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PubMed2006

Multidisciplinary and interdisciplinary management of chronic pain.

Multidisciplinary and interdisciplinary pain management programs incorporate a biopsychosocial model in assessing and treating pain and result in pain reduction, improved quality of life, and psychosocial functioning. Additionally, return-to-work and vocational outcomes may be seen in selected patients. Treatment teams may include a physiatrist, a physical or occupational therapist,a pain psychologist, a relaxation (biofeedback) therapist, vocational and therapeutic recreational therapists, social workers, and nurses. The key component to program success is collaborative ongoing communication among team members, the patient, and the case manager.

Chronic Disease↗
PubMed2006

Facial expressivity during the clinical interview as a predictor functional disability in schizophrenia. a pilot study.

Despite the central role of nonverbal behavior in regulating social interactions, its relationship to functional disability in schizophrenia has received little empirical attention. This study aimed at assessing the relationship of patients' spontaneous facial expressivity during the clinical interview to clinician-rated and self-reported measures of functional disability. The nonverbal behavior of 28 stabilized patients with schizophrenia was analyzed by using the Ethological Coding System for Interviews (ECSI). Functional disability was assessed using the Global Assessment of Functioning (GAF) scale and the Sheehan Disability Scale (DISS). Partial correlation analysis controlling for the confounding effects of neuroleptic treatment showed that facial expressivity was correlated with the GAF score (r=0.42, P=0.03) and the scores on the subscales of the DISS measuring work (r=-0.52, P=0.005) and social (r=-0.50, P=0.007) disability. In a multiple regression model, nonverbal behavior explained variation in patients' work and social disability better than negative symptoms. The results of this pilot study suggest that deficits in encoding affiliative signals may play a role in determining or aggravating functional disability in schizophrenia. One clinical implication of this finding is that remediation training programs designed to improve nonverbal communication could also serve as a useful adjunct for improving work and social functioning in patients with schizophrenia.

Adult↗
PubMed2005

Developmental exposure to terbutaline alters cell signaling in mature rat brain regions and augments the effects of subsequent neonatal exposure to the organophosphorus insecticide chlorpyrifos.

Exposure to apparently unrelated neurotoxicants can nevertheless converge on common neurodevelopmental events. We examined the long-term effects of developmental exposure of rats to terbutaline, a beta-adrenoceptor agonist used to arrest preterm labor, and the organophosphorus insecticide chlorpyrifos (CPF) separately and together. Treatments mimicked the appropriate neurodevelopmental stages for human exposures: terbutaline on postnatal days (PN) 2-5 and CPF on PN11-14, with assessments conducted on PN45. Although neither treatment affected growth or viability, each elicited alterations in CNS cell signaling mediated by adenylyl cyclase (AC), a transduction pathway shared by numerous neuronal and hormonal signals. Terbutaline altered signaling in the brainstem and cerebellum, with gender differences particularly notable in the cerebellum (enhanced AC in males, suppressed in females). By itself, CPF exposure elicited deficits in AC signaling in the midbrain, brainstem, and striatum. However, sequential exposure to terbutaline followed by CPF produced larger alterations and involved a wider spectrum of brain regions than were obtained with either agent alone. In the cerebral cortex, adverse effects of the combined treatment intensified between PN45 and PN60, suggesting that exposures alter the long-term program for development of synaptic communication, leading to alterations in AC signaling that emerge even after adolescence. These findings indicate that terbutaline, like CPF, is a developmental neurotoxicant, and reinforce the idea that its use in preterm labor may create a subpopulation that is sensitized to long-term CNS effects of organophosphorus insecticides.

Adenylyl Cyclases↗
PubMed2003

Patient-doctor communication.

