophane membrane, acetate buffer). Their survival data were compared to major HD registries and series. Survival was also evaluated as a function of mean arterial pressure (MAP), urea fractional clearance (Kt/V), and middle-molecule dialysis index (DI). Kaplan-Meier (with log-rank test) analysis and Cox proportional hazard model were used. Survival at short and long term was better in our series. This favorable survival difference was more obvious for older patients at the start of HD. It could not be accounted for by selection bias, but correlated with good MAP control without medication and with higher than usual Kt/V (1.67 +/- 0.41) and DI (1.47 +/- 0.38). Cox analysis including five covariates confirmed that survival was linked to MAP. It suggested that survival improvement might be expected from a DI increment of over 1.38 but not from a Kt/V increment of over 1.60. Adequate dialysis cannot be reduced to numbers; it should include both sufficient small- and middle-molecule diffusion and ultrafiltration with arterial pressure control without need for antihypertensive medication. The long-term satisfactory survival remains the best index of overall dialysis adequacy.

Adult↗
PubMed1998

Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness.

OBJECTIVE: Severe and persistent mental illnesses are often lifelong and characterized by intermittent exacerbations requiring hospitalization. Providing needed care within budgetary constraints to this largely publicly subsidized population requires technologies that reduce costly inpatient episodes. The authors report a prospective randomized trial to test the clinical effectiveness of a model of acute residential alternative treatment for patients with persistent mental illness requiring hospital-level care. METHOD: Patients enrolled in the Montgomery County, Md., public mental health system who experienced an illness exacerbation and were willing to accept voluntary treatment were randomly assigned to the acute psychiatric ward of a general hospital or a community residential alternative. There were no psychopathology-based exclusion criteria. Treatment episode symptom improvement, satisfaction, discharge status, and 6-month pre- and postepisode acute care utilization, psychosocial functioning, and patient satisfaction were assessed. RESULTS: Of 185 patients, 119 (64%) were successfully placed at their assigned treatment site. Case mix data indicated that patients treated in the hospital (N = 50) and the alternative (N = 69) were comparably ill. Treatment episode symptom reduction and patient satisfaction were comparable for the two settings. Nine (13%) of 69 patients randomly assigned to the alternative required transfer to a hospital unit; two (4%) of 50 patients randomly assigned to the hospital could not be stabilized and required transfer to another facility. Psychosocial functioning, satisfaction, and acute care use in the 6 months following admission were comparable for patients treated in the two settings and did not differ significantly from functioning before the acute episode. CONCLUSIONS: Hospitalization is a frequent and high-cost consequence of severe mental illness. For patients who do not require intensive general medical intervention and are willing to accept voluntary treatment, the alternative program model studied provides outcomes comparable to those of hospital care.

Adult↗
PubMed2006

The meaning of anger for Australian Indigenous offenders: the significance of context.

The problem of overrepresentation of Indigenous offenders in Australian prisons highlights the need for effective tertiary intervention programs within correctional settings as a way of reducing Indigenous reincarceration. This study seeks to explore meanings of anger within an Indigenous context that might inform the development of more acceptable and potentially more effective rehabilitation programs. A methodology that acknowledges the importance of narrative, context, and culture was devised to explore how anger as an emotion is understood and experienced by a group of Indigenous men in a South Australian prison. Although some of the major themes reflected experiences of anger common to many offenders, it was evident that for these Indigenous men, anger was experienced within a broad social and political context that imbued the experience of anger with layers of culturally specific meaning. It is suggested that these layers of meaning constitute sufficient difference to warrant further exploration.

Adult↗
PubMed2002

Acceptability of condom availability in a U.S. jail.

Studies have documented the transmission of HIV in incarcerated populations resulting from injection drug use or sexual activity. Less than 1% of the jails and prisons in the United States allow inmates access to condoms, and none allows access to needles. Results of a survey to measure the acceptability of a condom distribution program at the Washington, DC. Central Detention Facility, where condoms are available to inmates, are presented here. Three hundred seven inmates and 100 correctional officers were surveyed from October 2000 through October 2001. The surveys demonstrate that the program is generally supported and thought to be important by inmates and correctional staff. The program has not resulted in any major security infractions and could be replicated in other correctional settings.

Adult↗
PubMed1993

The prevention of prenatal alcohol use: a critical analysis of intervention studies.

Alcohol is a major cause of birth defects and mental retardation in the U.S. The yearly cost to care for those affected has been estimated to be over $300 million. Prenatal education and counseling have been advocated as techniques to reduce alcohol use in pregnancy. The purpose of this study was to critically review investigations that used these methods in order to determine their effectiveness. Reports of relevant studies were found by searching Medline, the ETOH database and bibliographies of primary sources. Only five studies were identified that met predetermined selection criteria. As judged by usual methodologic standards for intervention programs, only one was of acceptable quality. None employed a randomized design, and only two compared the treatment group to a control group. Both these studies found no difference in alcohol use between control and intervention groups. An ethical argument was used by several authors to justify performing inadequately controlled studies. Since no intervention has proven to be superior to the usual care delivered to pregnant women, this problem can be overcome through the use of controls who receive this level of care. Despite the public health importance of prenatal alcohol use, interventions to alter this behavior have not been rigorously evaluated, and the benefits of any specific approach are unclear. Randomized trials are ethically justified and guidelines for undertaking such studies are proposed.

Cohort Studies↗
PubMed2006

A randomized, controlled trial of an interactive educational computer package for children with asthma.

