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PubMed1975

Early childhood development of four boys with 47, XXY karyotype.

In an epidemiological study, infants identified at birth as having sex chromosome anomalies are enrolled in a voluntary, long term evaluations program. Case histories are presented of the first four boys in the series to have a 47,XXY karyotype. They have been followed from birth for 6 to 9 years, with physical and psychological evaluations. Parents were informed in general terms of the child's genetic defect, and were offered continuing support and encouragement throughout the study. Close cooperation with the families was maintained. So far, the development of all these children has fallen clearly within the normal range and a reasonable healthy dpattern has been secured. Minor deviations in motor, speech and emotional development suggest a common underlying pattern, but four cases are too few on which to establish a relationship between karyotype and phenotype. The data suggest that the symptomatology reported in selected children with a 47,XXY karyotype may be strongly dependent on factors other than the chromosomal constitution, and that an appropriate familial and environmental situation may minimize elevated risks due to the marked genetic defect.

Adolescent↗
PubMed1995

Genetics in democratic societies--the Nordic perspective.

This report, with its emphasis on consensus points in the deliberations of the First Bioethics Workshop under the auspices of the Nordic Genome Initiative (an activity under the Nordic Council through its Nordic Programme Committee for Biotechnology), presents a Nordic perspective on the international discussion of ethical and legal issues relating to genetic testing. The Nordic countries have important common denominators with respect to political structure, education, religion, languages, cultural traditions and attitudes towards human values. A comprehensive national health service exists in all Nordic countries and there are important common legal foundations with great similarities between countries. However, in areas related to biotechnology there are considerable legal differences, but these differences do not necessarily reflect differences in underlying principles. Important ethical principles relevant to genetic testing that are shared by the Nordic countries include the concept of social justice with great stress on equality of treatment, the right to autonomy, the right to full disclosure of test results, strict confidentiality with respect to test results, the requirement that participation in testing programs must always be voluntary and based on information, and a responsible balance between risks or inconveniences on one hand and benefits on the other.

Abortion, Induced↗
PubMed2005

The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions.

OBJECTIVE: To determine whether Medicaid managed care is associated with lower hospitalization rates for ambulatory care sensitive conditions than Medicaid fee-for-service. We also explored whether there was a differential effect of Medicaid managed care by patient's race or ethnicity on the hospitalization rates for ambulatory care sensitive conditions. DATA SOURCES/STUDY SETTING: Electronic hospital discharge abstracts for all California temporary assistance to needy families (TANF)-eligible Medicaid beneficiaries less than age 65 who were admitted to acute care hospitals in California between 1994 and 1999. STUDY DESIGN: We performed a cross-sectional comparison of average monthly rates of admission for ambulatory care-sensitive conditions among TANF-eligible Medicaid beneficiaries in fee-for-service, voluntary managed care, and mandatory managed care. DATA COLLECTION/EXTRACTION METHODS: We calculated monthly rates of ambulatory care-sensitive condition admission rates by counting admissions for specified conditions in hospital discharge files and dividing the monthly count of admissions by the size of the at-risk population derived from a separate monthly Medicaid eligibility file. We used multivariate Poisson regression to model monthly hospital admission rates for ambulatory care-sensitive conditions as a function of the Medicaid delivery model controlling for admission month, admission year, patient age, sex, race/ethnicity, and county of residence. PRINCIPAL FINDINGS: The adjusted average monthly hospitalization rate for ambulatory care-sensitive conditions per 10,000 was 9.36 in fee-for-service, 6.40 in mandatory managed care, and 5.25 in voluntary managed care (p<.0001 for all pairwise comparisons). The difference in hospitalization rates for ambulatory care sensitive conditions in Medicaid fee-for-service versus managed care was significantly larger for patients from minority groups than for whites. CONCLUSIONS: Selection bias in voluntary Medicaid managed care programs exaggerates the differences between managed care and fee-for-service, but the 33 percent lower rate of hospitalizations for ambulatory care sensitive conditions found in mandatory managed care compared with fee-for-service suggests that Medicaid managed care is associated with a large reduction in hospital utilization, which likely reflects health benefits. The greater effect of Medicaid managed care for minority compared with white beneficiaries is consistent with other findings that suggest that managed care is associated with improvements in access to ambulatory care for those patients who have traditionally faced the greatest barriers to health care.

Adolescent↗
PubMed1994

Report of the NASPE Policy Conference training requirements for permanent pacemaker selection, implantation, and follow-up. North American Society of Pacing and Electrophysiology.