Communication is an important component of patient care. Traditionally, communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, but without a specific or intense focus on skills of communicating per se. The reliability and consistency of this teaching method left gaps, which are currently getting increased attention from medical schools and accreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specific clinical skill. In 1999, the Accreditation of Council for Graduate Medical Education implemented a requirement for accreditation for residency programs that focuses on "interpersonal and communications skills that result in effective information exchange and teaming with patients, their families, and other health professionals." The National Board of Medical Examiners, Federation of State Medical Boards. and the Educational Commission for Foreign Medical Graduates have proposed an examination between the. third and fourth year of medical school that "requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues" using standardized patients. One's efficiency and effectiveness in communication can be improved through training, but it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. The published literature also expresses belief in the essential role of communication. "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes". A systematic review of randomized clinical trials and analytic studies of physician-patient communication confirmed a positive influence of quality communication on health outcomes. Continuing research in this arena is important. For a successful and humanistic encounter at an office visit, one needs to be sure that the patient's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness. Patient concerns can be wide ranging, including fear of death, mutilation, disability; ominous attribution to pain symptoms; distrust of the medical profession; concern about loss of wholeness, role, status, or independence; denial of reality of medical problems; grief; fear of leaving home; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues are verbalized openly is fundamental to effective patient-doctor communication. The clinician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring clinician. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required. Counseling around unhealthy or risky behaviors is an important communication skill that should be part of health care visits. Understanding the psychology of behavioral change and establishing a systematic framework for such interventions, which includes the five As of patient counseling (assess, advise, agree, assist, and arrange) are steps toward ensuring effective patient-doctor communication. Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient: the physician knew best and the patient accepted the recommendation without question. This era is ending, being replaced with consumerism and the movement toward shared decision-making. Patients are advising each other to "educate yourself and ask questions". Patient satisfaction with their care, rests heavily on how successfully this transition is accomplished. Ready access to quality information and thoughtful patient-doctor discussions is at the fulcrum of this revolution.

Clinical Competence↗
PubMedDate not supplied

Malaria surveillance in New York City: 1991-1996.

BACKGROUND: The transmission of malaria has increased in recent years in many countries where it was once eradicated or under control, and malaria remains a major cause of morbidity and mortality throughout the developing world. Imported cases of malaria have been increasing in New York City and throughout the United States during the past decade. The New York City Department of Health has modified its malaria surveillance program in order to improve the assessment of diagnosis and treatment of malaria in New York City residents and to provide appropriate advice to health professionals who treat these patients. OBJECTIVES: To describe the epidemiologic and clinical characteristics of laboratory-confirmed cases of malaria diagnosed in New York City residents from January 1, 1991, through December 31, 1996. METHODS: The retrospective study of case reports was carried out by the Malaria Surveillance Program of the Bureau of Communicable Diseases, New York City Department of Health, New York City, NY. It included the laboratory diagnosis of malaria and the species involved, and included also descriptive epidemiologic information of patients with malaria (age, sex, race/ethnicity, date and place of onset of illness, travel history, immigration status, previous history of malaria, history of blood transfusion, drugs used for treatment or prophylaxis), as well as a record of clinical complications of the infection (thrombocytopenia, hemolysis, anemia, cerebral malaria, renal failure, respiratory distress syndrome, fatal outcome). RESULTS: Malaria was diagnosed in 988 residents of New York City during the 5-year period from January 1, 1991, through December 31, 1995. The largest number of cases, 254 (26%), occurred in 1996, with the majority of these cases (76%) observed between the months of May and October. Sixty-four percent (627) of these cases were males. The age range of cases was from newborn (first day of life) to 83 years (median, 31 years). Of the 962 cases of whom the racial/ethnic identity was known, 580 (59%) were black/non-Hispanic and 255 (26%) were Asian/Pacific Islander. Travel outside of the United States was reported by 958 patients, the majority to Africa (569/958, 59%). Only 139 patients (14%) claimed the use of malaria prophylaxis during travel. Plasmodium falciparum was identified in 505 (51%) and P. vivax in 356 (36%) of the cases. Clinical complications included hemolysis with severe anemia, thrombocytopenia, cerebral malaria, renal failure, and respiratory distress syndrome. All four fatal cases involved infections with P. falciparum, either alone or in combination with another plasmodia species. CONCLUSIONS: Imported cases of malaria occur frequently in New York City and may be associated with serious complications. Health care providers should consider this diagnosis in patients who have recently travelled or arrived from abroad, presenting with headache, fever, and other constitutional symptoms. There are many missed opportunities for the use of malaria prophylaxis, and physicians should familiarize themselves with current recommendations for malaria prophylaxis for travel to areas of the world where people are at risk for the transmission of malaria.