OBJECTIVE: The purpose of this study was to evaluate the impact and acceptability of an educational multimedia program designed to promote self-management skills in children with asthma. METHODS: We conducted a randomized, controlled trial with measures at baseline and 1- and 6-month follow-up. The trial was conducted in pediatric outpatient respiratory clinics in 3 United Kingdom hospitals. Participants included 101 children aged 7 to 14 years under the care of hospital-based asthma services. The children were randomly assigned to receive an asthma information booklet alone or the booklet plus The Asthma Files, an interactive CD-ROM for children with asthma. Asthma knowledge was the primary outcome measure. Other measures included asthma locus of control, lung function, use of oral steroids, and school absence. RESULTS: At the 1-month follow-up (n = 99), children in the computer group had improved knowledge compared with the control group and a more internal locus of control. There were no differences in objective lung-function measures, hospitalizations, or oral steroid use. The study participants were positive in their evaluation of the intervention. At the 6-month follow-up (n = 90), significantly fewer children in the intervention group had required oral steroids and had had time off school for asthma in the previous 6 months. The difference did not reach statistical significance in the intention-to-treat analysis for both steroid use and school absence. CONCLUSION: The Asthma Files was found to be an effective and popular health education tool for promoting asthma self-management skills within pediatric care.

Asthma↗
PubMed2003

Funding public health: The public's willingness to pay for domestic violence prevention programming.

OBJECTIVES: The author investigated the willingness of the general public to pay for domestic violence prevention programs. METHODS: An experimental design was used in a telephone survey of 522 California adults. One of 11 funding methods and one of 4 dollar amounts were randomly assigned to each respondent. RESULTS: Most respondents (79.4%) reported support for domestic violence prevention programming. They were most willing to pay 5 US dollars or less via "user fees" (e.g., increased fines for batterers) and humanitarian "donations" (e.g., sales of special postage stamps). CONCLUSIONS: Health departments that want to increase their domestic violence prevention programming need to identify widely accepted methods by which funds can be raised. The methods used here can be applied to numerous public health activities and issues.

Adolescent↗
PubMed1998

The cost of reaching National Cholesterol Education Program (NCEP) goals in hypercholesterolaemic patients. A comparison of atorvastatin, simvastatin, lovastatin and fluvastatin.

OBJECTIVE: Recognising the importance of treating hyperlipidaemia, the National Cholesterol Education Program (NCEP) has established widely accepted treatment goals for low density lipoprotein cholesterol (LDL-C). Medications used most commonly to achieve these LDL-C goals are HMG-CoA reductase inhibitors. The relative resource utilisation and cost associated with the use of reductase inhibitors of different LDL-C lowering efficacy are unknown, but are major health and economic concerns. The objective of this study was to determine the mean total cost of care to reach NCEP goals with various reductase inhibitors. DESIGN: In a randomised, 54-week, 30-centre controlled trial we compared resources used and costs associated with treating patients to achieve NCEP goals using 4 reductase inhibitors: atorvastatin, simvastatin, lovastatin and fluvastatin. PATIENTS AND PARTICIPANTS: The trial studied 662 patients; 318 had known atherosclerotic disease. INTERVENTIONS: Reductase inhibitor therapy was initiated at recommended starting doses and increased according to NCEP guidelines and package insert information. For patients who did not reach the goal at the highest recommended dose of each reductase inhibitor, the resin colestipol was added. MAIN OUTCOME MEASURES AND RESULTS: Patients treated with atorvastatin, compared-with other reductase inhibitors, were more likely to reach NCEP goals during treatment (p < 0.05), required fewer office visits (p < 0.001) and less adjuvant colestipol therapy (p = 0.001). Consequently, the mean total cost of care (1996 values) to reach NCEP goals was lower with atorvastatin [$US1064; 95% confidence interval (CI): $US953 to $US1176] compared with simvastatin ($US1471, 95% CI: $US1304 to $US1648), lovastatin ($US1972; 95% CI: $US1758 to $US2186) and fluvastatin ($US1542; 95% CI: $US1384 to $US1710). Results were similar for patients with or without known atherosclerotic disease. CONCLUSIONS: In patients requiring drug therapy for hypercholesterolaemia, NCEP LDL-C goals are achieved significantly more often using fewer resources with atorvastatin compared with simvastatin, lovastatin or fluvastatin.

Aged↗
PubMed2006

Serious crisis in the practice of international health by the World Health Organization: the Commission on Social Determinants of Health.

The Commission on Social Determinants of Health (CSDH) is the latest effort by the World Health Organization to improve health and narrow health inequalities through action on social determinants. The CSDH does not note that much work has already been done in this direction, does not make a sufficient attempt to analyze why earlier efforts failed to yield the desired results, and does not seem to have devised approaches to ensure that it will be more successful this time. The CSDH intends to complement the work of the earlier WHO Commission on Macroeconomics and Health, which has not had the desired impact, and it is unclear how the CSDH can complement work that suffers from such serious infirmities. Inadequacies of both commissions reflect a crisis in the practice of international health at the WHO, stemming from a combination of unsatisfactory administrative practices and lack of technical competence to provide insights into the problems afflicting the most needy countries. Often the WHO has ended up distorting the rudimentary health systems of the poor countries, by pressuring them into accepting health policies, plans, and programs that lack sound scientific bases. The WHO no longer seems to take into account historical and political factors when it sets out to improve the health situation in low-income countries--which is supposed to be the focus of the CSDH. An alternative approach is suggested.

Advisory Committees↗