NASPE proposes and supports the concept of a two-tracked training system in cardiac pacing. Track I training will properly train physicians for the prescription of pacemakers and the monitoring of pacemaker patients, and track II training will properly prepare physicians for the implantation of pacemakers. Regardless of specialty (cardiologist or surgeon) or training venue (cardiac pacing fellowship, cardiac electrophysiology and pacing fellowship, sabbatical or mentor sponsored training), it is recommended that these minimum standards be required for hospital credentialing. NASPE also supports the voluntary institution by training program directors of core pacing training in cardiovascular disease and cardiac electrophysiology fellowships. This core training does not in itself constitute proper track I or II training for physicians interested in adequately prescribing, monitoring, or implanting cardiac pacemakers.

Cardiac Pacing, Artificial↗
PubMed2003

Smallpox vaccination: a national survey of emergency health care providers.

UNLABELLED: Concerns about bioterrorism have prompted a national voluntary smallpox (SP) vaccination program in the United States. Although emergency health care providers are among the first targeted for vaccination, little is known about how these providers view the risks and benefits of SP vaccination. OBJECTIVES: To assess the willingness of emergency health care personnel to receive pre-event SP vaccination prior to the start of the national program. METHODS: The authors conducted a national cross-sectional, anonymous survey of 1,701 emergency physicians, nurses, and mid-level practitioners working full time in 13 adult and pediatric academic emergency departments in large U.S. cities in November and December 2002. The main outcome measure was willingness to be vaccinated against SP. Secondary outcomes included the prevalence of self-reported contraindications, and reasons for and against vaccination. RESULTS: 732 emergency health care providers returned questionnaires (response rate 43%). Overall, 73% (95% CI = 66% to 80%) were willing to receive pre-event SP vaccination. 18% (95% CI = 14% to 23%) reported contraindications to vaccination, and 50% (95% CI = 39% to 61%) of these providers were willing to receive pre-event SP vaccination. Self-protection (72%) was the most common reason cited for desiring vaccination against SP; concern about vaccine-related adverse events (54%) was the most common reason cited for not wanting immunization. CONCLUSIONS: Most emergency health care providers express a willingness to receive pre-event SP immunization; self-protection is a principal motivating reason. A subset of health care providers, however, may place themselves at increased risk by desiring vaccination despite contraindications.

Adult↗
PubMed2006

Effects of isometric training at different knee angles on the muscle-tendon complex in vivo.

The purpose of this study was to investigate the influences of isometric training at different joint angles on the muscle size and function of the human muscle-tendon complex in vivo. Furthermore, we tried to gain a better understanding of the mechanisms involved in angle specificity after isometric training from the aspect of neuromuscular adaptation and the changes in the properties of the muscle-tendon complex. Nine males completed 12-week unilateral training program (70% of maximal voluntary contraction (MVC) x 15 s x six sets) on the knee extensors at 50 degrees (shorter muscle length: ST) and 100 degrees (longer muscle length: LT). The internal muscle force (mechanical stress) is higher at 100 degrees than at 50 degrees because of the difference in the moment arm length, although there were no difference in the relative torque level, contraction and relaxation times, and repetition between ST and LT. Before and after training, isometric strength at eight angles and muscle volume were determined. Tendon elongation of knee extensors was measured by ultrasonography. There was no significant difference in the rate of increment of muscle volume between the protocols. Tendon stiffness increased significantly for LT, but not for ST. Although significant gain was limited to angles at or near the training angle for ST, increases in MVC at all angles were found for LT. These results suggest that only mechanical stress (internal muscle force imposed on muscle and tendon) contributes to adaptation in the tendon stiffness, although metabolic (relative torque level, etc.) and mechanical stress relate to muscle hypertrophy. Furthermore, increment of tendon stiffness for LT might contribute to increase torque output at smaller angles other than the training angle.

Adaptation, Physiological↗
PubMed2004

Public access defibrillation in out-of-hospital cardiac arrest: a community-based study.