Adolescent↗
PubMedDate not supplied

Change is necessary in a biological engineering curriculum.

Success of a Biological Engineering undergraduate educational program can be measured in a number of ways, but however it is measured, a presently successful program can translate into an unsuccessful program if it cannot adjust to different conditions posed by technical advances, student characteristics, and academic pressures. Described in this paper is a Biological Engineering curriculum that has changed significantly since its transformation from Agricultural Engineering in 1993. As a result, student numbers have continued to climb, specific objectives have emerged, and unique courses have been developed. The Biological Resources Engineering program has evolved into a program that emphasizes breadth, fundamentals, communications skills, diversity, and practical engineering judgment.

Curriculum↗
PubMed2000

Recent advances in research on multistage tumorigenesis.

Tumour development is a multi-step process during which genetic and epigenetic events determine the transition from a normal to a malignant cellular state. In the past decade, extensive effort has been made not only to define the molecular mechanisms underlying progression to malignancy but also to predict the development of the disease and to identify possible molecular targets for therapy. Common to most tumours, several regulatory circuits are altered during multistage tumour progression, most importantly, the control of proliferation, the balance between cell survival and programmed cell death (apoptosis), the communication with neighbouring cells and the extracellular matrix, the induction of tumour neovascularization (angiogenesis) and, finally, tumour cell migration, invasion and metastatic dissemination. De-regulation of each of these processes represents a rate-limiting step for tumour development and, hence, has to be achieved by tumour cells in a highly selective manner during tumour progression. In this review we summarize recent advances in cancer research that have provided new insights in the molecular mechanisms underlying the transition between one tumour stage and the next and into their concerted action during tumour progression. Cultured human tumour cell lines as well as transgenic and knock-out mouse models of tumorigenesis have been instrumental in these experimental approaches.

Cell Differentiation↗
PubMed1994

The management of acute respiratory infections in Honduras: a field test of the Focused Ethnographic Study (FES).

The World Health Organization has recently developed an ethnographic research manual, The Focused Ethnographic Study (FES) for ARI, whose purpose is to facilitate Acute Respiratory Infection (ARI) program development by providing information about the context in which families perceive and respond to ARI, and by identifying factors that facilitate or impede prompt care-seeking for children with pneumonia. The methodology is focused around answering a set of pre-defined "Programme Managers' Questions" which represent the main concerns and needs of ARI programs. The FES is designed to address both the need for in-depth information about the household and community-level factors which affect the management of ARI, and the need for timely, program relevant, and focused information. A field test of this manual was conducted in Honduras, and a number of recommendations to the local ARI program were developed concerning improving communication about ARI with mothers of young children. The Honduran field-test of the FES shows how systematic ethnographic research can be conducted and translated into concrete recommendations for bridging the social and communication gap which so often exists between health workers and the communities they serve.

Acute Disease↗
PubMed2004

Processes of care during a randomized trial of office-based treatment of opioid dependence in primary care.

Improving office-based treatment of opioid dependence requires an evaluation of processes of care. We evaluated the care provided by physicians to opioid dependent patients during a trial of office-based methadone maintenance. We conducted chart audits and a focus group. Audits identified lapses in monitoring of urine toxicology results and paperwork completion. The focus group identified the logistics of dispensing, the receipt of urine toxicology results, difficulties arranging psychiatric services, communications with the opioid treatment program, and non-adherence to medication as problematic. Strategies to support logistical aspects of office-based care should be developed. Chart audits and mentoring should be considered as a mechanism to foster quality care. These processes of care are likely to require attention for treatment using methadone or buprenorphine.

Adolescent↗
PubMed1993

Enhancing clinical competence using a collaborative clinical education model.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether students in collaborative (two students to one Clinical Instructor [2:1]) learning placements differed on measures of clinical competence as compared with their peers in traditional (1:1) clinical placements. SUBJECTS: The population examined consisted of intermediate-level students in the physical therapy program at the University of Toronto. METHODS: The outcome measure of clinical competence in this study was a weighted score acquired from the university's Evaluation of Clinical Competence (ECC) form. Seven subgroup clinical competence scores as well as the total clinical competence score were analyzed. RESULTS: The collaborative learning group demonstrated significantly higher scores on all aspects of the ECC instrument. CONCLUSION AND DISCUSSION: This result suggests that achievement of clinical competence in patient evaluation, program planning, implementation of treatment, communication, management skills, professional behavior, and documentation were enhanced through collaborative learning.

Adult↗
PubMed2000

Changing behavior to maintain a healthy home.

Multidimensional strategies involving interpersonal interaction, strategic alliances and targeted use of the media have been shown experimentally to be the most effective behavioral change programs. Health providers need to communicate with schools and community groups, as well as work with product manufacturers and consumer and health organizations. Together these groups can collaborate with the media to communicate accurate information and guidance to the public. Planning effective public health and behavioral change campaigns involves diagnosis and identification of the target behavior. The intervention message must be focused, tested and refocused. Effective communication, crucial to public health campaigns, uses multiple channels and provides frequent repetition of the message.

Health Behavior↗
PubMed1985

The impact of aging on human sexuality.

Review of gerontological and medical literature reveals the need for education for lay persons and professionals about the effects of the aging process on human sexuality. Primary prevention of psychosocial problems and sexual dysfunction could be abated by including accurate information about sexuality and aging and effective communication techniques in sexuality education programs, including those with young adults. In addition, professional preparation of health educators must include the skills and knowledge needed in this area.

Aging↗
PubMed1996

In vitro models for the effects of sex hormones on neurons.

The results of these two in vitro models share some striking similarities. In both, estrogen was able to induce or promote the formation of either dendrites themselves in hippocampal neurons or dendritic specializations in PC12 neurites, and these specializations were then able to induce interneural interactions. In both models, androgen was able to promote the development of axons that branched frequently, while not directly fostering interneuronal contact. These findings recapitulate in part some of the effects of estrogen and androgen on neurons in vivo and suggest the inherent ability of cells of neural crest origin to respond to these hormones with specific neural morphogenetic programs designed to alter interneuronal communication. In these ways, it seems likely that both sex hormones are acting as neural growth factors in cells that express the appropriate receptor, leading to stereotyped changes in neural growth and pattern formation. Through the examination of such subcellular mechanisms, we hope to further understand the effects of sex hormones on brain development and the ontogeny of behavioral, cognitive, and reproductive differences between the sexes.

Animals↗
PubMed1997

The public health aspects of complex emergencies and refugee situations.

Populations affected by armed conflict have experienced severe public health consequences mediated by population displacement, food scarcity, and the collapse of basic health services, giving rise to the term complex humanitarian emergencies. These public health effects have been most severe in underdeveloped countries in Africa, Asia, and Latin America. Refugees and internally displaced persons have experienced high mortality rates during the period immediately following their migration. In Africa, crude mortality rates have been as high as 80 times baseline rates. The most common causes of death have been diarrheal diseases, measles, acute respiratory infections, and malaria. High prevalences of acute malnutrition have contributed to high case fatality rates. In conflict-affected European countries, such as the former Yugoslavia, Georgia, Azerbaijan, and Chechnya, war-related injuries have been the most common cause of death among civilian populations; however, increased incidence of communicable diseases, neonatal health problems, and nutritional deficiencies (especially among the elderly) have been documented. The most effective measures to prevent mortality and morbidity in complex emergencies include protection from violence; the provision of adequate food rations, clean water and sanitation; diarrheal disease control; measles immunization; maternal and child health care, including the case management of common endemic communicable diseases; and selective feeding programs, when indicated.