BACKGROUND: The dissemination and use of automated external defibrillators (AEDs) beyond traditional emergency medical services (EMS) into the community has not been fully evaluated. We evaluated the frequency and outcome of non-EMS AED use in a community experience. METHODS AND RESULTS: The investigation was a cohort study of out-of-hospital cardiac arrest cases due to underlying heart disease treated by public access defibrillation (PAD) between January 1, 1999, and December 31, 2002, in Seattle and surrounding King County, Washington. Public access defibrillation was defined as out-of-hospital cardiac arrest treated with AED application by persons outside traditional emergency medical services. The EMS of Seattle and King County developed a voluntary Community Responder AED Program and registry of PAD AEDs. During the 4 years, 475 AEDs were placed in a variety of settings, and more than 4000 persons were trained in cardiopulmonary resuscitation and AED operation. A total of 50 cases of out-of-hospital cardiac arrest were treated by PAD before EMS arrival, which represented 1.33% (50/3754) of all EMS-treated cardiac arrests. The proportion treated by PAD AED increased each year, from 0.82% in 1999 to 1.12% in 2000, 1.41% in 2001, and 2.05% in 2002 (P=0.019, test for trend). Half of the 50 persons treated with PAD survived to hospital discharge, with similar survival for nonmedical settings (45% [14/31]) and out-of-hospital medical settings (58% [11/19]). CONCLUSIONS: PAD was involved in only a small but increasing proportion of out-of-hospital cardiac arrests.

Aged↗
PubMed1999

Longitudinal decline in measured firefighter single-breath diffusing capacity of carbon monoxide values. A respiratory surveillance dilemma.

Seattle firefighters participate in a voluntary annual medical surveillance program including measurements of ventilatory capacity (FVC and FEV1) and single-breath diffusing capacity of carbon monoxide (DLCO). From 1989 to 1996, average % predicted DLCO (Crapo) for all participating firefighters declined from 94.4% (95% confidence interval [CI]: 93.4% to 95.5%) to 87.3% (95% CI: 86.2% to 88.3%), with no significant change in average FVC or FEV1. A random-effects regression model based on data from 812 firefighters with at least two annual sets of DLCO measurements showed the expected associations between DLCO and age, height, gender, race, ventilatory capacity, and smoking. In addition, two important temporal changes were observed, including, for an average firefighter, a large mean decline in DLCO of -1.02 ml/min/mm Hg associated with year of measurement, and a relatively smaller decline of -0.006 ml/min/mm Hg associated with number of fires fought. Although the stability of ventilatory capacity over time is reassuring, the marked temporal decline in diffusing capacity among this population of firefighters raises issues of concern. Interpretation of the observed decline poses a dilemma in terms of the reliability and efficacy of diffusing capacity as a screening tool, in whether DLCO is subject to unacceptable technical variability or whether it might provide more sensitive detection of early adverse respiratory effects of smoke inhalation.

Adult↗
PubMed1981

Psychiatric illness in U.S. Air Force Viet Nam prisoners of war: a five-year follow-up.

The U.S. Air Force prisoners of war (POWs) experienced a profound degree of stress during the Viet Nam War. The psychiatric status of this population has been monitored by an ongoing voluntary follow-up program from the time of repatriation through the following five years. Data indicate a significant degree of psychiatric readjustment problems, which were greatest among POWs captured before 1969. These findings support the association of an unusually stressful environment with an increased incidence of psychiatric illness.

Adjustment Disorders↗
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↗
PubMed2004

Predictors of premature termination of inpatient treatment for anorexia nervosa.

OBJECTIVE: The authors examined predictors of premature dropout from a voluntary specialized inpatient treatment program for anorexia nervosa. METHOD: One hundred sixty-six consecutive patients with anorexia nervosa received an admission assessment that consisted of a diagnostic interview and psychometric measures of core eating pathology and associated psychopathology. Survival analysis was used to examine the rate, timing, and prediction of dropout. Predictors included a variety of clinical, demographic, and psychometric variables. RESULTS: Compared with program completers, program dropouts were more likely to have the binge eating/purging type of anorexia nervosa (65% versus 26%), had lower restraint scores, and reported more intense maturity fears and concerns about weight. CONCLUSIONS: Patients with the binge eating/purging type of anorexia nervosa are significantly less likely to complete inpatient treatment for the disorder.

Adult↗
PubMed1991

Integration of mother and child health services in Ethiopia.

In Wollo region of Ethiopia, various non-governmental officers have been working closely with each other and with the Regional Health Department to implement the policy of daily integrated mother and child health services. The record cards, registers, procedures and training courses of the separate 'vertically' organized services were brought together to enable the development of a model integrated service. There were improvements in accessibility, acceptability and output of the services. The system was evaluated by a joint Ministry of Health and UNICEF team, and was adopted for use in the rest of Ethiopia.

Adolescent↗
PubMed1995

Palliative care services: what needs assessment?