Cause of Death↗
PubMed1990

A model of methods for influencing prescribing: Part I. A review of prescribing models, persuasion theories, and administrative and educational methods.

The purpose of this literature review is to develop a model of methods to be used to influence prescribing. Four bodies of literature were identified as being important for developing the model: (1) Theoretical prescribing models furnish information concerning factors that affect prescribing and how prescribing decisions are made. (2) Theories of persuasion provide insight into important components of educational communications. (3) Research articles of programs to improve prescribing identify types of programs that have been found to be successful. (4) Theories of human inference describe how judgments are formulated and identify errors in judgment that can play a role in prescribing. This review is presented in two parts. This article reviews prescribing models, theories of persuasion, studies of administrative programs to control prescribing, and sub-optimally designed studies of educational efforts to influence drug prescribing.

Cognition↗
PubMed1981

Validity of the Missouri Children's Picture Series as a predictor of childhood sleep disturbances.

In view of recent findings in a retrospective study by two of the authors, the present research was designed to systematically assess the validity of the Missouri Children's Picture Series sleep disturbances scale. Study I compared groups of restless sleepers and nocturnal enuretics with matched cohorts attending a summer residential program for children with communication-related disorders. Study II examined the relation of two MCPS scales to parent reports of corresponding problems, using a multitrait-multimethod matrix, individual correlations, and cluster analysis. Neither study provided convincing evidence for the validity of the sleep disturbance scale.

Adolescent↗
PubMed2005

IrreC/rst-mediated cell sorting during Drosophila pupal eye development depends on proper localisation of DE-cadherin.

Remodelling of tissues depends on the coordinated regulation of multiple cellular processes, such as cell-cell communication, differential cell adhesion and programmed cell death. During pupal development, interommatidial cells (IOCs) of the Drosophila eye initially form two or three cell rows between individual ommatidia, but then rearrange into a single row of cells. The surplus cells are eliminated by programmed cell death, and the definitive hexagonal array of cells is formed, which is the basis for the regular pattern of ommatidia visible in the adult eye. Here, we show that this cell-sorting process depends on the presence of a continuous belt of the homophilic cell adhesion protein DE-cadherin at the apical end of the IOCs. Elimination of this adhesion belt by mutations in shotgun, which encodes DE-cadherin, or its disruption by overexpression of DE-cadherin, the intracellular domain of Crumbs, or by a dominant version of the monomeric GTPase Rho1 prevents localisation of the transmembrane protein IrreC-rst to the border between primary pigment cells and IOCs. As a consequence, the IOCs are not properly sorted and supernumerary cells survive. During the sorting process, Notch-mediated signalling in IOCs acts downstream of DE-cadherin to restrict IrreC-rst to this border. The data are discussed in relation to the roles of selective cell adhesion and cell signalling during tissue reorganisation.

Animals↗
PubMed2006

Biomonitoring and biomarkers: exposure assessment will never be the same.

Using modern analytical technology, it is now possible to measure almost any chemical present in our bodies. The future role of classical exposure assessment will perhaps be marginalized because biomonitoring programs can directly measure the concentration of chemicals that are present in biologic matrices. Although the concentration of chemicals in the environment will continue to be measured and related to exposure parameters, the prioritization of the national environmental agenda will be dictated by biomonitoring. Recent biomonitoring studies have examined the levels of >200 chemicals. Biomonitoring data, by themselves, are not informative in helping consumers understand their individual health risk. A major challenge facing those who conduct biomonitoring programs is how to best communicate the information to the public. In this article, we review benefits and challenges, along with select results from the Centers for Disease Control and Prevention's 2005 National Report on Human Exposure to Environmental Chemicals. We recommend that these data be carefully interpreted, with the goal of establishing baseline exposure information, rather than creating surrogates for conclusions about human health risk.

Biomarkers↗