A survey of all district health authorities in England was conducted in order to describe current patterns of needs assessment and contract setting for palliative care services. Outcome measures included the completion of needs assessments in the past five years, the type of data used for needs assessment, and recommendations for service development. Copies of contracts for palliative care services were requested and analysed according to duration of contract, and audit requirements. A 74% response rate was achieved. Over half the health authorities had not carried out a needs assessment or service review of palliative care services in the past five years. Of those that had undertaken needs assessment, about one-quarter were planning more review work, and most of the reports expressed the need for more information on many aspects of palliative care. Copies of contracts with specialist palliative care providers were supplied by 38 health authorities, with the majority being of only one year's duration. Although conducted within an English context, the study findings have wider implications for the process of effective health care purchasing.

Contract Services↗
PubMed1978

A model for the coordination of international donor activities with national government health services.

This study is a descriptive analysis of an attempt to coordinate donor agency and government activities in the national leprosy control program of the Philippine Islands. A twofold strategy is employed to realize this purpose: (1) the evolution of the present coordinated program as recorded in both published and unpublished documents is described, and (2) an opinion survey of Philippine personnel active in the present leprosy control program is reported. The most significant finding, in terms of relating the Philippine experience to other areas of donor-recipient exchange, is the emergence of a model of coordinated effort where a donor agency's assistance to a foreign national government is transmitted through a third indigenous and intermediary organization. By advancing the interests of both donor and recipient organizations, this approach has the potential of promoting a successful coordination of activities which might not otherwise be attained.

Financing, Organized↗
PubMed2001

Medicaid managed care in New York City: recent performance and coming challenges.

OBJECTIVES: This study evaluated New York City's voluntary Medicaid managed care program in terms of health care use and access. METHODS: A survey of adults in Medicaid managed care and fee-for-service programs during 1996-1997 was analyzed. RESULTS: Responses showed significant favorable risk selection into managed care but little difference in use of health care services. Although some measures of access favored managed care, many others showed no difference between the study groups. CONCLUSIONS: The early impact of mandatory enrollment will probably include an increase in the average risk of managed care enrollees with little change in beneficiary use and access to care.

Adolescent↗
PubMed2006

Carbon accounting rules and guidelines for the United States forest sector.

The United States Climate Change Initiative includes improvements to the U.S. Department of Energy's Voluntary Greenhouse Gas Reporting Program. The program includes specific accounting rules and guidelines for reporting and registering forestry activities that reduce atmospheric CO2 by increasing carbon sequestration or reducing emissions. In the forestry sector, there is potential for the economic value of emissions credits to provide increased income for landowners, to support rural development, to facilitate the practice of sustainable forest management, and to support restoration of ecosystems. Forestry activities with potential for achieving substantial reductions include, but are not limited to: afforestation, mine land reclamation, forest restoration, agroforestry, forest management, short-rotation biomass energy plantations, forest protection, wood production, and urban forestry. To be eligible for registration, the reported reductions must use methods and meet standards contained in the guidelines. Forestry presents some unique challenges and opportunities because of the diversity of activities, the variety of practices that can affect greenhouse gases, year-to-year variability in emissions and sequestration, the effects of activities on different forest carbon pools, and accounting for the effects of natural disturbance.

Agriculture↗
PubMed1977

Analysis of clinically occult and mammographically occult breast tumors.

Findings by xeromammography and clinical examination were compared in 16,000 self-selected women aged 45-64 who participated in a voluntary breast cancer screening program. A total of 138 malignancies were detected: 108 (78%) by mammography and 78 (57%) by clinical examination. Mammography was more effective for large breasts, fatty breasts, and in older women. Conversely, clinical examination was more effective for small breasts, dense breasts, and retroareolar lesions. Clinical detection decreased strikingly for lesions with negative lymph nodes, in situ and microinvasive lesions, deeply situated lesions, and lesions where microcalcifications were the sole mammographic finding.

Age Factors↗
PubMed2006

Spinal surgery and patient safety: a systems approach.

In every spinal procedure, identifying the specific patient, proper surgical site, and pathologic lesion for surgical intervention are crucial patient safety concerns. The 1999 Institute of Medicine report "To Err is Human" identified adverse events associated with surgery. Both the American Academy of Orthopaedic Surgeons and the North American Spine Society have had voluntary, systems-based programs in place for several years to address wrong patient, wrong procedure, and wrong site surgery. Beginning July 1, 2004, the Joint Commission on the Accreditation of Healthcare Organizations mandated that hospitals comply with the JCAHO Universal Protocol. In addition to surgical site marking, the protocol incorporates additional factors, such as calling a time out before skin incision to do a final systems check of patient identification, surgical site, records, imaging studies, equipment, and review of preoperative medication.

Humans↗